Aging and Skin Changes: Pressure Ulcers PDF

Changes in the Body Physical Appearance Begins 4 decade of life Hair loss, gray hair, & wrinkles Reduced tissue elasticity Decrease in stature Physiological Changes of Aging -Rate of skin regeneration decreases -Number of melanocytes decreases -Amounts of collagen and elastin decrease -Den...

Changes in the Body Physical Appearance Begins 4 decade of life Hair loss, gray hair, & wrinkles Reduced tissue elasticity Decrease in stature Physiological Changes of Aging -Rate of skin regeneration decreases -Number of melanocytes decreases -Amounts of collagen and elastin decrease -Density of the dermal blood supply decreases -Sweat gland function decreases -Gradual loss of sensory receptors -Thinning of the subcutaneous layer -less insulation of body to cold & heat (also affected by diminished blood flow to skin & extremities) -increase vulnerability to infections/disorders -Aging is associated with graying, thinning, and loss of hair - Number of hair follicles decreases with age - Remaining follicles grow at slower rates and contain lower concentrations of melanin - Reduces hair's protective ability to screen the scalp from sunlight Observed Hair Changes Men hairline recedes or male pattern baldness may occur increased hair growth in ears, nostrils, & on eyebrows loss of body hair Women Usually do not bald, but may experience a receding hairline hair becomes thinner Increased hair growth about chin & around lips loss of body hair, Generalized loss of body hair and head hair Decrease in functioning pigment-(producing cells-graying) Observed Toenail Changes Become thicker & more difficult to cut Grow more slowly May have a yellowish color Thickened fingernails & toenails Integumentary system - Consists of the skin and its accessory structures - Changes are visibly noticeable Layers of the skin: -Epidermis -Dermis -Subcutaneous Observed Skin Changes - Epidermis The number of epidermal cells decreases by 10% per decade and they divide more slowly making the skin less able to repair itself quickly. Epidermal cells become thinner making the skin look noticeably thinner. Changes in the epidermis allows more fluid to escape the skin. Observed Skin Changes - Dermis The dermal layer thins Less collagen is produced The elastin fibers that provide elasticity wear out. ↓function of sebaceous & sweat glands contribute to dry skin These changes cause the skin to wrinkle and sag. Observed Skin Changes - SubQ The fat cells get smaller This leads to more noticeable wrinkles and sagging, vulnerability to pressure sores Some sun exposure necessary for vitamin D production but Chronic overexposure is associated with: üWrinkling üIrregular pigmentation üDevelopment of lesions üSkin cancer Healthy Skin Is Very Important Skin is the largest organ in the body Skin prevents infection from outside sources entering in to the body. The skin protects us from heat, cold and the elements. The skin helps regulate body temperature The skin permits the sensations of touch, heat, and cold. The skin stores fat and water to help with shock absorption and to prevent dehydration. What is a Pressure Sore? Also known as “pressure ulcers” , “decubitus ulcers” and “bed sores”. It is an injury to the skin and underlying tissue resulting from prolonged pressure and/or friction on the skin. Pressure against the skin reduces the blood flow to the skin and nearby tissue , stopping the flow of oxygen. What Causes Pressure Sores? Prolonged Pressure: An individual is lying or sitting in a position for a prolonged period of time. The flow of blood is decreased and/ or stops flowing to the area. The skin and tissue becomes damaged and reddens then opens. Friction: This is the resistance to motion. This may occur when the skin is dragged across a surface, such as when you change position or moved or repositioned by a care giver. If the skin is moist, (wet brief) the friction is worse and can cause significant skin and tissue damage. Who is at Risk for Pressure Sores? Individuals with: Poor health including those with chronic health conditions. Paralysis, heavy sedation or who are in a coma. Individuals who are post surgery/or have recently had a medical procedure where they are now less mobile and aware. People with fragile skin, skin tears and chronic skin problems such as rashes. Older adults – the skin of older adults is generally more fragile. Lack of sensory perception - spinal cord injuries, neurological disorders that result in loss or decreased sensation. Weight loss- this is more common during prolonged illness. The loss of fat and muscle result in less cushioning between bones and a hard surface.  