The Skin Safety Model: Reconceptualizing Skin Vulnerability in Older Patients

By Campbell, Jill L.; Coyer, Fiona M. et al. | Journal of Nursing Scholarship, January 2016 | Go to article overview

The Skin Safety Model: Reconceptualizing Skin Vulnerability in Older Patients


Campbell, Jill L., Coyer, Fiona M., Osborne, Sonya R., Journal of Nursing Scholarship


Skin is the largest organ in the human body and is vulnerable to a multitude of threats. Within the acute care setting, older patients (those 65 years of age and older) are particularly vulnerable to skin integrity threats and subsequent skin injury (Carville, 2012). While the impact of pressure ulcers (PUs) in the acute setting is well understood, there are a range of potential iatrogenic skin injuries that are often regarded as an inevitable part of aging yet remain underappreciated, underreported, and somewhat invisible within this setting. Beyond PUs, other iatrogenic skin injuries include skin tears, medical adhesive-related skin injury (MARSI), incontinence-associated dermatitis (IAD), peristomal or periwound moisture-associated skin damage (MASD), and intertriginous dermatitis (ITD; Table 1). Skin integrity threats in older individuals arise from interactions between skin changes associated with aging; presence of multiple comorbidities; polypharmacy; changes in mobility, continence, and cognition; as well as the risks of acute illness and subsequent hospitalization. Maintaining skin integrity in the older acute care patient is an ever-present challenge for healthcare providers. These challenges are compounded by shrinking financial and clinical resources, a rapidly aging population, and the expectation that patients remain safe from harm.

For several decades, PU prevention has been the primary focus of maintaining skin integrity. Moreover, the terms pressure ulcer prevention and maintaining skin integrity have, to some extent, become interchangeable. However, like PUs, the prevalence of these other skin injuries is significant (see Table 1), yet unlike PUs, their impact in the acute care setting is underappreciated. These iatrogenic skin injuries have the potential to impact on morbidity, mortality, cost, and burden of care, in addition to causing pain, disfigurement, or disability. Importantly, any skin injury sustained in the delivery of health care should be classified as an adverse event. Further, research is emerging that strategies to prevent one iatrogenic injury can have positive effects on preventing other skin injuries (Coyer et al., 2015).

Historically, despite shared risk factors, skin injury prevention and management programs address a single skin injury (e.g., PU). For individuals, underappreciation of the complexity and scope of skin integrity risks can result in adverse skin integrity outcomes. For healthcare providers, this singular approach to skin injury prevention and management can result in fragmented, duplicated, inconsistent care that often takes place in silos. In response to the range of potential iatrogenic skin injuries, a multitude of injury-specific conceptual frameworks have been published (Beeckman et al., 2015; Black et al., 2011; LeBlanc & Baranoski, 2011; McNichol, Lund, Rosen, & Gray, 2013). However, to our knowledge, there is no framework that represents a unified, holistic paradigm for maintaining skin integrity. This gap represents an opportunity for an innovative paradigm shift. This article presents a framework that views skin as a complex organ, vulnerable to a multitude of threats and injuries. These diverse yet interrelated injuries can result from complex interactions between patient and systems factors as well as acute situational stressors. The framework draws together important concepts into a single unified paradigm, highlighting the interconnection of the spectrum of skin frailty antecedents and resultant skin injuries. This article argues that the imperative to prevent the diverse range of iatrogenic skin injuries in older hospitalized patients warrants a new skin safety conceptual framework.

Aim

The aim of this article is to develop a unique skin safety model (SSM) that offers a new and unified perspective on the diverse yet interconnected antecedents that contribute to a spectrum of potential iatrogenic skin injuries in older hospitalized adults. …

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