why skin matters?! · images have been removed from the powerpoint slides in this handout due to...
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![Page 1: Why Skin Matters?! · Images have been removed from the PowerPoint slides in this handout due to copyright restrictions. Wound Care 1 ©TCHP Education Consortium, November 2012, Revised](https://reader033.vdocuments.net/reader033/viewer/2022043012/5faa021cf5349277c662486c/html5/thumbnails/1.jpg)
Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Wound Care©TCHP Education Consortium, 11/2012,
Rev. May 20201
Why Skin Matters?!TCHP Wound Care Class
Skin Assessment
Wound Ostomy Continence Team
Overview of “Why Skin Matters”
• Cost of HAPU $$$$• Pressure ulcers cost ~$11.6 billion per year in the US. • Cost of individual patient care ranges from $500 to $152,000 per pressure ulcer.
• Minnesota Adverse Health Care Events Reporting Law in 2005 – 1st in Nation• Center for Medicare and Medicaid Services – Oct 1, 2008
Legal: More than 17,000 lawsuits related to PU/ year
87% of verdicts from NH cases goes to Plaintiff
Average award is $13.5 million
Highest award is $312 million in one case!
It is the second most common claim after wrongful death and greater than falls or emotional distress.
Significance
• Reduced quality of life• Patients & caregivers
• Increased morbidity and mortality • About 60,000 patients die each year.
• Pain and discomfort
• Stress
• Anxiety
• Depression
• Decreased autonomy, spiritual and security
• Decreased social functioning
Anatomy and Physiology of Skin
• Largest organ of the body!
• Weight: 6‐8 pounds
• Size of adult skin: 3000 square inches
• Thickness varies:• 0.5mm – 6mm
• Eyelids vs palms or soles of feet
• Receives 1/3 of the bloodsupply in the body
Anatomy and Physiology of Skin
• Has the ability to self‐regenerate every 4‐6 weeks• This is a defense mechanism against infection
• Skin is constantly exposed to changing environments
Seen here in a scanning electron micrograph, the epidermis is a tough coating formed from overlapping layers of dead skin cells, which continually slough off and are replaced with cells from the living layers beneath.‐National Geographic
Anatomy and Physiology of Skin
• pH is 4‐6.5 (average is 5.5)• This is called the “acid mantle”
• Protects against bacteria• The more basic pH = more prone to bacteria
• Soap and water = alkaline
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Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Wound Care©TCHP Education Consortium, 11/2012,
Rev. May 20202
Skin pH
• Skin pH is 4‐6.8 with mean of 5.5• Depends on area of body
• Urine, stool, soap and frequent cleansing will increase pH to more basic levels• Pooled urine changes pH to 7.1 – or alkaline shift = this contributes to overgrowth of bacteria
• Patients with fecal incontinence are 22x more likely to
develop pressure ulcers
Skin Layers: Epidermis
Outermost layer made of epidermal cells
Thin and avascular
Repairs and regenerates itself
Skin Layers: Epidermis
• Function of Epidermis:• Protective barrier• Organization of cell content• Synthesis of Vitamin D
• Division and mobilization of cells
• Maintain contact with dermis
• Pigmentation – (contains melanocytes)
• Allergen recognition • Differentiates into hair, nails, sweat glands and sebaceous glands
Skin Layers
•Dermis• Thicker layer• Contains a network of:
• blood vessels
• hair follicles
• lymphatic vessels
• sebaceous glands
• sweat and scent glands
• nerve endings
Skin Layers: Dermis
• Function of the Dermis:• Supports structure
• Interlocking dermal‐epidermal junction
• Mechanical strength
• Supplies nutrition• Resists shearing forces• Inflammatory response
Skin Layers: Dermis
•Made up of Protein: Collagen and Elastin• Collagen: major structural protein that gives skin its strength
• Elastin: responsible for skin recoil and resiliency• Allows skin to be stretched and released
• Collagen anchors dermis to hypodermis (subcutaneous tissue) which covers fascia, muscle and bone
![Page 3: Why Skin Matters?! · Images have been removed from the PowerPoint slides in this handout due to copyright restrictions. Wound Care 1 ©TCHP Education Consortium, November 2012, Revised](https://reader033.vdocuments.net/reader033/viewer/2022043012/5faa021cf5349277c662486c/html5/thumbnails/3.jpg)
Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Wound Care©TCHP Education Consortium, 11/2012,
Rev. May 20203
Skin Layers: Hypodermis
• Subcutaneous Tissue• Composed of adipose and connective tissue
• Filled with major blood vessels, nerves and lymphatic vessels
• Attaches dermis to underlying structures• Holds skin in place to cover bones and muscles
• Provides thermal insulation and cushioning to body
• Acts as a ready reserve of energy• Mechanical “shock absorber”
Functions of Skin
•Body Image•Sensation •Regulation of body temperatures•Protection•Metabolism of vitamin D formation •Maintains water balance
Functions of Skin
Body Image Maintenance of body form
Appearance
Attributes
Expression
Functions of Skin
•Sensation• Abundant nerve receptors in skin• Touch • Heat/Cold• Pain/ Itch• Pressure • Moisture
Lack of sensation = HIGH risk for pressure ulcers!!!!
