By Sue Briggs, Bsc Cert Ed RGN, Dip HSW, MSc student and Matron in South Yorkshire
As the matron of a care home, promoting healthy skin of service users is one of my priorities. I have undertaken research into maintaining healthy skin and found an excellent video that outlines the function of the skin, applying treatments as well as some other useful advice on how to move service users in bed to prevent friction to skin or pressure sores developing. It also outlines how to apply creams or ointments and how to use infection control methods including effective hand hygiene - as contact is the main mode of infection. I give staff copies of Nursing Times practical procedures for handwashing No1 (D Gould) which I have used for a few years as information is still current best practice.
Research shows that handwashing is seen as the most important way of preventing nosocomial infection. It removes transient organisms effectively and when combined with an antiseptic agent or alcohol hand-rub, can reduce the number of resident organisms (Lautenbach 2001, Macdonald 2004). I have been promoting staff awareness and have asked everyone to watch the skin video and put into practice what they have seen and learnt from this.
We are all now more aware of the different types of skin and types of tissue damage; staff observe conditions like acanthosis which is epidermal thickening, as seen on patients with plaques of psoriasis. We can assess the thickness or thinness of skin, report dryness or reddening or erythema, and notice those who have prominent veins, sebaceous cysts, cellulitis, sagging skin or rashes. We are also more aware of the vulnerability of older people?s skin. Erythema infectiosum normally affects children but can occur in adults who may develop a rash and joint pains in the hands, wrists and knees (Clinical, NT 2004 p29).
Service users with venous hypertension are monitored as damage to valves within the veins can result in reflux of venous blood and high pressure in the smaller vessels. This can then result in oedema and leakage of blood cells, which causes discolouration and hardening of the tissues, which are then prone to injury and can be slow to heal.
Changes in skin colour as you age are quite normal and can include brown liver spots; but any other mole or patch of skin that itches, bleeds or feels abnormal, gets bigger or becomes darker or crusty, should be checked by a doctor. Staff and service users are advised to pat dry fragile skin instead of rubbing, and to use emollients 20 to 30 minutes before sparingly applying any prescribed steroid creams to enhance their absorption. They should also wear gloves when applying steroid creams.
I have liaised with the continence service, arranged training and worked with care staff and service users to undertake continence assessments on all the service users. Staff are encouraged to promote continence and avoid using talcum powder, and to wash skin with emollient washes rather than soap, and change incontinent service users regularly.
I have undertaken examinations of all service users? skin health and have involved the tissue viability nurse where service users have been admitted with complex needs, including pressure ulcers. Several of our service users have vulnerable skin and we provide different types of pressure-relieving mattresses and cushions.
Staff are now starting to realise the importance of promoting healthy skin and they assist service users to use emollients such as aqueous cream, and emulsifying ointment for some clients is added to their bath. Polytar plus or ceanol shampoo is used for itchy scalps and dandruff. Some clients suffer with eczema and psoriasis and staff assist service users to apply the prescribed topical treatment. Our activity organiser is also involved in maintaining skin integrity and she provides hand and nail care and can arrange aromatherapy, if this is the service user?s wish.
My role is to ensure that service users have full care and staff have been given various training, including how to care for clients with stroke or other disabling illnesses where service users? hands and fingers become contracted. It is important that the affected hand and fingers are washed and that nails are kept clean and short to prevent them digging into the palm of their hand or further injury to skin.
I try to inform people of the dangers of sunbathing but many think it only happens to other people and they continue to go on using the sunbed. Some older people do not believe in using sun creams and this is another health promotion issue. Whilst we have to respect individuals? views, we also have a duty of care to ensure that service users do not come to harm. Staff are also shown how to care for the surrounding skin of people who have colostomies or ileostomies.
Continuing education and learning is ongoing as we strive to maintain service users? wellbeing. Undertaking a full assessment helps to identify if they have any allergies which can affect the skin in the form of eczema, urticaria and angioedema. Service users may be exposed to allergens, which then release the chemical called histamine from the mast cells of sensitised individuals and this causes redness(vasodilatation), itching (irritation of nerve endings) and swelling (increased vascular permeability which can be manifested and red, itchy, swollen rash (urticaria).
This has been an enjoyable reflection of what I do to promote skin health for staff and service users. I am also going to follow on from this by developing some staff training and an information booklet and I may undertake a survey in the home to decide if information leaflets on maintaining healthy skin for service users would be helpful.
Clinical, Nursing Times(2004), 100, 2, 29
Lautenbach E (2001) Practices to improve handwashing compliance. In Markowitz A (Ed) Making Health Care Safer. A Critical Analysis of Patient Safety Practices.Rockville MD Agency for healthcare Research and Quality publications.
Macdonald A et al (2004) Performance feedback of hand hygiene, using alcohol hand gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs. Journal of Hospital Infection. 56, 1, 56-63
Nursing Times practical procedures for nurses handwashingNo1 (D Gould) Seaton Health Care Group.