Skin Skin Integrity/Wound Integrity/Wound Care OverviewCare OverviewPresented by Felecia Briggs MS, APRN-Presented by Felecia Briggs MS, APRN-

CC

June 5th, 2010June 5th, 2010

SkinSkin

Skin is the largest body organ, Skin is the largest body organ, constituting approximately 15% of the constituting approximately 15% of the total adult body weighttotal adult body weight

It is a protective barrier against disease It is a protective barrier against disease causing organisms, a sensory organ for causing organisms, a sensory organ for pain, temperature, and touchpain, temperature, and touch

It synthesizes vitamin DIt synthesizes vitamin D *Injury to the skin poses as a threat to *Injury to the skin poses as a threat to

safety and triggers a complex healing safety and triggers a complex healing process (P&P, 2009, p.1279)process (P&P, 2009, p.1279)

Layers of the skinLayers of the skin The skin has two layers but are separated by a The skin has two layers but are separated by a

membrane often referred to as the dermal-membrane often referred to as the dermal-epidermal junction.epidermal junction.

Epidermis-has several layers, the stratum Epidermis-has several layers, the stratum corneum is the thin outermost layer of the corneum is the thin outermost layer of the epidermis. The SC consists of flattened, dead, epidermis. The SC consists of flattened, dead, keratinized cells. The cells originate from the keratinized cells. The cells originate from the innermost layer of the epidermis, called the innermost layer of the epidermis, called the basal layer.basal layer.

Cells in the basal layer divide, proliferate, and Cells in the basal layer divide, proliferate, and migrate towards the epidermal surface. Once migrate towards the epidermal surface. Once they reach the SC they flatten and die-this they reach the SC they flatten and die-this constant movement ensures replacement of constant movement ensures replacement of cells lost during shedding or desquamation.cells lost during shedding or desquamation.

Stratum CorneumStratum Corneum

The thin SC protects underlying The thin SC protects underlying cells and tissues from dehydration cells and tissues from dehydration and prevents entrance of certain and prevents entrance of certain chemical agents. chemical agents.

It also allows evaporation of It also allows evaporation of water from the skin and permits water from the skin and permits absorption of certain topical absorption of certain topical medicationsmedications

The DermisThe Dermis The inner layer of the skin provides tensile The inner layer of the skin provides tensile

strength, mechanical support, and strength, mechanical support, and protection to the underlying bones, muscles, protection to the underlying bones, muscles, and organs.and organs.

It differs from the SC in that it consists It differs from the SC in that it consists mostly of connective tissue and few skin mostly of connective tissue and few skin cells. cells.

Collagen (a tough, fibrous protein) blood Collagen (a tough, fibrous protein) blood vessels, and nerves are in the dermal layer.vessels, and nerves are in the dermal layer.

Fibroblasts, which are responsible for Fibroblasts, which are responsible for collagen formation are the only distinctive collagen formation are the only distinctive cell type within the dermis. cell type within the dermis.

InjuryInjury

When the skin is injured, the When the skin is injured, the epidermis functions to resurface the epidermis functions to resurface the wound and restore the barrier wound and restore the barrier against invading organisms while against invading organisms while the dermis responds to restore the the dermis responds to restore the structural integrity (collagen) and structural integrity (collagen) and the physical properties of the skin.the physical properties of the skin.

Age alter skin characteristics and Age alter skin characteristics and makes it more vulnerable to damagemakes it more vulnerable to damage

How aging affects skinHow aging affects skin Age-related changes such as reduced skin Age-related changes such as reduced skin

elasticity, decreased collagen, and thinning elasticity, decreased collagen, and thinning of underlying muscles and tissues, cause of underlying muscles and tissues, cause the older adult’s skin to be easily torn in the older adult’s skin to be easily torn in response to mechanical trauma, especially response to mechanical trauma, especially shearing forces (i.e., sliding them across shearing forces (i.e., sliding them across the bed versus lifting them during position the bed versus lifting them during position changes).changes).

Reduced nutritional intake increases risk Reduced nutritional intake increases risk for pressure ulcer development and for pressure ulcer development and impaired wound healing (P&P, 2009, impaired wound healing (P&P, 2009, p.1279).p.1279).

Aging issues con’tAging issues con’t The attachment between the epidermis The attachment between the epidermis

and dermis becomes flattened in older and dermis becomes flattened in older adults. Allowing the skin to be easily torn adults. Allowing the skin to be easily torn in response to mechanical trauma ( i.e., in response to mechanical trauma ( i.e., tape removal).tape removal).

Concomitant medical conditions and Concomitant medical conditions and polypharmacy also affect wound healingpolypharmacy also affect wound healing

Aging causing a diminished inflammatory Aging causing a diminished inflammatory response, resulting in slow response, resulting in slow epithelialization and wound healing epithelialization and wound healing

HypodermisHypodermis

The hypodermis decreases in size The hypodermis decreases in size with age. Therefore, older adults with age. Therefore, older adults have little subcutaneous fat padding have little subcutaneous fat padding over their bony prominences—so over their bony prominences—so they are at greater risk for skin they are at greater risk for skin breakdown.breakdown.