Most sensitive areas = increased nerve endings:
LipsNipplesFingertips
Functions of Skin
• Regulation of body temperature • 98.6 F / 37 C
• Thermoregulatory mechanisms:• Circulation
• Blood vessels dilate to dissipate heat
• Blood vessels constrict to shunt heat to body organs
• Sweating
• 2‐5 million sweat glands
Functions of Skin
•Protection• Safety against sunburn• Melanin in the epidermal cells protects against ultraviolet light
• Metabolism• Vitamin D formation
• Presence of sunlight
• This activates the metabolism of calcium and phosphate and minerals (important in bone formation)
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Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Wound Care©TCHP Education Consortium, 11/2012,
Rev. May 20204
Functions of Skin
• Protection• Barrier to germs and poisons
• Normal floral = • Staph Aureus• Diphtheroids• Gram neg bacilli• NOT Candida
• Chemical defenses
• Sweat, oils, wax from skin glands contain lactic acid and fatty acid
• These acids make skin pH acidic to kill bacteria and fungi
Functions of Skin
• Maintenance of water balance
• Prevents loss of water through evaporation• < 10% moisture –cells shrink = increase invasion of bacteria• > 30‐40% moisture level = maceration
• Increased permeability• Increased risk of injury from friction
Healthy Skin
• Protect from Sun• Wear sunscreen
• Don’t smoke• Narrows blood vessels to skin• Depletes of oxygen and nutrients• Damages collagen and elastin• Increase in wrinkles
• Be gentle on skin• Moisturize
• Nutrition• Eat fruits, vegetables, whole grains and lean proteins• Drink plenty of water
• Manage stress
Skin Challengeswith Aging
• Age‐Related changes:• Functions decline• Epidermal/dermal junction flattens
• Decreases skin strength
• Increases risk for tearing
• 20% loss of dermal thickness = paper thin skin• Reduction of collagen fibers, blood vessels, nerve endings
• Reduction of hormones = delayed wound healing
• Melanocytes shrink (decrease in volume)• Increases sensitivity to sun
Skin Challengeswith Aging
• Age‐Related changes:• Decreased sweat production
• Leads to increased dryness and flaking
• Less able to retain moisture = risk of dehydration
• Reduction in pain perception• Vulnerable to trauma from shoes/stepping on objects
• Nutrition changes• Medications – steroids, antibiotics can change skin flora
Skin Challenges at End of Life
• Risk factors• Aging• Dry and fragile skin• Poor healing• Prone to injury• Immobility
• Tissue ischemia
• Poor nutrition/hydration• Impaired oxygenation
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Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Wound Care©TCHP Education Consortium, 11/2012,
Rev. May 20205
Skin Challenges with Bariatric Population
• In 2015–2016, the prevalence of obesity was 39.8% in adults and 18.5% in youth.
• Changes in skin physiology:• Greater skin to weight ratio• Reduced vascularity and perfusion• Increase moisture
• Skin folds are source of redness, moisture, pressure ulcers
• Watch for cellulitis, skin infections, lymphedema, intertrigo and pressure ulcers
Skin Challenges with SCI Population
• 450,000 persons are living with SCI in USA• 8000 NEW SCIs every year
• 82% Males• Ages 16‐30
• Causes:• Motor vehicle accidents (44%)• Acts of violence (24%)• Falls (22%)• Sports (8%) (2/3 of sports injuries are from diving)• Other (2%)
• Average age = 33.4 years old
• Quadriplegia is slightly more common than paraplegia.
Skin Challenges with SCI Population
• Risk factors for pressure ulcers• Immobility
• Urinary incontinence• Severe spasticity• Preexisting conditions
• Advanced age, smoking, lung/cardiac disease, diabetes, impaired cognition
• Residence in a nursing home
• Malnutrition and anemia
Start Seeing Skin!
Elements of Basic Skin Assessment
• Remember to look at the WHOLE patient and not just the HOLE in the patient!!!!
Elements of Basic Skin Assessment
• Temperature• Normally warm to touch
• Warmer = inflammation
• Cooler = poor vascularization
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Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Wound Care©TCHP Education Consortium, 11/2012,
Rev. May 20206
Elements of Basic Skin Assessment
• Color• Intensity:
• Pale = poor circulation
• Normal color tones:
• light ivory to deep brown
• Yellow to olive
• Light pink to dark ruddy pink
• Hyperpigmentation or Hypopigmentation
• Variation is melanin deposits?
• Blood flow concerns?
