The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [303]
regulation of temperature
physical and immunological protection
excretion and preservation of water balance
sensory perception
psychosocial: how the individual is perceived, and their own perceptions of their body image.
The skin is made up of three layers: epidermis, dermis and deep subcutaneous layer (Figure 9.1).
Figure 9.1 Skin and subcutaneous layer.
Reproduced from Tortora and Derrickson (2009).
Epidermis
The epidermis is the outer coating of the skin and contains no blood vessels or nerve endings. The cells on the surface are gradually shed and replaced by new cells which have developed from the deeper layers; this process takes approximately 28 days. The epidermis has hairs, sweat glands and the ducts of sebaceous glands passing through it. It provides an efficient natural barrier (Burr and Penzer 2005).
Dermis
The dermis is the thicker layer which contains blood and lymph vessels, nerve fibres, sweat and sebaceous glands. It is made up of white fibrous tissue and yellow elastic fibres which give the skin its toughness and elasticity. It provides the epidermis with structural and nutritional support (Holloway and Jones 2005).
Subcutaneous layer
The subcutaneous layer contains the deep fat cells (areolar and adipose tissue) and provides heat regulation for the body. It is also the support structure for the outer layers of the skin (Tortora and Derrickson 2009). Maintaining skin integrity, through good personal hygiene, will allow this complex system to provide an efficient natural barrier to the external environment.
It is important to remember that the skin is a changing organ, affected by internal and external factors, temperature, air humidity and age (Burr and Penzer 2005). It has a great ability to adapt to changes in the environment and stimuli but will be affected by ill health and immobility (McLoughlin 2005). Its integrity, continuity and cleanliness are essential to maintaining its physiological functions.
The ageing process can adversely affect the skin structure. Skin tissue becomes thin and less elastic and resistant to trauma and shearing forces. The blood supply is reduced as cells are replaced more slowly, which adversely affects healing. Transmission of stimuli from sensory receptors slows and can lead to damage. The production of natural oils declines and can lead to dry skin which increases the risk of infection and tissue breakdown (Penzer and Finch 2001). Hence extra care should be taken when washing and drying elderly patients; nursing interventions can protect and restore the skin’s natural barrier (Ersser et al. 2005).
Evidence-based approaches
Personal cleanliness is a fundamental value in society. Often, when patients become unwell they depend on nurses to assist them with meeting their personal hygiene needs. When this occurs, it is important that the nurse observes and assesses the patient’s needs on an individual basis.
Hygiene is a personal entity and everyone will have their own individual requirements and standards of cleanliness. In this way, ‘nurses must take care not to impose their own norms on patients and clients and should respect their autonomy in decisions concerning care’ (Spiller 1992, p.431). Within the assessment, the patient’s religious and cultural beliefs should be taken into account and incorporated into care. Personal hygiene is individual to that person and is also based on family influences, peer groups, economic and social factors (Cooper 1994).
In Western culture, privacy is of the utmost importance and considered to be a basic human right. However, in some religions like Islam, modesty is crucial and can be challenging to manage in the hospital setting (Hollins 2009). Patients may feel a great deal of embarrassment having to depend on another person to help them with this extremely private act. It is therefore surprising to find that so little reference is made