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

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


• 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


• 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



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



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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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



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!!!!


• Temperature• Normally warm to touch

• Warmer = inflammation

• Cooler = poor vascularization



Rev. May 20206


• 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?


• Moisture• Dry or moist to touch

• Hyperkeratosis (flaking, scales)• Eczema

• Dermatitis, psoriasis, rashes

• Edema


• Turgor• Normally returns to original state quickly

• Slow return = dehydration? Aging?


• 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!



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



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!


• 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


• 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


• 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



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

Documents

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