Elements of Basic Skin Assessment
• Moisture• Dry or moist to touch
• Hyperkeratosis (flaking, scales)• Eczema
• Dermatitis, psoriasis, rashes
• Edema
Elements of Basic Skin Assessment
• Turgor• Normally returns to original state quickly
• Slow return = dehydration? Aging?
Elements of Basic Skin Assessment
• Integrity• No open areas• Types of skin injury
• Trauma/burns
• Pressure/ neuropathic ulcers
• Vascular wounds
• Arterial wounds
• Surgical wounds
• Refer to wound assessment/ documentation
Watch out for……
• FLT’s…….• Funny Little Things
Look under devices!
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Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Wound Care©TCHP Education Consortium, 11/2012,
Rev. May 20207
Comprehensive Skin Assessment
• https://www.youtube.com/watch?v=L1OpaWDAv_A
How Skin Heals
Partial Thickness Damage
• Partial thickness skin damage• Damage is confined to the epidermis and superficial dermis skin layers
• Shallow wounds• Wounds are moist and painful
(due to exposure of nerve endings)
• Wounds are bright pink or red
• Wound edges are often torn in appearance
• Vulnerable to further damage from moisture or friction
How Partial Thickness Injuries Heal
• Repair of partial thickness skin damage• Regeneration
• Damage is confined to epidermal and superficial dermal layers – collagen matrix of dermis is intact
• Epithelial cells will reproduce
• Trauma triggers inflammatory response• Erythema, Edema, Serous exudate
• Epidermal resurfacing begins
• Day 7 ‐ new blood vessels sprout• Day 9‐ Collagen fibers are visible
• Collagen synthesis continues until about day 10‐15
Full Thickness Damage
• Full thickness skin damage• Damage involves total loss of skin layers
• (epidermis and dermis and deeper layers)
• Ischemic changes from pressure can damage tissue deep inside
How Full Thickness Injuries Heal
• Repair of full thickness skin damage• Scar formation
• Damage is deeper – to deeper dermal structures (hair follicles, sebaceous glands and sweat glands), subcutaneous tissue, muscle, tendons, ligaments, bone
• Damage is permanent.
• Healing is done by primary or secondary intention• Primary intention – surgical closure
• Secondary intention –scar formation
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Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Wound Care©TCHP Education Consortium, 11/2012,
Rev. May 20208
Scar formation process
• Scar formation process is complex with several phases:• Hemostasis phase
• Clot formation
• Inflammatory phase• Clean up phase
• Takes 3‐4 days usually
• Proliferation phase• Vascular integrity restored
• New connective tissue is growing
• Granulation tissue growth
• Wound contraction
• Maturation / Remodeling phase• Strength remains less than normal
Prolonged Inflammatory Phase
Stuck in Inflammatory phase – Colonization to Infection
• When host resistance fails to control the growth of microorganisms, localized wound infection results!
Prolonged Inflammatory Phase
• Contaminated and Colonized• Bacteria are present within the wound• There is a steady state of replicating organisms that maintain a presence in the wound but do not cause delayed healing
Prolonged Inflammatory Phase
• Critically Colonized• The bacterial burden in the wound bed is increasing.• This burden initiates the body’s immune response locally but not systemically
• The wound is no longer healing at the expected rate
Prolonged Inflammatory Phase
• Infected• Bacteria are present within the wound and are multiplying
• There is an associated host immune response locally and then systemically
• The wound is painful and may increase in size.
• Patient presents at ill – fever, chills, elevated inflammatory labs, wound culture positive
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Images have been removed from the PowerPoint slides in this handout due to copyright restrictions.
Wound Care©TCHP Education Consortium, 11/2012,
Rev. May 20209
Skin Is Oriented to Healing
• We need to:• Catch it early! …. Frequent skin inspections!!!• Create the environment to promote wound healing!!!!
References
• Wound Care Essentials, Sharon Baranoski and Elizabeth Ayello
• Health Research & Educational Trust (2017, April). Hospital Acquired Pressure Ulcers/ Injuries (HAPU/I): 2017. Chicago, IL: Health Research & Educational Trust. Accessed at http://www.hret‐hiin.org/
• Acute and Chronic Wounds: Current Management Concepts, 3rd
Edition, Ruth Bryant and Denise Nix
References
• Overview. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/puover.html
• The Joint Commission. Quick Safety 43: Managing medical device‐related pressure injuries, July 2018
• National Pressure Ulcer Advisory Panel (NPUAP). NPUAP Pressure Injury Stages (accessed Oct 8, 2018)
• Are we ready for this change?. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool1.html
References
• Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, 2015–2016. NCHS data brief, no 288. Hyattsville, MD: National Center for Health Statistics. 201
• National Spinal Cord Injury Association Resource Center Fact Sheets. 2002‐18 Spinal Cord Injury Information Pages. https://www.sci‐info‐pages.com/factsheets.html#Factsheet #2:
• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Third Ed.). Cambridge Media: Osborne Park, Western Australia; 2019