Perspective of Nursing Care from Past to Future by Matron Marley

By Margaret Heale, RN, MSc, CWOCN

I have been living with my daughter for almost a year and helping out at a nursing home where my granddaughter works. I don't remember having this problem last year but my skin is just on fire at times, itchy, itchy, itchy! I found a cream but ran out and couldn't remember what it was called. When I got to the pharmacy and told the lady there that I was in search of a product whose name I thought sounded like 'Narnia' she pointed me in the right direction. Then, to my surprise, she added, "but remember not to go through the wardrobe door or you might get more than you bargained for." We laughed so much I remembered I best go to the feminine hygiene section. I just wanted a slim little pad, you know for the odd cough or sneeze, but—ohhh—what a choice!

As I went home I started to ponder the differences old age seems to bring. In our youth we give our skin so little thought but really quite suddenly mine changed, though I remember waking up to the beginning of that change rather abruptly years before. I leaned out of my bed to pick up a mirror from the floor, so gravity hung my skin differently, the light reflecting from behind illuminated a different face, saggy, baggy. There I was staring at my fate. Then I burst out laughing and was transformed into a beauty. I decided no face lifts for me, just a wide smile (though I do agree with Mrs. Obama – never say never).

Finding the Right Skin Care Products for Your Skin

The sudden change I speak of happened when I was 56-years-old. The area under my chin had gotten baggy a while before but now I noticed the shading beneath my eyes was a more complete semicircle and my jowls began to become defined. That is when I decided to use a daily moisturizer. Up until that point the only thing to go on my face was water. It took me ages to find a skin care product that would not set my face on fire. There was an apricot scrub that almost sent me to the emergency room, my face and lips became swollen and I was as red as a beet for a day; if it had been Christmas time I could have lead the sleigh.

I became sensitive to my regular moisturizing cream about 10 years later and searched for hypoallergenic ones thereafter. I steer clear of lanolin which I hear is a common component of moisturizers that people can react badly too. It is such a shame that this beautifully natural moisturizer causes problems in some people. (Voegell 2010). Other common sensitizers in creams are fragrances, alcohols, parabens, beeswax, propylene glycol and there are many, many more. If you look at the contents, it is possible to be sensitive to any ingredients. Trial and error works for most people, and keeping to the simplest is a good strategy particularly, in the caregiving setting.

The Importance of Moisture Balance for Skin Function

Keeping the skin clean and moisturized is key to ensuring it is able to perform as designed. The skin is a multifunctional organ. It stops us from falling apart and dehydrating. It protects us from our environment (heat, cold, chemicals, sunlight, mechanical trauma). Other essential functions are vitamin D production, and communication through movement, smell, touch and expression. It allows us not just to feel in order to protect ourselves, but is fundamental to our perception of where we are in space, known as "proprioception." This highly underrated sensation is interfered with when people suffer with neuropathy. If someone is unable to sense their feet, a curb can be misjudged and when the foot is not quite angled correctly, down they go.

Once dry, the function of the skin is compromised and tiny cracks allow debris and bacteria to enter. Irritants that normally would not breach the tough surface layer find entry to the more vulnerable base layers. The skin reacts by becoming inflamed – we itch, we scratch. There are many conditions that cause dry skin, including peripheral vascular disease, diabetes, hypothyroidism, eczema, psoriasis, liver and kidney disease.

Here at Rose Cottage where I volunteer, they don't just have a cream to protect from incontinence, they have a couple of different moisturizers too. How different from when I was matron and could hardly get a nappy (sorry, diaper) rash ointment let alone a moisturizer for the face of a patient.

Identifying Age-Appropriate Skin Care Solutions

So what are the changes in the skin over time that as nurses we should be aware of? The skin of the neonate is immature and lacks some of the components that allow strong cohesion between the epidermis and the dermis. This makes them much more prone to tape stripping and sensitivity to pH changes either from urine and stool or soap and skin products. Children generally have highly resilient skin but they do develop problems with eczema and sensitivity to skin products, soaps, and creams.

