Skin Anatomy

The skin is the largest organ of our body, covering 18 square feet and weighing approximately 12 pounds. Despite positive characteristics, the skin is always susceptible to and at risk of injury and breakdown. Maintaining skin integrity equals maintaining skin health, and this includes people of any age. Older adults are at a higher risk because of the skin aging process. As skin ages, the junction between the epidermis and dermis thins and flattens, reducing circulation. Moisturizing factors in older adults also reduce, thus causing dry, flaky skin and increased risk of skin breakdown. Skin that is vulnerable to injury, damaged, or unable to heal is considered to have a skin integrity issue. Intrinsic and extrinsic factors affect skin integrity, but prolonged extrinsic factors make the skin more vulnerable to become injured or impaired. When skin is altered, the chance of infection, limb loss, and even death increases. Intrinsic factors may or may not include diabetes, skin diseases, poor nutrition, or vascular diseases, among others. Extrinsic factors may or may not include pressure, friction, shearing, falls, immobility, and surgical procedures, among others.¹

Skin Layers

The skin is composed of three layers that function to maintain skin integrity consistently. The clinician must have a good understanding of the skin structure layers to determine the patient’s precise, overall skin health.

1. Epidermis – provides a waterproof barrier and creates our skin tone
2. Dermis – contains tough connective tissue, hair follicles, and sweat glands
3. Subcutaneous layer or hypodermis – fat and connective tissue

Skin Functions

To keep the skin in its optimum healthy state, it must perform a list of vital functions. Functions include thermoregulation, vitamin D synthesis, sensation, protection, body image, water retention, and electrolyte balance. Our skin is the protector of regulation, sensation, and protection. If the skin is damaged or impaired, it affects all skin functions, resulting in poor skin integrity.^1,2

Skin Assessment

An accurate and thorough skin assessment is imperative in identifying risk factors and maintaining skin integrity. Skin impairments can range from superficial to tissue level of destruction at bone level. The following are key components to evaluate during skin assessment.³

1. Color – Redness, bruising, or purpura? Skin tone affects the color of damaged skin.
2. Temperature – Warm? Cold? Indicates possible infection
3. Texture – Dry, cracked, excoriated, denuded, fibrotic?
4. Moisture – What is the cause?
5. Integrity – Epidermal stripping, blisters, open areas, skin tears?
6. Location – Can help identify the cause of poor skin integrity

Common Causes and Mechanisms of Skin Breakdown

Compromised skin can have numerous causes. Friction, shear, moisture, pressure, and trauma are all causes of skin breakdown. These factors can work together or alone to damage and injure skin. Immobility, poor nutrition, incontinence, medications, hydration, impaired mental status, and loss of sensation are other culprits in skin breakdown. Mechanical injury develops from friction and shearing forces; this can take place while sitting or lying in bed. You can reduce mechanical injury by using assistive devices, lowering the head off the bed, lifting and not dragging during transfer, and making sure clothing and linens are not bunched or wrinkled.² Friction is a mechanical injury: two forces rubbing together, such as when skin is dragged across bed linen during transfer. After injury, the skin may appear reddened, rough, excoriated, and superficially injured. Avoid dragging patients across the bed, and consider using devices for moving assistance.⁴ Shear is both gravity and friction against the skin surface that is caused by mechanical injury. The layers of skin rub together, or the skin remains stationary, and underlying tissue moves, stretches, angulates, or tears the underlying capillaries and blood vessels, causing tissue damage.⁵ The end result of shearing is a deep, undermining wound.⁴

Skin Integrity Promotion Strategies

The following are strategies to promote and maintain skin integrity:⁶

• Moisturize dry skin to maximize lipid barriers; moisturize at minimum twice daily.
• Avoid hot water during bathing; this will increase dry, cracked skin.
• Protect skin with a moisture lotion or barrier as indicated. Most common skin barriers contain one or more of the following: silicone, petrolatum, dimethicone, or zinc oxide.
• Pad and protect vulnerable areas with transparent, hydrocolloid, composite, and/or foam-type dressings.
• Daily skin inspection: LIGHTING, LOOK, LISTEN, FEEL, REPORT.
• Keep the head of the bed flat or below 30 degrees as tolerated.
• Use a mechanical lift for moving bariatric patients.
• Use draw sheets to pull up, transfer, and position your patients. DO NOT drag.
• Encourage a well-balanced diet.
• Encourage fluids.

Conclusion

Bolstering skin integrity management for your patients requires understanding best practices and a team effort approach; this includes caregivers, family, and clinicians. Identifying poor skin integrity early on, those at risk, and comorbidity issues will foster positive outcomes. Utilize skin and wound care products to prevent and manage skin breakdown in patients with non-intact or intact skin.

References

1. Holloway S, Jones V. The importance of skin care and assessment. Br J Nurs. 2017;14(22):1172–6.

2. WoundSource Practice Accelerator Series. Using the RED SKIN mnemonic for assessment, prevention, and treatment of pressure injuries and ulcers. WoundSource.com. https://pages.woundsource.com/using-the-red-skin-mnemonic-pressure-inju…. Accessed December 30, 2018.

3. Dean J. Skin health: prevention and treatment of skin breakdown. Transverse Myelitis Assoc J. 2011;5.

4. Murphree RW. Impairments in skin integrity. Nurs Clin North Am. 2017;52(3):405–17.

5. Livingston M, Wolvos T. Scottsdale Wound Management Guide: A Comprehensive Guide for the Wound Care Clinician. 2nd ed. Malvern, PA: HMP Communications; 2015.

6. National Pressure Ulcer Advisory Panel (NPUAP). Shear force slide set. http://www.npuap.org/resources/educational-and-clinical-resources/shear…. Accessed December 30, 2018.