Vulnerable skin within the skin microclimate is caused by a multitude of factors that are often aggravated by one another. Urine and feces, for example, have a negative impact on the skin as a result of the microorganisms and enzymes they contain. These factors break down the skin barrier and...
by Susan Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary
Part 1 in a two-part series looking at the basics of preventing and managing moisture-associated skin damage in the long-term care setting.
Age-Related Skin Changes
The long-term care setting has changed over the years: it has become an even more concerning issue because our population is no longer just older adults looking for a place to age, but now includes a wave of acutely ill individuals with multiple comorbidities. And yet despite these changes, skin issues continue to be a problem. Moisture from any source increases the skin’s permeability and decreases the barrier function. The outmost layer of the epidermis, the stratum corneum, is normally slightly acidic and protects the body from pathogens when intact. If the skin is compromised by moisture or moisture with friction, a break in the surface can allow pathogens to enter. As we age, normal changes take place that lessen the skin’s ability to bounce back from daily wear and tear:
- Epidermis thins.
- Skin is more easily stretched, causing decreased elasticity.
- Barrier function becomes less effective.
- Thermoregulation is impaired.
- A 20% loss in dermal thickness occurs.
- Sagging of skin occurs.
- Loss of subcutaneous fat occurs, resulting in atrophy.
Skin Care Plan
So, with the added stress of comorbidities and the addition of a source of moisture, a greater toll is taken on the largest organ of the body. A susceptibility to pathogens and the ever-present potential for skin injury are compounded. Prevention, of course, is number one. So, our plan after a thorough assessment is this: MOVE, CLEANSE, MOISTURIZE, and REPEAT.
MOVE the resident around frequently to stimulate air flow and circulation and all other good normal body functions.
CLEANSE with gentle moisturizing soaps for daily hygiene and immediately following any episodes of incontinence.
MOISTURIZE as a matter of routine, and be careful with perfumed lotions. I like adding three drops of baby oil to the bedside bath basin for anyone with dry skin, it’s just enough for daily care. For showering, baby bath is great, and, again, you don’t need a lot, but used on a regular basis with after-bath moisturizer it will help maintain supple skin.
REPEAT: This is a never-ending story.
Cleansing the skin with soap and water decreases the acid mantle, and considering we are dealing with skin that has already had a loss of oil production along with a reduction in dermal thickness, the environment is ripe for damage to occur with very little provocation. Homeostasis within the body relies on the skin maintaining just the right moisture balance, and somewhere after the age of thirty, even under pristine circumstances, we need to help nature out a bit.
What Is Moisture-Associated Skin Damage?
Moisture-associated skin damage (MASD) is inflammation and erosion of the skin caused by prolonged exposure to a source of moisture. MASD is based on the chemical content of moisture, friction, and the presence of pathogenic organisms. This is a top-down injury; meaning the injury starts at the surface and works its way inward to become a partial-thickness wound.
Moisture-Associated Skin Damage Versus Pressure Ulcers
MASD differs from pressure ulcers (injuries) in that pressure injuries they are bottom-up injuries, meaning they work their way from inside out, as a result of mechanical forces. Characteristics differentiating them on assessment are as follows:
- Diffuse different superficial spots
- May be mirrored (copied) lesion on adjacent surface
- Pink or red
- Partial-thickness, blistering
- No slough or eschar
- Painful itching or burning
- Limited to one spot
- Circular or regular in shape
- Red to bluish purple
- Partial- or full-thickness
- With or without slough or eschar
- Pain: yes or no
- Vulnerable to ischemia
Can you have both? Yes, it is very common to see an immobile resident present with continence issues and heavily exuding wounds. The trick here is to be aware of the causes of skin damage, assess all risks to the resident, and manage the moisture and the wound accordingly.
Often people say use common sense. I don’t believe in common sense, I believe in common knowledge, and the only knowledge that will be common about MASD for your staff is what you give them. So, teach them and make a plan and repeat!
About the Author
Susan M. Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary, is Wound Care Certified through National Association of Wound Care since 2004. Currently, she consults in LTC and alternate care settings on wounds, skin care, and various other issues. She has been employed in the long-term care setting since 1969, spending 25 years in a long-term care rehabilitation facility where the focus was wound healing therapies.
NADONA/LTC has been a leading advocate and educational organization for DONs, ADONs, and nurses in long-term care since 1986. With 40 state chapters, it continues to be the largest organization representing nurses working in both post-acute and long-term care settings. NADONA/LTC offers a wide array of services to its members, including educational materials; conferences; executive fellows program, webinars, scholarships; Nurse Leader, Licensed Practical Nurse and Assisted Living certification programs; a mentoring program; and a quarterly journal, The Director. Through its publications and programs, NADONA/LTC reaches approximately 20,000 nurses who are employed in long-term care. For more information regarding NADONA/LTC, please contact their offices at 800-222-0539 or visit their website at www.nadona.org.
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.