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Skin Breakdown

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Skin Breakdown

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Course Number:

This course is not approved by the California Department of Social Services (CDSS).

In this 1 hour course, the participant will learn about skin breakdown. Knowing how to care for a person's skin and protect them from skin breakdown are important to help them stay healthy. By the end of this course, you will know and be able to apply: how to recognize skin changes; how to protected aged skin; knowledge about the integumentary system; and how to treat healing skin.

Course Information:
  • Online Training Course
  • Credit Hours: 1
  • How to Recognize Skin Changes
  • How to Protected Aged Skin
Helpful Instructions?
 Purchasing Courses for Yourself Purchasing Courses for Yourself:

This Training course is delivered 100% online through our Online Campus. In order to enroll you in a course we will need to collect your First Name, Last Name and Email Address.

When you place your order we will create an account for you, or add the courses to your existing account if you are a return customer. Access to the Online Campus is based on your email address. If you are a return customer, please purchase using the same email address used previously to avoid creating a duplicate account.

The course(s) you purchase will be available within 10 minutes of purchase and your login information will be sent to the email address you provide.
 Purchasing Courses for Others Purchasing Courses for Others:

This Training course is delivered 100% online through our Online Campus. If you are purchasing for others or your employees, please make sure to provide the First Name, Last Name, and Email Address of the person who you are purchasing for.

IMPORTANT: Access to the Online Campus is based on email addresses. If you are purchasing for multiple people, each person must have a unique email address to access the Online Campus. DO NOT USE THE SAME EMAIL ADDRESS FOR DIFFERENT INDIVIDUALS!

When you place your order we will create accounts for each individual you are purchasing for. If you are a return customer, please purchase using the same email address used previously to avoid creating duplicate accounts.

Example: Jim is buying a course for Bob. Jim will provide Bob’s First, Last and Email before the course is added to cart. Jim then uses his personal information for the checkout process.

We understand no one likes to give out their information and that’s why we only require the course attendee’s First Name, Last Name and Email to add the course to your shopping cart.

The course(s) you purchase will be available within 10 minutes of purchase and each person’s login information will be sent to the email address you provide.


Course Outcomes

  • 1. Skin changes are among the most visible signs of aging. Evidence of increasing age includes wrinkles and sagging skin.
  • 2. Skin protects the body from the environment, helps control body temperature and fluid and electrolyte balance, and contains nerve receptors that allow a person to feel sensations such as touch, pain, and pressure.
  • 3. The skin can be divided into three main parts:
  • a. The outer part (epidermis) contains skin cells, pigment, and proteins.
  • b. The middle part (dermis) contains blood vessels, nerves, hair follicles, and oil glands. The dermis provides nutrients to the epidermis.
  • c. The inner layer under the dermis (the subcutaneous layer) contains sweat glands, some hair follicles, blood vessels, and fat. Each layer also contains connective tissue with collagen fibers to give support and elastin fibers to provide flexibility and strength.
  • 4. Skin changes are related to environmental factors, genetic makeup, nutrition, and other factors. The greatest single factor, though, is sun exposure.
  • 5. With aging, the epidermis thins, even though the number of cell layers remains unchanged.
  • 6. Aging skin thus appears thinner, more pale, and translucent.

  • A. Common Skin Issues
  • 1. Thin, frail skin
  • i. As skin ages it becomes naturally thinner, as much as 20% thinner. In some older residents, the skin becomes so thin that it is like delicate paper.
  • ii. Elder skin injures more easily, heals more slowly, and is prone to bruising. Elder skin can tear and bleed even from mild bumps or even removing a simple bandage.
  • iii. Since thinning of the skin is a normal part of aging, nothing can be done to prevent it.

  • 2. Dry skin
  • i. Dry skin is defined as an irritation of the skin due to inadequate water or oil concentration of the skin.
  • ii. It feels rough and tight when touched; may appear flaky or gray and ashen.
  • iii. As we age, skin gets thinner and is less able to retain moisture. As it becomes dry and thin, elderly skin is prone to cracking, itching, and pain.
  • iv. Dry skin is also more easily torn. This can lead to the introduction of bacteria. Since the elderly have a more difficult time fighting off bacteria and other illness, it is vital to prevent tears and bacterial introduction.