Immobility- the individual is not able to move themselves resulting in long periods of time with Poor nutrition and hydration Excess moisture and/ or dryness - skin that is overly moist is more likely to be injured and tears easily. Very dry skin increases the risk of friction. Bowel and urinary incontinence- bacteria from urine and fecal matter (stool) can cause serious local infections and can lead to life threatening infections. Medical conditions- ex. Diabetes, vascular diseases. Smoking- Smoking reduces the amount of blood flow and limits the oxygen in the blood. Smokers wounds tend to heal more slowly.  Signs & Symptoms Warning signs of pressure ulcers are:  Unusual changes in skin color or texture  Swelling  An area of skin that feels cooler or warmer to the touch than other areas  Tender areas A.Early Signs:  Discoloration of parts of the skin- those with pale skin tend to develop red patches, while people with darker skin tend to get purple or blue patches (Discolored patches not turning white when pressure is applied)  A patch of skin that is spongy or hard  Pain, tenderness or itchiness in the affected area. B. Later Signs: The skin may not be broken at first, but if the pressure ulcer gets worse it may form:  An open wound or blister.  A deep wound which reaches the deeper layers of the skin.  A very deep wound that may reach the muscle and bone. Figure 1: early and late signs. Stages of pressure ulcers There are different stages of pressure ulcers, Stage 1 being the least serious and Stage 4 being the most serious condition. STAGE I: A persistent area of skin redness that does not disappear when pressure is removed. The skin is not broken. The site may be tender, painful, firm, soft and warm or cool compared to the surrounding skin. Stage I: (the difference between blanchable and non-blanchable erythmas). STAGE II: The outer layer of skin (epidermis) and the inner layer (dermis) is damaged or lost. The wound bed (open area) may be shallow and pinkish or red. The wound may look like an abrasion, fluid-filled blister or shallow crater. STAGE III: A full thickness of skin is lost. The loss of skin usually exposes the fat layer. The ulcer/sore looks like a “crater.” The bottom of the wound bed may have yellowish tissue. The damage may extend beyond what you see to below layers of healthy skin. STAGE IV: The pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur. Stage III: (full-thickness loss of skin) Common sites of pressure ulcers For people who use a wheelchair, pressure sores often occur on skin over the following sites:  Tailbone or buttocks  Shoulder blades and spine Back of arms and legs where they rest against the chair For people who are confined to a bed, common sites include the following:  Back or sides of the head and ears  Shoulder blades and elbows  Hip, lower back or tailbone (buttocks)  Heels, ankles and skin behind the knees and inner aspect of the knees  common sites of pressure ulcers (on wheelchair and semi-sitting). common sites of pressure ulcers for bedridden patients from supine lying {on the left} and from side lying {on the right} Complications from Pressure Sores ⚫ Cellulitis: cellulitis is an infection of the skin and connected tissues. It can cause severe pain, redness, and swelling. People with nerve damage can often not feel this pain. Cellulitis can lead to life threatening complications. ⚫ Bone and joint infections: the infection from the pressure sore can travel into the joints and bones. This can damage cartilage and may reduce the function of the joints and limbs. ⚫ Cancer: This is possible with chronic non-healing wounds. This can be aggressive and requires surgery. ⚫ Sepsis is a complication caused by the body’s overwhelming and life-threatening response to an infection, which can lead to tissue damage, organ failure, and death. ⚫ Sepsis is often associated with infections of the lungs (e.g., pneumonia), urinary tract (e.g., kidney), skin, and gut. Signs of Sepsis There is no single sign or symptom of sepsis. It is, rather, a combination of symptoms. Since sepsis is the result of an infection, symptoms can include infection signs (diarrhea, vomiting, sore throat, etc.), as well as ANY of the symptoms below: ⚫ Shivering, fever, or very cold- Extreme pain or discomfort - sweaty skin ⚫ Confusion or disorientation ⚫ Short of breath - High heart rate Diagnosis 1.History If an individual has a history of a period of immobility followed by the discovery of a warm, red, spot over a bony prominence, a pressure ulcer can usually be confirmed. 