Pressure UlcersPressure Ulcers

Synonymous terms- pressure ulcer, Synonymous terms- pressure ulcer, pressure sore, decubitus ulcer, and pressure sore, decubitus ulcer, and bedsore are all terms used to describe bedsore are all terms used to describe impaired skin integrity due to impaired skin integrity due to unrelieved, prolonged pressure.unrelieved, prolonged pressure.

A pressure ulcer is a localized injury to A pressure ulcer is a localized injury to the skin and other underlying tissue, the skin and other underlying tissue, usually over a bony prominence, as a usually over a bony prominence, as a result of pressure or pressure in result of pressure or pressure in combination with shear and/or frictioncombination with shear and/or friction

Contributing factors to Contributing factors to Pressure Ulcer DevelopmentPressure Ulcer Development

Any client experiencing decreased mobility, Any client experiencing decreased mobility, decreased sensory perception, fecal or urinary decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition are at incontinence, and/or poor nutrition are at greater risk for pressure ulcer developmentgreater risk for pressure ulcer development

Pressure is the main cause of injury-tissues Pressure is the main cause of injury-tissues receive oxygen & nutrients and eliminates receive oxygen & nutrients and eliminates metabolic waste via the blood. Therefore, any metabolic waste via the blood. Therefore, any factor that interferes w/blood flow directly factor that interferes w/blood flow directly interferes with cell metabolism and the interferes with cell metabolism and the function or life of the cellfunction or life of the cell

Pathogenesis of Pressure Pathogenesis of Pressure ulcersulcers

Three pressure related factors Three pressure related factors contribute to pressure ulcer contribute to pressure ulcer development:development:

Pressure Intensity- if pressure Pressure Intensity- if pressure applied over a capillary exceeds applied over a capillary exceeds normal capillary pressure of 15 to normal capillary pressure of 15 to 32mm Hg and the vessel is occluded 32mm Hg and the vessel is occluded for a prolonged period of time—for a prolonged period of time—tissue ischemia can occurtissue ischemia can occur

Clinical presentation of Clinical presentation of obstructed blood flowobstructed blood flow

After a period of tissue ischemia-if the After a period of tissue ischemia-if the pressure is relieved and the blood flow returns pressure is relieved and the blood flow returns the area turn red.the area turn red.

The effect of this redness is vasodilation (blood The effect of this redness is vasodilation (blood vessel expansion) called hyperemia (redness).vessel expansion) called hyperemia (redness).

Evaluate the area of hyperemia by pressing a Evaluate the area of hyperemia by pressing a finger over the affected area-if it blanches finger over the affected area-if it blanches (turns lighter in color) and the erythema (turns lighter in color) and the erythema returns when you remove your finger-the returns when you remove your finger-the hyperemia is transient and is an attempt to hyperemia is transient and is an attempt to overcome the ischemic episode.overcome the ischemic episode.

If the area does not If the area does not blanchblanch

Blanching occurs when the normal red Blanching occurs when the normal red tones of the light skinned client are tones of the light skinned client are absent. Blanching does not occur in absent. Blanching does not occur in clients with darkly pigmented skin.clients with darkly pigmented skin.

Therefore, is an erythematous area does Therefore, is an erythematous area does not blanch when you apply pressure then not blanch when you apply pressure then deep tissue injury is possible.deep tissue injury is possible.

Understanding skin structure helps you Understanding skin structure helps you maintain skin integrity and promote maintain skin integrity and promote wound healingwound healing

Pressure durationPressure duration Low pressure over a prolonged period Low pressure over a prolonged period

causes tissue damage as well as high-causes tissue damage as well as high-intensity pressure over a shorted period intensity pressure over a shorted period of timeof time

Extended pressure occludes blood flow Extended pressure occludes blood flow and nutrients therefore contributing to and nutrients therefore contributing to cell deathcell death

Clinical Implications require you to Clinical Implications require you to evaluate the amount of pressure being evaluate the amount of pressure being applied to an area as well as inspected it applied to an area as well as inspected it to se if it blanches in response to touchto se if it blanches in response to touch

Tissue ToleranceTissue Tolerance The ability of tissue to endure pressure The ability of tissue to endure pressure

depends upon the integrity of the tissue and depends upon the integrity of the tissue and the supporting structures.the supporting structures.

Extrinsic factors of shear, friction, and Extrinsic factors of shear, friction, and moisture affect the ability of the skin to moisture affect the ability of the skin to tolerate pressuretolerate pressure

Also the ability of the underlying skin Also the ability of the underlying skin structures (blood vessels and collagen) to structures (blood vessels and collagen) to assist in redistributing pressure also play a assist in redistributing pressure also play a role in ulcer development.role in ulcer development.

Systemic factors such as poor nutrition, Systemic factors such as poor nutrition, increased aging, low blood pressure all affect increased aging, low blood pressure all affect the tissue’s tolerance to externally applied the tissue’s tolerance to externally applied pressure. pressure.