  • 3. Skin Tears
  • i. Thin skin is more susceptible to abrasions, tearing and cutting.
  • ii. Coupled with decreased sensations in the skin, elders with thinning skin can easily tear their skin by contacting a sharp object they don't feel until the damage is already done.
  • iii. Small cuts and/or abrasions which remain untreated leave the elder at risk for developing infections.
  • 4. Pressure / Decubitus Ulcers
  • i. Called by many names: pressure sores; bed sores; pressure ulcers. Caused by unrelieved pressure over a bony prominence which results in decreased circulation to the underlying tissue and tissue death.
  • ii. Four Stages of Decubitus Ulcer:
  • a. Stage 1: a defined skin area is characterized by persistent redness (darker skin may come with hues of red, purple of blue). When the affected area is pressed, the skin does not turn to normal— a key indication that skin breakdown (decubitus ulcer) has already begun. (
  • b. Stage 2: A blister, an abrasion, or a shallow crater or open sore has formed; the surrounding area of which may appear to be irritated and red in color; still only skin deep.
  • c. Stage 3: a deep crater, where thick skin loss involves impairment in the skin’s underlying tissue. The depth of damage may reach the fascia, but does not pass through it. May be able to visualize, in the wound bed, tendon or muscle.
  • d. Stage 4: The depth of damage reaches the bone, muscle, or the supporting tendons and joint. Furthermore, tunneling and shelving may also occur in a stage 4.
  • 5. Skin Cancer
  • i. Skin cancer is the most common form of cancer among the elderly in the United States. In fact, nearly one million Americans age 65 and older develop skin cancer each year. (
  • ii. The main cause of skin cancer is sun exposure. Sun damage and ultimately skin cancer is caused when the ultraviolet or UV rays in sunlight break down the elastin or elastic tissue in the skin causing wrinkles, sagging, stretching, blotchiness, and changes to moles.
  • iii. Skin cancer can also become a real concern in the elderly as a lifetime of sun exposure and damage can add up and take its toll. The more sun and UV rays a person is exposed to during their lifetime, the higher their risk for skin cancer. Sun damage cannot be reversed.
  • B. Risk Factors
  • 1. Moisture
  • i. Too much topical moisture over-hydrates the skin, making it weak and more sensitive to friction, shear and breakdown.
  • ii. Primary sources of excess skin moisture include sweating, bowel and bladder incontinence, and wound drainage.
  • 2. Immobility
  • i. Weakness, stiffness, paralysis, pain, fear of falling, anxiety and depression can all be causes for immobility.
  • ii. The consequences of lack of movement are often muscle atrophy, weakness and shortening; possible deep vein thrombosis and pulmonary embolus; mechanical pressure, moisture and function can result in pressure sores.
  • iii. There is decreased cardiac output and decreased oxygen circulation and fluid loss. As a result, within a short while of being immobile, the risk of postural hypotension, falls and skin breakdown rises.
  • 3. Incontinence
  • i. Incontinence is the body’s inability to control the flow of urine and / or feces.
  • ii. Incontinence can cause multiple skin complications, such as:
  • a. Maceration : over-exposure to moisture can cause the skin to become macerated (waterlogged), which makes the skin very fragile. This added fragility puts the skin at greater risk for damage caused by friction, shear, and pressure. Once skin is macerated, even gentle rubbing by bed linens, clothing, wipes, and wash cloths can cause injury.
  • b. Dermatitis: a common condition related to incontinence is dermatitis. Otherwise known as perineal dermatitis, which involves the irritation and breakdown of the skin as a result of over-exposure to moisture and chemicals in urine and feces.
  • c. Bacterial Infection: another risk associated with incontinence is bacterial growth and infection. Incontinence allows the skin's surface to come in contact with bacteria from waste products. This is particularly dangerous for the elderly whose skin may be characteristically dry. Dry skin provides an opportune breeding ground for bacterial growth since micro-organisms can be absorbed through skin cracks and fissures. When left unchecked, in a conducive environment, bacteria can literally double in number every 20 minutes!
  • d. Exposure To Caustic Agents: one of the caustic agents contained in urine is ammonia. Ammonia increases the pH of the skin causing irritation. Ammonia is also used by bacteria as a source of nutrition, contributing to the reproduction of more micro-organisms. Without proper treatment, the cycle goes on and on. Individuals with bowel incontinence are at an even higher level of risk for bacterial colonization of the skin.
  • e. Fungal Infection: the damp, warm skin found with incontinence is ideal for the large increase of pathogenic fungi. A skin rash that is fiery red, itches, and burns is usually of fungal origin, and requires treatment with an anti-fungal medication in order to heal.
  • 4. Impaired circulation and decreased sensation
  • i. Disease processes such as peripheral artery disease, diabetes, multiple sclerosis and fibromyalgia can cause swelling in the legs and arms and pain in the peripheral nervous system.
  • ii. This pain and swelling can cause the resident to limit movement, consciously or subconsciously, to prevent discomfort. The subsequent limitation then allows for skin breakdown.
  • iii. Elders with impaired sensation are also at risk for injuries caused by heat, cold and trauma. Loss of sensation places a resident at risk for burns from common appliances such as heating pads and electric blankets. They are also at risk for cold injuries from ice packs or frost bite.

