Older Adults

Skin Assessment

This assessment should focus on redness or irritation; risk of skin cancer in r/t history of skin cancer, light skin, history of cigarette smoking, a weakened immune system or prolonged sun exposure; wound that has not healed in a reasonable amount of time; presence of a pressure injury.

Variations:

Check for the texture, firmness, temperature, or tightness to help assess dark skin. Irritation may manifest as hyperpigmentation or hypopigmentation rather than erythema.

Compare the same body part to each other when assessing for skin changes as skin tones can vary in the body.

To determine skin tone, use body areas that are less exposed to the sun (e.g. upper arms, palms of the hand, soles of the feet, etc…) Sunburn can manifests as pink, red, purple or a darkening of the skin.


Q: An older client reports they often have areas on their skin that bruise or bleed easily when they bump into something. What information should the nurse provide?

Simplified rationale: As people age, the skin becomes thinner, less elastic, and loses fat and collagen, making it more fragile. This can cause easy bruising, especially for those on blood thinners or aspirin. Sweat and oil glands produce less, leading to dry skin. Clients should be taught to drink plenty of fluids, use moisturizing lotions or creams, and protect their skin from the sun while still getting enough sunlight for vitamin D.


Expected Skin Variation

  • Older may have looser skin or uneven skin tone (skin becomes thinner and more prone to injuries)

  • Subcutaneous fat decreases (less insulation = more prone to temp. fluctuations and skin injuries; may affect absorption of fat-soluble medications as well)

  • Sweat glands produces less sweat (i. risk of heat stroke)

  • Decrease of pigment-containing cells causing older adults to look pale and translucent

  • Age spots (“Liver spot”)

  • Elasticity of the skin also decreases. (skin of older adults who have extensive sun exposure can appear tough and leathery)

  • Bruising (may be exacerbated by taking blood thinners).

  • Sebaceous glands generates less oil in menopausal older adults and male adults over 80.

  • Skin tags, warts, discoloration, seborrheic keratosis


Common skin conditions:

  • Eczema

  • Fungal infections

  • Pruritus

  • Asteatotic eczema: may present as cracked and itchy skin (Caused by very dry skin)

  • Nummular eczema: circular-shaped reddened patches (Caused by very dry skin)

  • Rosacea, results in red blushing or flushing in the face

  • Seborrheic dermatitis: scaly, flakey, erythematous patches and results in a condition of dandruff on the scalp.


Unexpected Skin Variations

  • Skin Lesions or Conditions

    • Macules: flat, discolored lesions less than 10 mm in diameter. (freckles and flat moles)

      • Note these spots and track them for changes.

    • Papules are elevated lesions greater than 10 mm. (seborrheic keratoses)

      • Common occurrence in older adults but could also indicate underlying internal cancer.

    • Nodules are firm papules that extend below the surface of the skin. (e.g. cysts or lipomas)

    • Vesicles are elevated lesions less than 10 mm in diameter filled with serous fluid. (dermatitis or a herpes flare).

    • Bullae are blisters greater than 10 mm and are filled witha serous fluid. (dermatitis, burns, insect bites, or occur with some autoimmune diseases).

    • Pustules are vesicles filled with pus. (bacterial infection or inflammatory disorder)

    • Urticaria are hives and presents as elevated lesions that are itchy and red (caused by outside determinants such as sunlight and heat).

    • Pressure injury are usually painful and localize and may involve damage to the underlying tissue depending on the severity of the injury. Common in the sacrum, buttocks, and bony prominences (heels, elbows, knees, and hips).

      • Stage 1: Area is reddened but has not broken the skin yet; nonblanchable, and painful.

      • Stage 2: Area has broken down to the dermal layer of the skin; a shallow open ulcer and serum-filled blister is present.

      • Stage 3: Area is characterized by full-thick breakdown into the dermal layer of skin; visible fatty tissue, dead tissue (slough which can be yellow, tan, gray, green, or brown and is usually moist. Eschar is usually black or brown which needed to be removed to promote wound healing). Wound may tunnel deeper than the surface level.

      • Stage 4: Area is the same as stage 3 but visible bone, muscle, and tendons.

      • Unstageable: wound is completely covered by slough or eschar and depth cannot be clearly determined

    • Skin Cancer

      • Risk factors: long-term sun exposure, light skin tone, red or blond hair color, a weakened immune system, routine use of tanning beds, history of severe childhood sunburns that resulted in blisters.

      • Manifestations of concern: rough/scaly areas, reddened patches, weepy wounds that do not seem to heal within an acceptable period, any changes in the skin or a mole; any lesions with an irregular shaped, uneven borders, size larger than ¼ inch, and are tan, brown, gray, black or blue-black should be biopsied.


Health Promotion: avoid long sun exposures; use broad-spectrum sunscreen with SPF 30 or higher; protective lip balm, a hat with a wide brim, sunglasses with 99% or 100% UV absorption, protective clothing should be worn; avoid sun lamps and tanning bed; quitting smoking; get sufficient nutrition and drink enough fluids as dehydration increases the risk of skin damage. If any changes in skin condition, encourage clients to contact provider for a thorough skin exam.


Head, Eyes, Ears, Nose, and Mouth

Head

Inquire about headaches or migraines. Record any medications they take and investigate the severity and longevity of the episodes.

Headaches may indicate tumors, anxiety, depression, or osteoarthritis; previous had injuries may lead to further inquiries about balance, gait, or safety of their environment.

Eyes

Physical changes to the structure of the eye and decreased visual acuity are expected. But some issues may lead to vision loss and blindness. If pt. have sudden blurry visions, floaters, pain in one or both eyes, double visions, or redness or swelling around the eyes should be reported to their provider.

Ears

Gather accurate subjective data on potential hearing loss from older adults who may not be aware that they are having hearing loss. Pain or discharge from the ear should necessitate further examination.

Nose