Skin Integrity/Wound Care Overview Presented by Felecia Briggs MS, APRN-C June 5th, 2010

Skin Skin is the largest body organ, constituting approximately 15% of the total adult body weight 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 is a protective barrier against disease causing organisms, a sensory organ for pain, temperature, and touch It synthesizes vitamin D 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) *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 The skin has two layers but are separated by a membrane often referred to as the dermal-epidermal junction. 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. 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. 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. 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 It also allows evaporation of water from the skin and permits absorption of certain topical medications

The Dermis The inner layer of the skin provides tensile strength, mechanical support, and protection to the underlying bones, muscles, and organs. 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. 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. 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. Fibroblasts, which are responsible for collagen formation are the only distinctive cell type within the dermis.

Injury 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. 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 Age alter skin characteristics and makes it more vulnerable to damage

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

Aging issues con’t 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). 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 Concomitant medical conditions and polypharmacy also affect wound healing Aging causing a diminished inflammatory response, resulting in slow epithelialization and wound healing Aging causing a diminished inflammatory response, resulting in slow epithelialization and wound healing

Hypodermis 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. 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 Synonymous terms- pressure ulcer, pressure sore, decubitus ulcer, and bedsore are all terms used to describe impaired skin integrity due to unrelieved, prolonged pressure. 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 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 Any client experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition are at greater risk for pressure ulcer development 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 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: 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 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

Clinical presentation of obstructed blood flow After a period of tissue ischemia-if the pressure is relieved and the blood flow returns the area turn red. 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). 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. 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 Blanching occurs when the normal red tones of the light skinned client are absent. Blanching does not occur in clients with darkly pigmented skin. 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. 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 Understanding skin structure helps you maintain skin integrity and promote wound healing

Pressure duration Low pressure over a prolonged period causes tissue damage as well as high-intensity pressure over a shorted period of time 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 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 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 The ability of tissue to endure pressure depends upon the integrity of the tissue and the supporting structures. 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 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. 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. 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 sensory perception Impaired mobility Impaired mobility Alteration in level of consciousness Alteration in level of consciousness Shear Shear Friction Friction Moisture Moisture

Classification of pressure ulcers Stage I- Intact skin with nonblanchable redness of a localized area, usually over a bony prominence 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 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

Classification con’t 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). 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 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 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. 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 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 *Unstageable ulcer-bottom of page 1282

Wound with nonviable tissue Granulation tissue- is red moist tissue composed of new blood cells, the presence of which indicates progression towards healing 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 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 Measuring the size of the wound provides overall changes in size which is an indicator for wound healing progress. 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 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 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 Assess for any redness, warmth, maceration and edema- if present can be sign of wound deterioration

Wound Defined A wound is a disruption of the integrity and function of tissues in the body A wound is a disruption of the integrity and function of tissues in the body All wounds are not equal All wounds are not equal Knowing the etiology of the wound is important because treatment varies depending on the underlying disease process Knowing the etiology of the wound is important because treatment varies depending on the underlying disease process

Wound Classifications/Healing Process Primary intention- wound that is closed Primary intention- wound that is closed Secondary intention- wound edges are not approximated 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 ) Tertiary intention- wound is left open for several days to assess infection/healing process then the wound edges are approximated (P&P )

Complications of Wound Healing Hemorrhage Hemorrhage Infection Infection Dehiscence-the partial or total separation of wound layers 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 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 Serous Serous Purulent Purulent Serosanguineous Serosanguineous Sanguineous Sanguineous (pg. 1287) (pg. 1287)

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