  • 5. Improper transfer technique
  • i. Improper placement of staff hands while assisting with transfers can cause skin tears and bruises.
  • ii. Improper use of assistive devices can cause skin tears and bruises as well.
  • iii. Friction and shearing are caused when staff improperly adjust a resident’s position while on a solid, often cloth - covered, surface, such as a bed.
  • 6. Medications:
  • i. Medications, such as diuretics, can cause skin dryness and slacking of the skin. Also, long term use of steroids can cause skin fragility, thus increasing the risk of skin breakdown.
  • ii.The elderly should avoid using topical steroids for longer than necessary. Topical steroids can quicken the thinning of skin and can make skin tears worse.
  • 7. Prolonged, lifetime sun exposure:
  • i. Sunlight can cause: loss of elasticity (elastosis); noncancerous skin growths (keratoacanthomas); pigment changes such as liver spots; thickening of the skin.
  • ii.Sun exposure has also been directly linked to skin cancers, including basal cell cancer, squamous cell carcinoma, and melanoma.
  • C. Prevention
  • 1. Nutrition and Hydration:
  • i. Provide a healthy diet and encourage lots of fluids, especially water. Good nutrition will help make skin more resistant to breakdown and the resident will be more likely to heal and fight off infection should it occur.
  • ii. Encourage the resident to eat the right kinds of foods. This means a balanced diet with servings from all food groups.
  • iii. Extra calories, especially from protein, are important for repairing damaged tissues if a resident does have skin breakdown.

  • 2. Meticulous Incontinent Care:
  • i. The best prevention against skin damage caused by incontinence is to keep the skin dry. The best disposable incontinence products have a soft top sheet next to the skin and an absorbent core which quickly wicks the moisture away and traps it there. These features help in keeping the skin dry.
  • ii. Change incontinence products as soon as soiling occurs to avoid excessive skin wetness.
  • iii. Maintain the skin at its natural pH range by using formulated skin products designed for incontinence care.
  • iv. Use a barrier ointment or cream to minimize direct contact with urine and feces.
  • v. Cleanse gently to avoid friction.
  • 3. Regular Bathing:
  • i. Bathe frequently using mild soap.
  • ii. Avoid very hot water as it dries skin.
  • iii. Dry skin by patting rather than rubbing.
  • iv. Also, use of wet wipes for cleaning when a shower or bath is not possible.
  • 4. Moisturize:
  • i. The best treatment for dry skin is lubrication. Over the counter lotions and moisturizers are the perfect solution to rehydrate elderly skin. Severely dry skin may need to be treated with prescription medicated creams.
  • ii. Humidifiers can also be used to put more moisture into the air as a dry environment can also hasten the drying of elderly skin.
  • 5. Turning and Repositioning:
  • i. Reposition frequently.
  • ii. When seated in a wheelchair, do weight shifts every 15 minutes.
  • iii. When lying in bed, reposition minimally every 2 hours.
  • iv. Use pillows or wedges behind the back and between bony areas, such as knees and ankles.
  • v. “Float” heels and ankles off of the bed by supporting the lower leg with a pillow.
  • vi. Keep the head of the bed up less than 30 degrees to prevent shearing of skin from sliding down or the need to be pulled back up.
  • 6. Staff training:
  • i. Train staff in safe placement of hands during transfer assistance;
  • ii. Train staff in proper use of assistive equipment to prevent injuries;
  • iii. Train staff in evaluation of skin and community policy on reporting skin abnormalities.
  • D. Responses to Skin Issues
  • 1. Report to MD
  • i. When a skin issue is observed, notification to the treating / primary physician occurs according to community policy in accordance with the severity of the issue.
  • ii. Timely documentation of all skin abnormalities and community / care response.
  • 2. Home Health
  • i. Request a referral to a home health agency for wound care.
  • ii. Home health is also a great resource for staff training / teaching in wound care, skin care and prevention of pressure related breakdown.


Preventing skin breakdown is much easier than treatment and there are many identified risk factors that can be modified to prevent skin breakdown.

As caregivers of the elderly, we must handle their fragile skin with care, providing moisture and cleanliness at all times, to ensure their continued good health.

Additional Information

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Course Type Online Course

Skin Breakdown