Skin care in nursing: A critical discussion of nursing practice and research

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Abstract

Skin (self-)care is part of human life from birth until death. Today many different skin care practices, preferences, traditions and routines exist in parallel. In addition, preventive and therapeutic skin care is delivered in nursing and healthcare by formal and informal caregivers. The aim of this contribution is a critical discussion about skin care in the context of professional nursing practice. An explicit skin assessment using accurate diagnostic statements is needed for clinical decision making. Special attention should be paid on high risk skin areas, which may be either too dry or too moist. From a safety perspective the protection and maintenance of skin integrity should have the highest priority. Skin cleansing is the removal of unwanted substances from the skin surface. Despite cleansing efficacy soap, other surfactants and water will inevitably always result in the destruction of the skin barrier. Thousands of products are available to hydrate, moisturize, protect and restore skin properties dependent upon their formulation and the concentration of ingredients. These products intended to left in contact with skin exhibit several actions on and in the skin interfering with skin biology. Unwanted side effects include hyper-hydration and disorganization of lipid bilayers in the stratum corneum, a dysfunctional barrier, increased susceptibility to irritants and allergies, and increases of skin surface pH. Where the skin barrier is impaired appropriate interventions, e.g. apply lipophilic products in sufficient quantity to treat dry skin or protect the skin from exposure to irritants should be provided. A key statement of this contribution is: every skin care activity matters. Every time something is placed on the skin, a functional and structural response is provoked. This response can be either desired or undesired, beneficial or harmful. The choice of all skin care interventions in nursing and healthcare practice must be based on an accurate assessment of the skin and concomitant health conditions and on a clearly defined outcome. A standardized skin care and skin care product language is needed for researchers planning and conducting clinical trials, for reviewers doing systematic reviews and evidence-base summaries, for nurses and other healthcare workers to deliver evidence-based and safe skin care.

Introduction

The skin is the largest organ of the human body and plays a fundamental role for survival, for staying healthy or becoming ill. Beside these biological functions skin appearance and its perception by oneself and by others is crucial for self-esteem, wellbeing and social acceptance. Empirical evidence suggests that the way we look determines how we feel (Gupta and Gilchrest, 2005) and how we perceive others health, attractiveness, success and age (Fink et al., 2012).

Skin (self-)care including washing, bathing and numerous approaches for beautification are part of human life from birth until death since the beginning of mankind (Blanco-Davila, 2000, Evans, 2004, Routh et al., 1996). Besides personal preferences and beliefs, skin care activities are influenced by culture, geographical region, availability of sanitary structures (e.g., public baths), knowledge, industrial developments and marketing strategies (Ashenburg, 2007, Fotoh et al., 2008). Today many different preferences, traditions and skin care behaviours exist in parallel.

From a health and nursing care perspective, the skin is the target of various interventions. Over life there are certain periods where people are unable to care for their skin for themselves. This is typically the case very early in life (baby care), during periods of severe illness, disability or care dependency, in advanced age and at the end of life. In these situations, individuals usually receive skin care interventions from others like informal (e.g., parents, partners) or formal (e.g., nurses, nurse assistants) care givers. This means that the caregivers become responsible for choosing and conducting appropriate interventions. Although often regarded as a rather basic task, which in professional nursing practice is often delegated to less qualified personal (McCloskey et al., 2015, Walsh et al., 2003), skin care is complex and challenging. Unfortunately, current skin care is not always beneficial (Cowdell et al., 2014, Cowdell and Steventon, 2015).

The aim of this contribution is a critical discussion about skin care in the context of professional nursing practice. We explore skin care from conceptual, practical, educational and research perspectives. Special emphasis is given to classification and discussion of skin cleansing and caring procedures, substances, and the challenges we face today. A major statement of this critical discussion is that both over- and undersupply of skin care in nursing practice is common and that many activities may even be harmful.

Section snippets

What is skin care?

The term skin care is widely used both by the public and health professionals. However, a clear and accepted definition is lacking. The Medical Subject Headings of the National Library of Medicine thesaurus defines ‘Skin care’ as ‘Maintenance of the hygienic state of the skin under optimal conditions of cleanliness and comfort…” (National Library of Medicine, 1994). This definition it includes activities like washing, bathing, cleansing, and the use of soaps, detergents, oils, etc.

