Applied Skin Flashcards
Skin damage in nursing practice
- pressure ulcers
- surgical wounds
- traumatic wounds
- ulcerating cancers
- burns
- non-infectious/infectious conditions
- chronic LT conditions
- allergies
Nurses role in managing patients with skin damage
- to identify and assess patients skin including skin mapping
- identify risk factors
- carry out wound care
- aid patients with personal hygiene and continence needs
- escalate to MDT
- administer medications
SSKIN bundles
The SSKIN care bundle assessment to be used alongside the water low assessment tool
- Surface - equipment
- Skin inspection
- Keep moving - reposition schedule
- Incontinence - moisture may damage stratum corneum
- Nutrition - MUST score
Braden Q
Tool for assessing children’s pressure areas
Focuses of occipital area
Skin assessment and identifying risk
OBSERVE»_space;>colour, mottling, dry, loose, abrasion
TOUCH»_space;> clammy, wet, sensitive, cap refill
POSITIONING»_space;> repositioning, pain or movement
CLOTHING»_space;> lose, restrictive, soiled
MEDICATIONS»_space;> creams, steroids, allergies
SKIN CONDITIONS»_space;> chronic, acute, infectious
MALNUTRITION»_space;> assessed alongside SSKIN bundle
SKIN MAP»_space;> document and repeat weekly
Wound assessment»_space;> categorise the wound
- vascular - arterial/venous/both
- neuropathic (diabetic)
- moisture associated dermatitis
- skin tear
- pressure ulcer
Think of cause - may be multifactorial
Pressure ulcer
A localised injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure, or pressure combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers.
Moisture associated skin damage
A reactive response of the skin to excessive moisture from sweat, urine, faecal matter or wound exudate, which could be observed as an inflammation and erythema with or without erosion. Typically there is a loss of the epidermis and the skin appears macerated and painful.
Medical device related pressure ulcer
A pressure ulcer that had developed due to sustained pressure from a medical device such as a plaster cast, splint, O2 therapy, masks, tracheostomy or urinary catheters.
Stage 1 pressure ulcer
- intact skin with a localised area of non-blanchable erythema, which may appear differently in darkly pigmented skin
- presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes
- colour changes do not include purple or maroon discolouration, these may indicate deep tissue pressure injury
Stage 2 pressure ulcer
- partial thickness loss of skin with exposed dermis
- the wound bed is visible, pink/red, moist and may also present as an intact or ruptured serum-filled blister
- sub-cut/adipose is not visible, deeper tissues aren’t visible. Granulation tissue, slough and eschar aren’t present
Stage 3 pressure ulcer
- full thickness skin loss
- subcutaneous fat may be visible but bone, tendon or muscle aren’t exposed
- slough may be present but doesn’t obscure the depth of tissue loss. May include tunnelling
- depth of category 3 pressure ulcers vary by anatomical position. The bridge of nose, ear, occipital and alveolus don’t have subcutaneous tissue and therefore ulcers may be shallow.