2.Tests  Blood tests  Tissue cultures to diagnose a bacterial or fungal infection in a wound that doesn't heal with treatment Treatment of Decubitus Ulcers by Health Professionals Repositioning: If in bed, reposition at least every two hours. Side to side, using pillows under one side of the back and then reposition again and place a pillow on opposite side of underside of back. Use pillows and cushions/wedges between and under knees. Place cushion support under feet and ankles. Follow all health practitioners, physical, and occupational therapist and nursing orders as prescribed. If in wheel chair, encourage individual to reposition every 15 minutes, use tilt feature on chair to reposition every hour. Support: Special ordered air mattresses if medically necessary Wedges, cushions, and pillows. These are recommended and ordered by Physical and Occupational Therapists and Physicians. KEEP THE SKIN CLEAN AND DRY: Clean the skin with a mild soap and warm water and rinse thoroughly. Gently pat dry. Apply Lotions and ointments as prescribed- to prevent skin breakdown. This promotes skin integrity. It can be therapeutic to lightly massage the skin with prescribed lotions to prevent skin breakdown. This will also promote blood flow and circulation. Lightly massage the area with a “circle 8” motion with the fingertips. Never massage over an area of skin that is reddened or there is skin breakdown. ⚫ Inspect skin daily- Daily Health Checks. Watch for any changes in the skin and report this immediately! ⚫ Inspect for wrinkles and folds in the bedding and clothing that can irritate the skin and fix them. ⚫ Manage incontinence-This will help keep the affected area clean especially if the sore is on the sacral, buttocks or groin area. Checking the individual at a minimum every two hours for incontinence and changing them immediately when wet or soiled will help prevent breakdown. ⚫ Never double diaper ⚫ Nutrition and Healthy diet: this will promote wound healing. Physician may order an increase in calories and fluids, a high protein diet and vitamins and minerals to promote wound healing. ⚫ Wheel Chair Care and Assessment ⚫ Wheel chair should be inspected daily and cleaned. ⚫ Inspect cushion for signs of wear, for proper inflation, and for proper placement (facing correct direction). ⚫ Yearly PT wheel chair evaluation or as needed. ⚫ Inspect brakes, arm rests, foot rests, head rests, wheels and belts and contact wheel chair vendor as needed for repairs. ⚫ Make sure that all attachments, such as trays and tie downs are in good working order and are clean. Prevention 1.Repositioning and Mobility  When taking care of a bedridden individual, make sure to move the body every two hours. Also use a pillow to prop him up. If the patient has certain kinds of injuries, such as those to the spinal cord, make sure that he is moved in a way that is not cause more injury.  Ensure that the heels are free from the bed.  Place thin foam dressings under medical devices.  Reposition weak or immobile individuals in chairs hourly.  If the individual cannot be moved or is positioned with the head of the bed elevated over 30°, place a foam dressing on the sacrum.  Use heel offloading devices or foam dressings on individuals at high-risk for heel ulcers.  Heel offloading device. 2-Education  Teach the individual and family about risk for pressure injury.  Engage individual and family in risk reduction interventions. 3-Cut down on shear When lying down, make sure the bed is not elevated more than 30 degrees as to avoid sliding and friction. 4-Buy a special mattress There are special mattresses that can reduce the amount of pressure on the body.  Air-filled mattress (on the left),water filled mattress (on the right). 5-Provide proper nutrition and stay hydrated  Assess weight changes over time.  Provide nutritional supplements through meals and with oral medications, unless contraindicated.  To keep the skin of the patient healthy, make sure that the patient stays hydrated.  6-Skin Care  Inspect the skin at least daily for signs of pressure injury, especially non- blanchable erythema.  Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices. Avoid positioning an individual on an area of erythema or pressure signs.  When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent skin.  Clean the skin promptly after episodes of incontinence.  Use skin cleaners that are pH balanced for the skin.  Use skin moisturizers daily on dry skin. List of References American Diabetes Association ( 2012 ) : Standards of Medical Care in Diabetes - 2012. Diabetes Care ; 35 ( Supplement 1 ) : S11-50. American Diabetes Association ( 2012 ) : Diagnosis and Classification of Diabetes. Diabetes Care ; 35 ( Supplement 1 ) : S64-71. Chiarioni G , Whitehead WE , Pezza V , et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterol 2006/3 ; 130 : 657 664. Forsch Komplementarmed : Abdominal Massage Therapy for Chronic Constipation : A systematic Review of Controlled Clinical Trials , 1999 Jun ; 6 ( 3 ) : pages 149-51. Essential Books (Textbooks) Reference 1: Physical therapy for internal medicine, faculty of physical therapy, Cairo University. Reference 2: Geriatric care management 4th edition Recommended Books Physical therapy for internal medicine, faculty of physical therapy, Cairo University. Periodicals, Web Sites, etc.(www.aginglifecare.org)