In the recent

Who is in need for (special) skin care?

A perceived nursing care need very often leads directly to the intervention. In the current context, this means for example people who cannot wash themselves need to be washed. Unfortunately, this straightforward association provides no details about the number of washes needed, the frequency, methods, time of day when interventions should be provided, or the products to use (if any). In their report of one of the first systematic investigations into nursing practice for elderly patients over

How to do a skin assessment?

An appropriate skin assessment must include among other elements, an evaluation both of the individual and of their skin status or condition. Although widely used the concept of skin status is not well defined in nursing. Traditionally it plays a role in standardized pressure ulcer risk assessment, for example the items ‘skin appearance’, ‘skin tone’, and ‘skin sensation’ or ‘intact’, ‘red’, ‘grazed/excoriated’, and ‘exuding’ were introduced to assess the ‘(general) skin status’ (Gosnell, 1973,

What are the goals of skin care?

With reference to the above concepts and definitions three dimensions of outcomes can be identified: (1) comfort and well-being; (2) intact and healthy skin; (3) clean skin. The Nursing Outcomes Classification (NOC) provides the outcome ‘Comfort Status: Physical (2010) which matches the first dimension while ‘Tissue Integrity: Skin & Mucous Membranes (1101)’ defined as ‘Structural intactness and normal physiological function of skin and mucous membranes’ (Moorhead et al., 2013) corresponds to

Skin cleansing and (side) effects

Skin cleansing is the removal of unwanted substances such as dust, sweat, desquamating corneocytes, organic material, or remnants of cosmetic products. This complex mix of substances forms a glue-like mixture on the skin surface consisting of hydrophilic and lipophilic compounds. Before the widespread use of soaps mechanical devices (e.g., skin scrapers) or water were used for skin cleansing (Ashenburg, 2007, Routh et al., 1996). Large scale industrial production of soap started in the late

How to avoid harm?

In principle the skin is able to resist a wide range of external insults but this resistance changes during the life course with the functional capacity of the skin of new-borns, children, the aged is reduced compared with mid life adults (Lichterfeld et al., 2015a). In the presence of disease or functional impairment the capacity of the skin to resist external challenges is also reduced. Skin care practices also impair the skin's ability to resist external insults; for example even water and

How to improve impaired skin?

Impaired skin is common in nursing care for example dry skin, dermatitis (due to incontinence or venous hypertension), intertrigo, and various cutaneous lesions (Woo and Sibbald, 2009) and in these circumstances adverse effects from skin cleansing and contact with leave-on products become even more hazardous given that the irritative ingredients or microbes can penetrate the skin more easily and in greater amounts. Generally people with any form of dry skin or dermatitis should keep contact

Terminology

Both the providers and recipients of skin care face a vast range of skin cleansers and leave-on products. Selecting the right product in each circumstance is challenging because neither the product labelling or the list of ingredients indicate the likely performance of the product (Kuehl et al., 2003). Furthermore there are no clear and generally accepted terminologies both for various product formats such as creams, lotions, ointments and for product functions such as moisturizer and

Limitations

The aim of this review was to initiate fundamental discussions about skin care practices in nursing and healthcare. To meet this objective we have not considered in depth skin biology, the composition of cleansing and leave-on skin care products and have omitted many biophysical and biochemical details. Furthermore we focused on daily basic skin care in nursing practice and have not addressed the management of specific dermatological diseases or other medical problems that may affect the skin

Conclusions

Skin care is deeply embedded in human history and culture with today skin care being performed for aesthetic purposes including ‘cosmetic pleasure’ with the goal of increasing personal well-being (Fotoh et al., 2008, Neill, 2012, Steventon, 2013) and these processes are clearly influenced by subjective consumer requirements (Barton, 2012). However in formal healthcare and nursing the objectives change with the maintenance of skin integrity and the avoidance of harm are the major priorities for

Acknowledgment

We would like to express our special thanks to Prof. Michael Clark for the thoughtful revision of the English.
Conflict of interest

None declared.
Funding

There was no explicit funding.
Ethical approval

Not required.

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