Skin care in nursing: A critical discussion of nursing practice and research
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.
References (106)
- et al.
Skin health in older age
Maturitas
(2014) - et al.
Effects of petrolatum on stratum corneum structure and function
J. Am. Acad. Dermatol.
(1992) - et al.
Urea uptake enhances barrier function and antimicrobial defense in humans by regulating epidermal gene expression
J. Invest. Dermatol.
(2012) - et al.
Psychosocial aspects of aging skin
Dermatol. Clin.
(2005) - et al.
Dry skin in older adults
Geriatr. Nurs.
(2011) - et al.
Associations between individual characteristics and incontinence-associated dermatitis: a secondary data analysis of a multi-centre prevalence study
Int. J. Nurs. Stud.
(2014) - et al.
A multi-center prevalence study and randomized controlled parallel-group pragmatic trial to compare the effectiveness of standardized skin care regimens on skin health in nursing home residents: a study protocol
Int. J. Nurs. Stud.
(2015) - et al.
Dry skin in nursing care receivers: a multi-centre cross-sectional prevalence study in hospitals and nursing homes
Int. J. Nurs. Stud.
(2016) A pressure sore risk calculator for intensive care patients: ‘the Sunderland experience’
Intensive Crit. Care Nurs.
(1995)- et al.
How registered nurses, licensed practical nurses and resident aides spend time in nursing homes: an observational study
Int. J. Nurs. Stud.
(2015)
The primacy of vital signs – acute care nurses’ and midwives’ use of physical assessment skills: a cross sectional study
Int. J. Nurs. Stud.
Soaps: from the Phoenicians to the 20th century – a historical review
Clin. Dermatol.
Cost-consequence analysis of washing without water for nursing home residents: a cluster randomized trial
Int. J. Nurs. Stud.
Nurse-led inpatient care: opening the ‘black box’
Int. J. Nurs. Stud.
Skin pH: from basic science to basic skin care
Acta Derm. Venereol.
Stratum corneum fatty acids: their critical role in preserving barrier integrity during cleansing
Int. J. Cosmet. Sci.
A global perspective on caring for healthy stratum corneum by mitigating the effects of daily cleansing: report from an expert dermatology symposium
Br. J. Dermatol.
The Dirt on Clean: An Unsanitized History
Correlation between pH and irritant effect of cleansers marketed for dry skin
Int. J. Dermatol.
The composition and development of moisturizers
Interventions for preventing and treating incontinence-associated dermatitis in adults
Cochrane Data Base Syst. Rev.
Impact of a glycolic acid-containing pH 4 water-in-oil emulsion on skin pH
Skin Pharmacol. Physiol.
Pruritus in the older patient: a clinical review
JAMA
Treatmet od aged skin with a pH 4 skin care product normalizes increased skin surface pH and improves barrier function: results of a pilot study
J. Cosmet. Dermatol. Sci. Appl.
Beauty and the body: the origins of cosmetics
Plast. Reconstr. Surg.
Age-associated skin conditions and diseases: current perspectives and future options
Gerontologist
Clinical utility of the braden scale for predicting pressure sore risk
Decubitus
Nursing Interventions Classification (NIC)
Long-term treatment with moisturizers affects the mRNA levels of genes involved in keratinocyte differentiation and desquamation
Arch. Dermatol. Res.
The skin safety model: reconceptualizing skin vulnerability in older patients
J. Nurs. Scholarsh.
A survey of self-reported skin disease in the elderly African-American population
Int. J. Dermatol.
The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears
Int. Wound J.
Quantitative assessment of combination bathing and moisturizing regimens on skin hydration in atopic dermatitis
Pediatr. Dermatol.
Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings (protocol)
Cochrane Data Base Syst. Rev.
Skin cleansing practices for older people: a systematic review
Int. J. Older People Nurs.
Petrolatum: barrier repair and antimicrobial responses underlying this “inert” moisturizer
J. Allergy Clin. Immunol.
Silicones as nonocclusive topical agents
Skin Pharmacol. Physiol.
Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges
J. Wound. Ostomy Cont. Nurs.
Development of a standardized testing procedure for assessing the irritation potential of occupational skin cleansers
Contact Dermat.
The bath! Reassessing a familiar elixir in old age
J. Am. Geriatr. Soc.
Visible skin colouration predicts perception of male facial age, health and attractiveness
Int. J. Cosmet. Sci.
The effects of water exposure on biophysical properties of normal skin
Skin Res. Technol.
Cutaneous differences between Black, African or Caribbean Mixed-race and Caucasian women: biometrological approach of the hydrolipidic film
Skin Res. Technol.
The chemistry of skin cleansers: an overview for clinicians
Semin. Cutan. Med. Surg.
Stratum corneum lipid removal by surfactants: relation to in vivo irritation
Dermatologica
Acutely ill patients in internal medicine departments want treatment for undiagnosed, symptomatic skin conditions
Dermatology
An assessment tool to identify pressure sores
Nurs. Res.
Moisture-associated skin damage: overview and pathophysiology
J. Wound Ostomy Cont. Nurs.
Pathway to dry skin prevention and treatment
J. Cutan. Med. Surg.
Nursing assessment of the integument system
Occup. Health Nurs.
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