Skin care in nursing practice is very important, especially since the skin is responsible for protection, sensation, heat regulation, excretion, secretion and absorption.
- Protection – from wear and tear (subcutaneous fat beneath the skin acts as a shock absorber and helps to protect the body from trauma); against infection and chemicals (microorganisms cannot breach the barrier created by intact healthy skin); against UV radiation (melanin absorbs UV light and prevents it from damaging cellular DNA);
- Sensation – the skin is the body’s largest sensory organ. Its nerve receptors detect a number of different stimuli, including mechanical (eg. pressure) and thermal (heat or cold);
- Heat Regulation – the hypothalamus (found within the brain), which contains the temperature regulating centre, can trigger changes within the skin in response to temperature changes;
- Excretion – the skin excretes Carbon Dioxide, water, and sweat along with a number of waste products such as Sodium Chloride and Urea;
- Secretion – Sebacious glands (outgrowths of hair follicles) within the dermis secrete sebum, making the skin water-resistant;
- Absorption – the skin is a useful absorbent medium for medicines such as hormones and glyceryl trinitrate (for angina treatment), as well as for the application of topical medications aimed to treat skin diseases.
Skin, including intact skin, requires ongoing care. It needs to be kept clean, moisturised and free from infection, and this can be achieved through the use of emollient (moisturiser) therapy.
Moisturisers
Moisturisers come in the form of creams, lotions and ointments. The greasier they are, the better they are at rehydrating the skin.
Moisturiser Creams
Moisturiser creams are a mixture of oil and water, but they require stabilisers (chemicals) to prevent the cream from become contaminated by bacteria and fungi. Chemicals pose a risk for irritations. The upside to moisturiser creams is that they rub easily into the skin without leaving greasy traces.
NOTE: Always test moisturiser creams on a small area eg. on the patient’s back for a minimum of 48 hours – any persistent redness signals allergic reaction.
Moisturiser Lotions
Moisturiser lotions are liquid creams which tend to have a cooling effect on the skin. Whilst moisturiser lotions tend to be less effective at moisturising the skin than creams and ointments, they are considered to be a good choice for normal routine skincare.
NOTE: Moisturiser lotions contain preservatives/chemicals. Test lotions on a small area for a minimum of 48 hours – any persistent redness signals allergic reaction.
Moisturiser Ointments
Moisturiser ointments are oil-based, with the main ingredient usually being white soft paraffin, containing very little water. This makes ointments very greasy and messy. However, ointments are more effective than creams, and are ideal for very dry and inflamed skin especially when applied during night time. Ointments form a layer on the skin that prevents water loss, while providing further hydration to the skin.
NOTE: Ointments are unlikely to cause adverse reactions since preservatives are not needed as bacteria and fungi cannot grow within this medium.
Applying Moisturisers
- Wash skin (see bathing section below).
- Dry carefully by patting – DO NOT rub vigorously as doing so will damage delicate and dry skin, as well as aggravate itchy skin.
- Apply moisturiser immediately after while skin is warm and at its most receptive state. Start from the top and work downwards using downward strokes parallel to the direction of the hair follicles’ growth…this will prevent hair follicles from becoming blocked, leading to folliculitis (inflamed or infected follicles).
Bathing
Evaporation of water from the epidermis causes skin tightening, leading to dry skin. Hospital ambience, including the hot dry conditions and high temperature and chemical use on bed sheets, increases risk for dry skin.
DO…
- MOISTURISE the patient’s skin to reduce water loss (the surface film created by moisturisers help slow down water loss)
- ADD BATH OIL such as Oilatum, E45 Wash, or Aqueous Cream to the water, instead of soap, to promote rehydration of the skin due to the increased oil-to-water ratio (attn. patient safety – oils make baths slippery!)
DO NOT…
- Do not use soap on dry skin as soap worsens the problem since it removes the skin’s natural oils, increasing dehydration
- Do not over-wash the skin as this removes natural oils and commensal (harmless) bacteria that helps in the prevention of pathogen growth
The Scalp
The scalp is prone to becoming dry. Patients with a dry scalp usually respond well to appropriate shampoos which usually contain coal tar (eg. Polytar and T-Gel). Such shampoos need to be used on alternate days.
In case of irritation, a milder form of shampoo should be used. If dry scalp persists apply coconut oil at night.
Infections
Human skin is covered in commensal (harmless) bacteria and fungi. When the balance of commensal organisms is disrupted or when the skin integrity is breached, organisms penetrate the skin’s protective surface, resulting in cutaneous infections.
Bacteria
Bacteria can multiply quickly at body temperature, reaching harmful levels very fast. MRSA (Meticillin-Resistant Staphylococcus Aureus) and C.Diff (Clostridium Difficile) are two examples of such harmful bacteria.
Skin bacterial infections are most commonly caused by Staphylococcal and Streptococcal bacteria (eg. Impetigo and Folliculitis). These are more prominent in low hygienic conditions and in hot and wet climates. Such infections can be treated with a combination of antibiotics and good hygiene. Although superficial bacterial infections may respond to topical antibiotic treatment, oral antibiotics may be required for complete treatment. Additionally, topical antibiotics may also cause allergies, thus should be used with caution. NOTE: skin bacterial infections may be avoided by maintaining good hygiene and not itching.
Fungi
Fungi are organisms that live on both living and dead hosts.
Types of Fungal Infections include:
Tinea (Ringworm) can affect the body or the scalp. It is easily spread amongst children, and is often passed on from animals.
Candidiasis (Yeast) is usually found within skin folds following instances in which the skin is left wet. Pregnant women, the immuno-compromised, individuals on a broad spectrum of antibiotics, diabetics and HIV-positive individuals are more prone to getting Candidiasis.
Treatment for superficial fungal infections (eg. Tinea and Candidiasis) respond well to topical anti-fungal treatment, which should be applied diligently for the recommended time to avoid re-infection. Candida infection beneath the nail bed requires oral anti-fungal treatment, as topical treatment is unable to penetrate effectively in this case.
NOTE: Fungal infections can be avoided through proper skin care, including extra attention to skin folds with regards to washing and drying.
Parasites
Parasites are organisms that live on or within a host such as an animal or plant, getting food from the same host. Scabies, caused by mites, burrow into the skin, resulting in severe itching.
Viral Infections
Herpes Zoster (Shingles), a viral infection which is caused by the Varicella Zoster Virus (Chickenpox), is most commonly seen in individuals over 40 years of age. It causes pain which at times may be suicidal.
Herpes Simplex (causes Herpes), another viral infection, can be found in almost the whole adult population, although it may not produce visible symptoms.
Human Papilloma Virus (Warts) can affect people of all ages.
TREATMENT:
Herpes Simplex and Herpes Zoster are most commonly treated by Acyclovir, an antiviral treatment which can be used either topically or orally. Warts are usually removed with over-the-counter treatments containing salisylic acid, which basically burns away the thickened hard skin. Common warts may also be removed with Cryotherapy through the use of liquid nitrogen.
Infestations
When living creatures invade the body, an infestation occurs. Such living creatures may be seen miroscopically, and include mites (Scabies: see further up) and lice.
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Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing.
Claire aspires to continue studying following completion of her Nursing Degree, because she truly believes in lifelong education.
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