Alterations in the integument are a common occurrence in the elderly, especially for those living with chronic health problems. While disruptions in the integument may take many forms, some of the more common forms include pressure ulcers, dry skin and maceration secondary to moisture. The incidence of these conditions among the aged is staggering. In skilled and long-term care facilities prevalence of pressure ulcers range from 2.4 percent to 23 percent (NPUAP, 1989). Alteration in the integument from skin dryness was found to afflict 59% of elderly individuals living in retirement centers (Frantz & Kinney, 1986). Forty to sixty percent of elderly persons in long-term care settings experience urinary incontinence, representing a significant population of patients who are at risk for skin maceration and breakdown from excessive exposure to moisture (Yarnell & St. Leger, 1979).
The magnitude of the problem in terms of human suffering and economic burden on the health care system has begun to capture national attention. The Agency for Health Care Policy and Research (AHCPR) identified the prevention and treatment of pressure ulcers as one of the first of seven clinical conditions for clinical practice guidelines development. Considerations in the selection were the large numbers of individuals affected, the variability in practice and the uncertainty of treatment outcomes. The first of two clinical practice guidelines on pressure ulcers, Pressure Ulcers in Adults: Prediction and Prevention (AHCPR,1992), is described in the initial paper in this symposium. Its content, which focuses on risk factors for pressure ulcer development and early treatment to maintain the integument, forms the framework for the remainder of the symposium.
Maintenance of the integument has been traditionally a primary responsibility of nursing. This is especially crucial in the elderly population. Norton et al (1962) report clinical evidence indicating that if the continuity of nursing care lapses for only a brief period, it is sufficient for the immobilized patient to experience tissue damage. Unquestionably, the diagnosis and treatment of impaired skin integrity is an essential component of nursing practice. Unfortunately, the management of skin problems has been plagued by practices grounded in tradition that lack scientific evidence of efficacy and in some cases may be potentially harmful. Consideration of normal physiological changes associated with aging and their impact on skin impairments is often lacking in planning interventions for individuals with skin impairments.
It is the aim of this skin care symposium to review the common issues related to impaired skin integrity seen in the elderly population. These include dry skin, excessive exposure to moisture, and external pressure. The presence of these factors alter the integument in ways that predispose individuals to pressure ulcers. The papers provide a synthesis of the research findings related to these topics and propose interventions for controlling their untoward effects on the integument. Additionally, the symposium includes a comprehensive review of interventions for the treatment of chronic wounds, including pressure ulcers. Contained in this paper are research-based interventions for wound management that dispel many long-standing myths in nursing practice that have no scientific foundation.
Gerontological nurses play a pivotal role in managing problems associated with skin impairment in the elderly. It is essential that their practice be grounded in the latest knowledge related to prevention and treatment of alterations in the integument. Only through ongoing research and education can we insure that those entrusted to our care are receiving the high quality treatment they deserve.
- Frantz, R.A., Kinney, CN. Varíables associated with skin dryness in the elderly. Nurs Res 1986; 35(2):98-100.
- National Pressure Ulcer Advisory Panel. Pressure ulcers: incidence, economics, risk assessment. Consensus development conference statement. Decubitus 1989; 2<2):24~28.
- Norton, D., McLaren, R., ExtonSmith, A.N. An investigation of geriatric nursing problems in hospital London: Churchill Livingstone; 1975.
- Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults: Prediction and Prevention. Clin Pract Guide!, Number 3. AHCPR Publication No. 92-0047. Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, 1992.
- Yarnell, }., St. Leger, A. The prevalence, severity and factors associated with urinary incontinence in a random sample of the elderly. Age Ageing 1979; 8(2):81-85.