Why Skin Matters?! · Images have been removed from the PowerPoint slides in this handout due to...
Transcript of Why Skin Matters?! · Images have been removed from the PowerPoint slides in this handout due to...
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
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
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)
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
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
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!
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
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
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