Areas of significant adiposity can develop extremely deep category 3 pressure ulcers
Stage 4 pressure ulcers
- full thickness tissue with exposed bone, tendon or muscle
- slough or eschar may be present on some parts of the wound bed
- often includes tunnelling
- the depth of category 4 ulcers varies due to anatomical location
- category 4 ulcers can extend into muscle and supporting structures making osteomyelitis possible
- exposed bone/tenon is visible or directly palpable
Unstageable pressure ulcer
- depth unknown
- full thickness tissue loss in which the base of the ulcer is covered by eschar
- stable eschar on the heels serves as the body’s natural cover and should not be removed
Deep tissue injury
- resistant non-blanchable deep red areas of skin, intact or blood filled blisters caused by damage to underlying tissues
- common for a thin blister to form over the surface. Wound may be further covered by eschar
- these are often not visible until they have advanced to the point where treatment is significantly more problematic
- known to deteriorate quickly even under optimal care
Prevention is far more effective than cure:
- moisture lesions and the use of barrier creams
- pressure relieving devices»_space;> mattresses, cushions, etc
- skin massage
- nutritional interventions
- patient and carer education
- assessment and grading of pressure ulcers
- management»_space;> debridement and larval therapy
- negative pressure wound therapy and hyperbaric oxygen therapy
Wound healing - haemostasis
- happens within minutes
- vasoconstriction»_space;> reduce blood flow from damage vessels
- platelets detect collagen from damaged vessels and signal the formation of a fibrin clot
Wound healing - inflammation
- happens within 1-5 days
- vasodilation and release of histamine
- primary defence against pathogenic wound invasion
- histamine = capillary wall permeability and plasma proteins, leucocytes, antibodies and electrolytes exude into the surrounding tissues
- wound will become red, swollen and hot with tenderness for 1-3 days»_space;> may be mistaken for infection
- neutrophils , macrophages and lymphocytes»_space;> debris and bacteria
- diabetes»_space;> macrophages are reduced. Hypoxia wounds and malnourished wounds = delayed healing
- debris = osmolality increase and swelling increases, chronic wounds don’t progress from this stage, increase infection and levels of exudate. Wound swabs may reveal high levels of neutrophils = infection
Wound healing - proliferation
- happens within 3-24 days
- macrophages initiate fibroblasts to divide and produce collagen
- primary sutured wounds may feel like they have a ridge below an intact suture line - collagen formation
- angiogenesis»_space;> formation of new blood vessels. Join existing blood vessels forming loops. These are fragile and held with a collagen matrix
- granulation tissue»_space;> angiogenesis, granulation and collagen = wound edge contraction
- mitosis and epithelial migration»_space;> re-epithelialisation occurs and spans the granulating wound bed. Keratinocytes change polarity and span the wound front to rear migrating laterally across the wound = re-epithelialisation
- O2 optimal nutritional levels, protein, carbs, iron, vitamins A+C are vital
- hair follicles can re-grow from damaged appendages but in full thickness wounds they only grow around the outside of the wound hence why some scars are hairless
Wound healing - maturation - remodelling
- happens within 21 days
- collagen rich scar = several years
- collagen remodels to emulate pre-injury skin
- scar tissue is avascular, blood vessels are rationalised = thinning and fading of the scar
- the integrity of a scar will never reach that of undamaged skin, up desmosomes
- elastin that makes a scar more flexible can take several months to appear in skin tissue
Wound healing methods
PRIMARY INTENTION - union of wound edges under aseptic conditions (surgical traumatic laceration) with sutures
SECONDARY INTENTION - left open, heals through contraction and epithelialisation. Less cosmetic and likely to become infected
TERTIARY INTENTION - delayed primary closure, allows swelling and bleeding to reduce enforce primary closure
The skin and its functions applied to nursing»_space;> thermoregulation
- skin loses and insulates against heat loss
- evaporation, convection, conduction and radiation
- the hypothalamus responds to the temperature of the circulating blood
- arterioles in the dermis constrict, decreasing blood flow
- arterioles dilate cooling the body and sweat glands are stimulated
- inflammatory cells and pyrogens will increase the hypothalamus ‘thermostat’ an the body will retain heat until the increased temp is reached and then through sweating the body cools = pink, flushed skin
- temperature regulation is less effective in babies and small children
- hypothermia is one of the reversible causes of a cardiac arrest
The skin and its functions applied to nursing»_space;> formation of vitamin D
- lipid based 7-dehydrocholesterol in the skin is converted to vitamin D by the sunlight
- alongside calcium and phosphate = formation of bone
Treatment - supplements
- light therapy
- dietary advice
Complications - at risk»_space;> milk intolerances, vegan diets
- rickets, increase risk of CHD, cognitive impairment in older adults, asthma in children, cancer
Therefore the nurse has a role to identify, manage and promote vitamin D uptake
Other functions of the skin
Absorption
»> limited, transdermal patches, toxicity
Excretion
»> sweat, urea
Common disorders of the skin
- HPV
- herpes
- impetigo
- cellulitis
- ring worm
- dermatitis
- psoriasis
- acne vulgaris
- melanoma