Risk factors for Pressure Ulcer Risk factors for Pressure Ulcer DevelopmentDevelopment

Impaired sensory perceptionImpaired sensory perception Impaired mobilityImpaired mobility Alteration in level of Alteration in level of

consciousnessconsciousness ShearShear FrictionFriction MoistureMoisture

Classification of pressure Classification of pressure ulcersulcers

Stage I- Intact skin with Stage I- Intact skin with nonblanchable redness of a localized nonblanchable redness of a localized area, usually over a bony area, usually over a bony prominenceprominence

Stage II- Partial thickness skin loss Stage II- Partial thickness skin loss involving the epidermis, dermis or involving the epidermis, dermis or both. The ulcer is superficial and both. The ulcer is superficial and presents clinically as an abrasion, presents clinically as an abrasion, blister or shallow craterblister or shallow crater

Classification con’tClassification con’t

Stage III- Full-thickness tissue loss. Stage III- Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, Subcutaneous fat may be visible, but bone, muscle and tendons are not exposed. muscle and tendons are not exposed. Slough may also be present but does not Slough may also be present but does not obscure the depth of tissue loss. May obscure the depth of tissue loss. May include undermining and tunneling (p. include undermining and tunneling (p. 1283).1283).

Slough is the soft yellow or white stringy Slough is the soft yellow or white stringy substance attached to wound bed-it must substance attached to wound bed-it must be removed before a wound can heal be removed before a wound can heal properlyproperly

Classification con’tClassification con’t

Stage IV- Full thickness tissue loss Stage IV- Full thickness tissue loss w/exposed bone, tendon or muscle. w/exposed bone, tendon or muscle. Slough or eschar may be present on Slough or eschar may be present on some parts of the wound. Often included some parts of the wound. Often included undermining and tunneling.undermining and tunneling.

Eschar- is the black, brown or tan Eschar- is the black, brown or tan necrotic tissue noted in the wound. This necrotic tissue noted in the wound. This too must be removed before a wound too must be removed before a wound can heal can heal

*Unstageable ulcer-bottom of page 1282*Unstageable ulcer-bottom of page 1282

Wound with nonviable Wound with nonviable tissuetissue

Granulation tissue- is red moist Granulation tissue- is red moist tissue composed of new blood cells, tissue composed of new blood cells, the presence of which indicates the presence of which indicates progression towards healingprogression towards healing

Meanwhile, slough and eschar mean Meanwhile, slough and eschar mean that healing is not occurring that healing is not occurring properly and needs to be removed properly and needs to be removed from wounds for proper healing to from wounds for proper healing to occuroccur

Your roleYour role

Measuring the size of the wound provides Measuring the size of the wound provides overall changes in size which is an indicator overall changes in size which is an indicator for wound healing progress.for wound healing progress.

Measure depth by using a cotton tipped Measure depth by using a cotton tipped applicatorapplicator

Note any wound exudate-which describes the Note any wound exudate-which describes the amount, color, consistency and odor of wound amount, color, consistency and odor of wound drainage and is part of your wound assessmentdrainage and is part of your wound assessment

Assess for any redness, warmth, maceration Assess for any redness, warmth, maceration and edema- if present can be sign of wound and edema- if present can be sign of wound deterioration deterioration

Wound DefinedWound Defined

A wound is a disruption of the A wound is a disruption of the integrity and function of tissues in integrity and function of tissues in the bodythe body

All wounds are not equalAll wounds are not equal Knowing the etiology of the wound is Knowing the etiology of the wound is

important because treatment varies important because treatment varies depending on the underlying disease depending on the underlying disease processprocess

Wound Classifications/Healing Wound Classifications/Healing ProcessProcess

Primary intention- wound that is Primary intention- wound that is closedclosed

Secondary intention- wound edges Secondary intention- wound edges are not approximatedare not approximated

Tertiary intention- wound is left Tertiary intention- wound is left open for several days to assess open for several days to assess infection/healing process then the infection/healing process then the wound edges are approximated wound edges are approximated (P&P- 1284-5)(P&P- 1284-5)

Complications of Wound Complications of Wound HealingHealing

HemorrhageHemorrhage InfectionInfection Dehiscence-the partial or total Dehiscence-the partial or total

separation of wound layersseparation of wound layers Evisceration-with total separation of Evisceration-with total separation of

wound layers- penetration of visceral wound layers- penetration of visceral organs through a wound opening organs through a wound opening sometimes occurs-this is an sometimes occurs-this is an emergency and needs surgical repairemergency and needs surgical repair

Types of wound drainageTypes of wound drainage

SerousSerous PurulentPurulent SerosanguineousSerosanguineous SanguineousSanguineous (pg. 1287)(pg. 1287)

ReferenceReference

Potter, P. A., & Perry, A. G. (2009). Potter, P. A., & Perry, A. G. (2009). Fundamentals of NursingFundamentals of Nursing, 7, 7thth Ed. St. Ed. St. Louis, MO: Mosby.Louis, MO: Mosby.