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Skin is in

November 20, 2014
by Pamela Tabar, Editor-in-Chief
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Taking proactive care of the body’s largest organ is an extra challenge for older adults, whether it be on Worldwide Pressure Ulcer Prevention Day (Nov. 20) or any other day of the year. Everything from chair padding to eating habits, and cleansing products to bedding fabrics can play a role in skin breakdown.

Skilled nursing facilities need to take a holistic and multidisciplinary approach to residents’ skin health, coordinating the efforts of shift nurses, nutrition teams, direct-care workers and primary care clinicians, says Martie Moore, RN, chief nursing officer at Medline, Mundelein, Ill., and a member of the National Pressure Ulcer Advisory Panel (NPUAP).

“It needs to be many hands, one team,” Moore tells Long-Term Living. “The skin is the first line of protection from infection and injury, but it’s also an organ you want to preserve and love, instead of viewing it as utilitarian. You want to exercise it like you exercise your heart or your brain.”


Extra obstacles

Aging skin is thinner and more fragile than younger skin, but older adults have some extra challenges, too. Any of these can affect skin health:

  • Chronic diseases like diabetes and circulatory illnesses
  • Medication interactions
  • Poor diet and inadequate liquid intake
  • Over-exposure or under-exposure to sunlight

Moisturizing is important, but nourishing healthy skin also is about a diet, fluid intake, proper vitamin balance, sunlight and activity. “Proteins are the building blocks of the skin, yet the majority of the elderly population is malnourished,” Moore says.

External hydration is key, too, she adds. “Moisturizing is critical. You have to care for the skin from the inside and from the outside.”

Don’t forget the extremities, especially the feet, Moore adds, noting that special attention should be given to properly fitting footwear, good moisturization regimens and keeping a close eye on pressure points. “People forget about their feet. Some of the saddest ulcerations I’ve seen have been on the feet.”


Pressure ulcers are ugly on both a visual and an emotional level. Residents experience agonizing pain, caregivers chastize themselves and families express outrage. But Moore says it’s misleading to believe that pressure ulcers are an unfortunate fact of life in a nursing home. 

Color is skin deep

The prevalence of pressure ulcers can vary based on race and ethnicity, notes a 2014 article in the Journal of Gerontological Nursing. In a study of pressure ulcers at Stages 2 to 4 among older nursing home residents, black residents experienced pressure ulcer rates 1.7 times higher than white residents. Rates for Hispanic residents fell in between. The research upheld findings from a 2004 cohort study, which also noted higher rates for black residents versus white residents.

“To some extent, I think there’s still a bias that pressure ulcers occur with the elderly and that’s just what happens. We still have a kind of acceptance that skin just breaks down,” she says. “But when I work with families to educate them, they realize that we can work to prevent skin issues, just like we’d work to prevent heart issues.”

Skilled nursing caregivers know that immobile residents must be turned on a regular basis to prevent their resting on the same pressure points for too long. But even ambulatory residents need to be reminded to “shift those cheeks” and change positions more often, Moore says.

“The body is programmed to move around and off-lift its pressure points,” she says. “When people can’t move around well anymore, you have to become that role.”

For the first time, the NPUAP has joined forces with the European Pressure Ulcer Advisory Panel and the Pan Pacific Pressure Injury to develop new guidelines for pressure ulcer care and prevention. The new guidelines, which contain 575 evidence-based recommendations, are available via NPUAP’s website. A 72-page quick reference guide also is available as a free download.