Transcript Skin Integrity/Wound Care Overview

Skin Integrity/Wound
Care Overview
Presented by Felecia Briggs MS, APRN-C
June 5th, 2010
Skin
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Skin is the largest body organ, constituting
approximately 15% of the total adult body weight
It is a protective barrier against disease causing
organisms, a sensory organ for pain, temperature, and
touch
It synthesizes vitamin D
*Injury to the skin poses as a threat to safety and
triggers a complex healing process (P&P, 2009,
p.1279)
Layers of the skin
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The skin has two layers but are separated by a membrane
often referred to as the dermal-epidermal junction.
Epidermis-has several layers, the stratum corneum is the thin
outermost layer of the epidermis. The SC consists of
flattened, dead, keratinized cells. The cells originate from the
innermost layer of the epidermis, called the basal layer.
Cells in the basal layer divide, proliferate, and migrate towards
the epidermal surface. Once they reach the SC they flatten and
die-this constant movement ensures replacement of cells lost
during shedding or desquamation.
Stratum Corneum
 The
thin SC protects underlying cells and
tissues from dehydration and prevents
entrance of certain chemical agents.
 It also allows evaporation of water from
the skin and permits absorption of certain
topical medications
The Dermis
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The inner layer of the skin provides tensile strength,
mechanical support, and protection to the underlying
bones, muscles, and organs.
It differs from the SC in that it consists mostly of
connective tissue and few skin cells.
Collagen (a tough, fibrous protein) blood vessels, and
nerves are in the dermal layer.
Fibroblasts, which are responsible for collagen
formation are the only distinctive cell type within the
dermis.
Injury
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When the skin is injured, the epidermis
functions to resurface the wound and restore the
barrier against invading organisms while the
dermis responds to restore the structural
integrity (collagen) and the physical properties
of the skin.
Age alter skin characteristics and makes it more
vulnerable to damage
How aging affects skin
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Age-related changes such as reduced skin elasticity,
decreased collagen, and thinning of underlying
muscles and tissues, cause the older adult’s skin to be
easily torn in response to mechanical trauma,
especially shearing forces (i.e., sliding them across the
bed versus lifting them during position changes).
Reduced nutritional intake increases risk for pressure
ulcer development and impaired wound healing (P&P,
2009, p.1279).
Aging issues con’t
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The attachment between the epidermis and dermis
becomes flattened in older adults. Allowing the skin to
be easily torn in response to mechanical trauma ( i.e.,
tape removal).
Concomitant medical conditions and polypharmacy
also affect wound healing
Aging causing a diminished inflammatory response,
resulting in slow epithelialization and wound healing
Hypodermis
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The hypodermis decreases in size with age.
Therefore, older adults have little subcutaneous
fat padding over their bony prominences—so
they are at greater risk for skin breakdown.
Pressure Ulcers
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Synonymous terms- pressure ulcer, pressure
sore, decubitus ulcer, and bedsore are all terms
used to describe impaired skin integrity due to
unrelieved, prolonged pressure.
A pressure ulcer is a localized injury to the skin
and other underlying tissue, usually over a bony
prominence, as a result of pressure or pressure
in combination with shear and/or friction
Contributing factors to Pressure Ulcer
Development
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Any client experiencing decreased mobility, decreased
sensory perception, fecal or urinary incontinence,
and/or poor nutrition are at greater risk for pressure
ulcer development
Pressure is the main cause of injury-tissues receive
oxygen & nutrients and eliminates metabolic waste via
the blood. Therefore, any factor that interferes
w/blood flow directly interferes with cell metabolism
and the function or life of the cell
Pathogenesis of Pressure ulcers
Three pressure related factors contribute to
pressure ulcer development:
 Pressure Intensity- if pressure applied over a
capillary exceeds normal capillary pressure of 15
to 32mm Hg and the vessel is occluded for a
prolonged period of time—tissue ischemia can
occur
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Clinical presentation of obstructed
blood flow
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After a period of tissue ischemia-if the pressure is
relieved and the blood flow returns the area turn red.
The effect of this redness is vasodilation (blood vessel
expansion) called hyperemia (redness).