Teens struggle with acne and young adults with pilonidal cysts and continuing acne. As the saggy, baggy approaches, the changes in the skin relate to changes in collagen synthesis (I think of collagen like different grades of scaffolding). The moisture held within the skin can be increased by providing a barrier to slow transepidermal water loss (TEWL). Beeswax, petrolatum and lanolin will do this but feel greasy. Greasiness is reduced by emulsifying the lipids/oils with water which can increase the moisture held within the scaffolding.

Emulsification is more successful if sterols, surfactants and alcohols are used since the oil and water are better mixed and separate out less readily. Humectants like sorbitol, glycerin and urea absorb moisture and help to maintain hydration. Oils and fats harbor less bacteria than when emulsified and so preservatives and antiseptics are utilized.

As anyone who has read the ingredients on tub of moisturizer knows, the contents list can seem endless. As a nurse though, we mustn’t lose sight of what we are trying to achieve with the lotions and potions we apply (and how we apply them). I was reminded of this just yesterday. I was helping a young nursing assistant and she slathered on a ton of moisturizer to this poor lady's backside. I just mentioned to her that I would make sure she had a barrier cream for next time.

I dutifully did so and next day, would you believe it, the same assistant used the barrier cream on the poor ladies legs! As it was thicker than a moisturizer her skin tugged and pulled this way and that as it was quickly applied. The young girl complained it felt gritty and I tried to explain the grittiness is the silicone and that it melts with the warmth of the body. I was pleased when I gave her the moisturizer that she opted to use on the other leg. We had to leave the residents support stockings off though as her leg was so sticky. Interestingly, we also have sunscreen for some of our clients. I wonder if the staff would put this on to protect the buttocks from moisture and incontinence if it happened to be closer to hand!

The winter in cold climates is a dry season for skin. Humidity is mostly low and so transepidermal water loss is higher. Add to this heating systems that keep the air dry and frequent washing with soap and water and it is easy to see why the elderly particularly suffer with dry skin. Using moisturizers on a regular basis not only prevents obvious drying, itching, scratching and cracking but also has been demonstrated to decrease skin tears from minor shearing (Roberts 2007).

Examples of Exemplary Skin Care

Shortly after deciding to write this I saw two staff members put moisturizer on residents when helping with their morning hygiene (we use soap and water still). The first completed the residents wash and then started by moisturizing the lady's face and asked her to apply it and then do her arms. She then massaged the resident's back and did her feet and legs. Taking a wash cloth, the excess moisturizer was wiped away and skipped over the lady's front. Her legs were then dried off.

The second staff member had a different approach for another resident. She was giving a bed bath and after each section (we should discuss how this is done nowadays sometime) she moisturized and covered each section as she went. When she did the man's feet she spent much more time than I would have expected so I asked if she would do mine later. "Yes," she said. "I am a massage therapist. I'll give you a card." What a bonus! Before starting to dress him she dried between each toe and examined them, saying "he's diabetic you know, so we need to be extra sure that cream doesn't accumulate and the toes are well dried."

She impressed me. There is no way this would have occurred back in my nursing days. A back rub, yes. The use of a moisturizer, only if someone provided their own and there was extra time (a very rare event). Even dressing patients in our long-term care (gerry wards) did not happen till I was a matron. We have come a long way, but remember: the journey continues. What lays ahead will be even better. Care needs to be more family-focused and less driven by routine and convenience.

Sources
Roberts, MJ. Preventing and managing skin tears: A review. Journal of Wound, Ostomy and Continence Nursing. 2007 ;34(3):256-259.
Gray, M et al. Incontinence associated dermatitis: A Comprehensive review and update. Journal of Wound, Ostomy and Continence Nursing. 2012;39(1):61-75.
Voegell, D. Care or harm: exploring essential components in skin care regimens. British Journal of Nursing. 2010;19(13): 810-819

About The Author
Based on her extensive nursing experience Margaret Heale, Wound, Ostomy and Continence Nurse, takes us into the blog journal of a fictitious matron, "Perspective of Nursing Care from Past to Future by Matron Marley."

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.