By Dale Mayerson and Karen Thompson
Skin breakdown can be a serious issue for residents living in Long Term Care and sound nutrition is an important tool for prevention and management
Skin can become more dry and fragile as we age due to loss of natural oils and other factors. The connective tissue in the skin can lose its elasticity and strength, and age spots may begin to develop. By the time elderly residents move into long term care, their skin is showing definite signs of aging. Poor diet and lack of exercise, as well as chronic health conditions, can also take a toll on the skin. With less mobility and increased weight loss, frail and elderly seniors can be at risk for skin breakdown.
Our skin is considered the largest organ of the body. Our skin helps to regulate body temperature, protects us from outside hazards, acts as a barrier that protects our internal systems, and excretes waste materials through sweat glands.
Types of skin breakdown
There are many types of skin conditions that can lead to skin breakdown and open wounds. These include wounds of the legs caused by poor blood circulation that can lead to leg ulcers, as well as skin tears from injuries and falls from chairs and wheelchairs, and incontinence related dermatitis that could lead to open sores.
Decubitus ulcers, also called pressure sores or bed sores, are the most common type of skin breakdown These can be the result of pressure, shear or friction, and are seen more in people with poor mobility, incontinence and with malnutrition and dehydration. Poor health and frailty play roles, as do acute and chronic illness. A pressure ulcer is “staged” to determine the level of severity and how open and deep the wound is. A wound can be a shallow area or an open sore through skin and muscle, down to bone.
Diabetic foot ulcers are a separate concern caused by worsening circulation in the feet due to nerve damage, as a complication of diabetes. In the worst cases, where healing is limited due to the effects of diabetes, this can lead to lower limb amputation.
Skin care in LTC
When a resident moves into long term care, an individualized care plan is created and followed, and all care plans are assessed on at least a quarterly basis. According to the Ontario Long Term Care Home Act and regulations, skin condition and altered skin integrity will be included in every resident’s care plan. Treatments and interventions include nursing care, nutrition, physiotherapy and activation.
As well, regulations require that every home in Ontario has a formal interdisciplinary skin and wound care program to promote skin integrity, prevent the development of wounds and pressure ulcers, and provide effective skin and wound care interventions. The regulations also specify that skin and wound care is included as a topic of training to direct care staff.
According to Best Practice Guidelines developed by the Registered Nursing Association of Ontario, a head-to-toe skin assessment should be carried out with all residents at admission, and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences.
In many homes, a specialized tool is used to determine skin health. One example is the Braden Scale, which is a point-based system for measuring pressure sore risk. This is completed upon admission and kept as part of the resident’s chart.
It is much easier to prevent a wound than to heal one. The care team works towards all residents being as active and engaged as possible in order to provide optimal health and quality of life. For skin health, this is done through activities, nutrition, hydration, exercise and socialization, to keep residents active and healthy.
Personal Support Workers report all incidents of “altered skin integrity” and Nurses provide treatments to damaged or open areas of the skin. Sometimes, due to frailty and lack of mobility, open areas may become infected or cause sepsis. The typical resident at greatest risk of skin breakdown is elderly, frail, and incontinent, with poor nutrition and hydration and is confined to a bed.
Any bony prominence can be at risk, including edges of ears, shoulder blades, hipbones, spine, knees and ankles. Residents who are bed-bound may be physically turned or shifted every few hours to minimize the effects of pressure in one area. For bony areas such as ankles and feet, residents may wear booties or have a special frame to lift sheets from feet so there is no friction from rubbing on the sheets.
Nutrition and skin health
Residents are offered nutritious meals and snacks to encourage nutrients necessary for healthy skin. While all nutrients help to keep the body healthy, there are some that are known to be beneficial for skin.
Adequate calories are important for providing skin with the energy to grow new cells and remove old and damaged cells, and dietary protein keeps all layers of the skin structurally healthy. Protein also produces enzymes that help reactions in the body to happen quickly, which is essential to reduce aging and keep the top layer of the skin in strong and healthy condition.
Antioxidants such as vitamins A, C, E and the mineral selenium are known to minimize the damage of skin cells in the aging process through their ability to remove harmful chemicals from the body. These nutrients come from frequent intake of vegetables and fruits. Vitamin C is also a component of collagen, which helps in the health and elasticity of skin and helps in reducing infections.
Omega 3 fatty acids are important to keep the top layer of the skin strong and help to avoid the damaging atmospheric effects.
The mineral zinc helps to maintain the structure of skin, and may also help in the division of skin cells. This may play a role in healing of skin breakdown. Zinc also is involved in immune function, helping to heal skin infections.
In addition to these nutrients, fluids are also essential, since water conveys nutrients into the cells and removes toxins and waste materials from the skin. Water keeps the skin hydrated, which therefore keeps skin supple and limits wrinkles and sagging.
Maintaining optimal blood sugar levels is an important nutrition goal for people with diabetes, especially in dealing with diabetic foot ulcers.
Exercise and skin health
The body is healthier with activity. All residents should take advantage of daily exercise classes, or could simply walk or move around the home. Physical activity stimulates blood flow, carrying essential oxygen and nutrients around the body. Exercise also assists blood to carry waste materials from cells, keeping them working at peak efficiency.
Wounds are painful and lead to immobility, discomfort, isolation and in worst cases, can be fatal. They are also an expensive use of resources, including staff time, specialized supplies and costly treatments. It bears repeating that it is easier to prevent a wound than to heal one, and this is the reason for focused interdisciplinary attention on skin health for residents in long term care. A resident who is active, engaged, nourished, hydrated and active is more likely to maintain healthy skin.
Dale Mayerson, BSc, RD, CDE, and Karen Thompson, BA Sc, RD are Registered Dietitians with extensive experience in Long-term care. They are co-authors of “Menu Planning in Long Term Care and Retirement Homes: A Comprehensive Guide” and have participated for many years on the Ontario Long Term Care Action Group, an advocacy group of Dietitians in Canada.