Evaluate the area of hyperemia by pressing a finger
over the affected area-if it blanches (turns lighter in
color) and the erythema returns when you remove
your finger-the hyperemia is transient and is an
attempt to overcome the ischemic episode.
If the area does not blanch
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Blanching occurs when the normal red tones of the
light skinned client are absent. Blanching does not
occur in clients with darkly pigmented skin.
Therefore, is an erythematous area does not blanch
when you apply pressure then deep tissue injury is
possible.
Understanding skin structure helps you maintain skin
integrity and promote wound healing
Pressure duration
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Low pressure over a prolonged period causes tissue
damage as well as high-intensity pressure over a
shorted period of time
Extended pressure occludes blood flow and nutrients
therefore contributing to cell death
Clinical Implications require you to evaluate the
amount of pressure being applied to an area as well as
inspected it to se if it blanches in response to touch
Tissue Tolerance
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The ability of tissue to endure pressure depends upon
the integrity of the tissue and the supporting
structures.
Extrinsic factors of shear, friction, and moisture affect
the ability of the skin to tolerate pressure
Also the ability of the underlying skin structures
(blood vessels and collagen) to assist in redistributing
pressure also play a role in ulcer development.
Systemic factors such as poor nutrition, increased
aging, low blood pressure all affect the tissue’s
tolerance to externally applied pressure.
Risk factors for Pressure Ulcer
Development
Impaired sensory perception
 Impaired mobility
 Alteration in level of consciousness
 Shear
 Friction
 Moisture
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Classification of pressure ulcers
Stage I- Intact skin with nonblanchable redness
of a localized area, usually over a bony
prominence
 Stage II- Partial thickness skin loss involving the
epidermis, dermis or both. The ulcer is
superficial and presents clinically as an abrasion,
blister or shallow crater
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Classification con’t
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Stage III- Full-thickness tissue loss. Subcutaneous fat
may be visible, but bone, muscle and tendons are not
exposed. Slough may also be present but does not
obscure the depth of tissue loss. May include
undermining and tunneling (p. 1283).
Slough is the soft yellow or white stringy substance
attached to wound bed-it must be removed before a
wound can heal properly
Classification con’t
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Stage IV- Full thickness tissue loss w/exposed
bone, tendon or muscle. Slough or eschar may
be present on some parts of the wound. Often
included undermining and tunneling.
Eschar- is the black, brown or tan necrotic tissue
noted in the wound. This too must be removed
before a wound can heal
*Unstageable ulcer-bottom of page 1282
Wound with nonviable tissue
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Granulation tissue- is red moist tissue composed
of new blood cells, the presence of which
indicates progression towards healing
Meanwhile, slough and eschar mean that healing
is not occurring properly and needs to be
removed from wounds for proper healing to
occur
Your role
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Measuring the size of the wound provides overall
changes in size which is an indicator for wound
healing progress.
Measure depth by using a cotton tipped applicator
Note any wound exudate-which describes the amount,
color, consistency and odor of wound drainage and is
part of your wound assessment
Assess for any redness, warmth, maceration and
edema- if present can be sign of wound deterioration
Wound Defined
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A wound is a disruption of the integrity and
function of tissues in the body
All wounds are not equal
Knowing the etiology of the wound is
important because treatment varies depending
on the underlying disease process
Wound Classifications/Healing Process
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Primary intention- wound that is closed
Secondary intention- wound edges are not
approximated
Tertiary intention- wound is left open for several
days to assess infection/healing process then the
wound edges are approximated (P&P- 1284-5)
Complications of Wound Healing
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Hemorrhage
Infection
Dehiscence-the partial or total separation of
wound layers
Evisceration-with total separation of wound
layers- penetration of visceral organs through a
wound opening sometimes occurs-this is an
emergency and needs surgical repair
Types of wound drainage
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Serous
Purulent
Serosanguineous
Sanguineous
(pg. 1287)
Reference
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Potter, P. A., & Perry, A. G. (2009). Fundamentals
of Nursing, 7th Ed. St. Louis, MO: Mosby.