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Guidelines for Ensuring Skin Integrity Learning Guide

The Structure of Skin

Epidermis: The thin, top layer of skin surface

Dermis: The thicker layer underneath the surface

The dermis contains:


     Blood vessels: Tubes that carry blood through the body, with oxygen and food.


     Nerves: Fibers that carry sensations to and from the brain.


     Oil glands: Organs that secrete an oily lubricating fluid.


     Sweat glands: Organs that separate waste products from the blood and secrete them as sweat.


     Hair follicles: Organs that create hair.


     Fatty tissue: Layer of fat under the skin.


     Although it's not part of the skin, the fatty tissue provides a protective layer of padding (to prevent injury to underlying bones and muscles) and insulation (to keep heat in).

Functions of the Skin: What Skin Does

1. Controls body temperature

           a. Releases heat through sweat

           b. Constricts and expands surface blood vessels to insulate or cool the body.


    2. Protects against injury and disease

           a. Covers and pads muscles and bones, preventing damage.

           b. Forms a barrier against harmful organisms and infection.


    3. Provides sensations

           a. Nerve endings sense danger

           b. Sensitive to pressure, pleasure, pain, and temperature.


    4. Creates Vitamin D

           a. Produced by sunlight on the skin.


    5. Cares for itself.

           a. Self-lubricates with oil glands


    6. Warns of disease

           a. Changes in color, temperature, or moistness may signal illness.

The Aging of Skin: What happens


The skin and fatty tissue layer get thinner. The skin becomes less elastic.  Oil glands produce less oil, so skin is dry.  Blood vessel walls get thinner and more delicate, so they break easily.  Circulation of the blood slows down, so the skin is not getting as much oxygen and nutrition from the blood, causing the skin to become poorly nourished and fragile.


Because of these changes in the skin, older people:


    • Tend to feel cold


    • Suffer from skin tears


    • Heal slowly


    • Become wrinkled


    • Develop pressure sores


Caring for older skin: What to do


    ► Keep skin clean.

            •  Pat skin, don't rub, when washing or drying.

            •  Use powder sparingly—excess powder can cause irritation.


    ► Keep skin lubricated.

            • Use lotions liberally.

            • Frequent bathing with soap will dry the skin—use lotion cleansers.


    ► Keep skin creases and folds dry.


    ► Keep clothes and bedding dry.


    ► Eat nutritious food and drink lots of water.


    ► Change position often to improve circulation and prevent pressure sores.


    ► Don't disturb moles.


    ► Massage the skin, but avoid bony projections and irritated areas: Massage around but not directly on them.


    ► Use chair cushions and good beds.


    ► Inspect skin daily for redness, tears, blisters, scrapes, or irritated areas.


    ► Report problems to a nurse or doctor.


Skin problems

Decubitus ulcers (Bed sores or pressure sores)




    • Sustained pressure on the skin compresses the blood vessels and prevents nutrition and oxygen from getting to the skin cells. Over time, the skin tissue dies and decubitus                     ulcers develop.


    • The skin is under pressure where the bones press against the skin tissue, especially when the weight of the body or a body part is pushing down on a pressure point.


    • Body fluids such as urine and feces contain damaging chemicals. When they remain on the skin, they cause moist areas that become irritated and develop sores.


    • Friction from clothing or bedding can injure the skin and lead to skin ulcers.


What to report to the nurse, doctor, or supervisor:


    • A red pressure area that does not become normal after 20 minutes without pressure.


    • A reddened area of the skin that does not turn white when you push on it.


    • A skin area that is warm or hot to the touch


    • Any swelling


    • Any opening in the skin


    • Blisters, tears, craters, rashes, or holes


    • Scrapes or abrasions


    • Drainage or weeping from the skin


Be especially alert when you are caring for residents that are frail, don't move around much, or have poor nutrition. 

Patients with little or no feeling in  parts of the body, such as stroke victims, must be watched because they don't feel pressure spots and  change position when they should.


Preventing skin problems


    ► Encourage or help patients to walk or exercise several times a day.


    ► Encourage or help patients to keep their skin clean, dry, and lubricated.


    ► Encourage or help patients to keep their bedding free of wrinkles.


    ► Encourage or help patients to eat well and drink plenty of liquid.


   For patients who are in chairs most of the time:


    ► Encourage or help them to stand, walk, or shift their weight every 15 minutes.


    ► Teach them how to do chair push-ups with their arms.


    ► Teach them to sit with their knees at the same level as their hips, with their thighs horizontal to the chair. This will distribute their weight along their thighs and away from pressure points.


    ► If a patient cannot do these things, he or she should return to bed after an hour in a chair.


   For patients who are in bed most of the time:


    ► Teach them how to use side rails and the trapeze to change position frequently, at least every two hours. Be available to assist them if necessary. Even small shifts in body weight are helpful.


    ► When you are helping a patient to change position, move him or her carefully so you do not create friction and shearing between the skin and the bedding or clothes.


    ► The head of the bed should be raised as little as possible, no more than 30 degrees, to prevent sliding and pressure on the bony areas. If it must be raised higher for eating, it should be lowered an hour later.


    ► Massage the skin when possible, but avoid massaging pressure points or irritated areas.


   For patients who use special chair cushions or mattress overlay pads:


    ► Check to be sure that the pads are thick enough to do the job. Place your hand under the pad while the resident is on top of it—if you can feel the patient's body through the cushion, the pad is too thin.


   For patients with pressure sores:


    ► Keep weight and pressure off any reddened areas and wounds.


    ► Use pillows to elevate or separate body parts and keep pressure off an area, such as a pillow under the calf to raise the heel off the bed, or a pillow between the legs to keep the knees from touching each other.

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