The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [305]
Principles of care
Skin care is particularly important to prevent the colonization of Gram-positive and -negative micro-organisms on the skin, which if permitted to colonize lead to healthcare-associated infection (Parker 2004). By implementing simple personal hygiene measures, the risk of infection can be reduced.
An initial assessment of the skin using observational skills is essential to ascertain the skin’s general condition, colour, texture, smell and temperature (Penzer and Finch 2001). To accurately observe and assess changes in the skin, an understanding of the structure, function and factors that cause disruption is essential, to enable identification of those at increased risk (Ersser et al. 2005).
Factors that may influence the appearance of the tissue are as follows.
Nutritional and hydration state: imbalances will cause loss of elasticity and drying of the skin. Oedema will cause stretching and thinning of the skin (Potter and Perry 1995).
Incontinence: the presence of urine and/or faeces on the skin increases the normal pH of 4.0–5.5 and makes the skin wet, which increase the risks of tissue breakdown and infection (Ersser et al. 2005).
Age, health and mobility status of the individual: for example, the presence of pressure ulcers (Smoker 1999, Stockton and Flynn 2009).
Treatment therapies: for example, radiotherapy (skin may become moist and cracked), chemotherapy (some cytotoxic agents such as methotrexate can cause erythematous rashes), and continuous infusions of 5-fluorouracil (5-FU) can cause a condition called palmar–plantar erythrodysaesthesia syndrome, which presents with cracking and epidermal sloughing of the palms and soles (Lokich and Moore 1984). A low platelet count can lead to an increased risk of bruising and a decrease in the white blood cells can influence the rate of healing. Steroids may cause the skin to become papery and fragile.
Any concurrent conditions: for example, eczema, psoriasis, diabetes or stress, can affect the ability of skin to maintain its integrity (Holloway and Jones 2005).
Box 9.1 lists the specific considerations for skin care.
Box 9.1 Specific areas for skin consideration
Frail and papery skin should prompt the nurse to take extra care in the bathing process. Patients need to be involved in their care plans, ensuring that correct and or preferred lotions are used; this will maintain the integrity of the skin and prevent the skin from being compromised.
Areas of red skin. If redness is noted, wound prevention measures need to be implemented to prevent sores and ulcers from developing. These include good pressure-relieving positioning and repositioning and the use of barrier products in the form of creams, ointments and films (Voegeli 2008).
Open wounds. When open wounds are present, such as pressure ulcers, abrasions or cuts, preventive measures such as pressure-relieving mattresses should be used to prevent further breakdown (Philips and Buttery 2009) and dressings such as hydrocolloids used where appropriate to promote wound healing (Bouza et al. 2005).
Intravenous devices and drains. Frequently, patients have intravenous devices and wound drains inserted as part of their therapy and these should be handled with care to prevent the introduction of infection or the ‘pulling’ of the tubes.
Methods of perineal/perianal care
When the nurse is performing care of the perineal and/or perianal area, it is important that informed consent is sought and privacy maintained as the patient may be embarrassed or humiliated. It is important for the nurse and patient to engage in a two-way process where agreement is given for the nurse to provide care (DH 2001).
Meticulous care with these areas is vital, especially for those people who may be prone to infection. Problems can arise from treatment modalities; for example, radiotherapy can cause fistulas, diarrhoea, constipation and urinary tract infections. Vigilance with cleanliness can prevent some of these problems or reduce their severity. Whenever possible, patients should