Lesson 3: Skin Loss Via External Factors

Question 1

Friction Injury

Answer 1

Mechanical disruption of superficial skin layers when skin rubs/drags against another surface

Presentation:
- Superficial skin loss with irregular edges
- Tender and painful
- Pink/red wound red
- If chronic = thickening of skin (lichenification)

Prevention
-Gentle skin care
Low friction support surfaces
Heel elevation
Protective dressings to vulnerable surfaces

Management
- Absorb exudate
- Maintain moist surface
- Protect against friction
- Can use non-adherent dressing or zinc-based ointments

Question 2

Skin Tears

Answer 2

Traumatic separation of epidermal + dermal layers
- Partial = epidermis from dermis
- Full = dermis from subcutaneous tissue

Classification
- Type I = no skin loss
- Type II = partial skin/flap loss
- Type III = total skin/flap loss

Prevention
- Minimize tape/adhesives to skin
- Hydrocolloid dressing to base
- Routine skin care
- Padding to surfaces

Management
- Manage exudate
- Maintain moist wound surface
- Prevent trauma with removal
- Use adaptic, gauze, and kling or a gentle adhesive foam

Question 3

Medical Adhesive Related Skin Injury (MARSI)

Answer 3

Erythema and/or other indicators of skin damage that persist >30 mins after removal of adhesive product
- mechanical (stripping)
- contact dermatitis
- maceration

Risk factors
- Extremes of age
- Intervention intense care areas (ICU, ER, OR)
- Fragile skin d/t malnutrition, dermatological conditions
- Cytotoxic therapy like chemo and radiation

Prevention
- Avoid patient sensitivities
- Non-adhesive securement options
- Pick products based on clinical requirements

Question 4

Incontinence-Associated Dermatitis

Answer 4

Repeated exposure to stool and/or urine
Skin loss d/t friction, irritants or pathogens

Risk factors
- Fecal + urinary incontinence (fecal worse than urine)
- Fragile skin d/t extremes of life

Presentation
- Erythema, macerated, tender, fungal rash
- Limited to areas exposure to urine and stool

Prevention
- Regular toileting
- Use of containment devices with cleansers and moisturizers
- Absorptive products and moisture barrier products (Calivon, dimethicone, petrolatum)

Treatment
- Mild IAD
— Erythema and tenderness but NO skin loss
— Initiate prevention program
— Containment/absorptive products
— PH-balanced cleanser
— Moisture barrier ointment or liquid spray barrier
- Severe IAD
— Erythema and tenderness with skin loss
— Zinc oxide moisture barrier via “crusting” with stoma powder
— Hydrophilic paste to adhere to moist surface
— Folded strips of zinc oxide impregnated dressing
- IAD with candidiasis
— Crust with topical antifungal like fluconazole
— Reassess prevention program

Question 5

Dimethicone

Answer 5

• Non-occlusive and nongreasy
• Level I treatment
• For urine + formed stool

Question 6

Petrolatum

Answer 6

• For urine + formed stool
• Must be thin

Question 7

Zinc Oxide

Answer 7

For liquid stool

Question 8

Liquid Barrier Films

Answer 8

• For urine + formed stool
• Daily application

Question 9

Intertriginous Dermatitis

Answer 9

Skin damage d/t trapped moisture between body folds and mechanical trauma

Skin loss d/t
- Friction between opposing skin folds
- Stretch forces to overhydrated skin

Presentation
- Linear breaks at base of body folds
“kissing” symmetrical lesions
- Macerated skin

Prevention
- Absorptive/wicking products to base of skin folds
- Support surfaces with air flow
- Non-occlusive moisture barrier ointments

Treatment
- Dressing that absorbs moisture and separates skin folds
- Use antifungals for candidiasis

Question 10

Periwound MASD

Answer 10

Damage to periwound skin caused by exposure to wound exudate

Primary mechanism: maceration + inflammation

Presentation
- Macerated/erythema of periwound skin
- Patchy areas of skin loss

Prevention + Treatment
- Select appropriate fill and cover dressing for volume of wound exudate
- Protect periwound skin with liquid barrier film
“crust” if indicated

Question 11

Peristomal MASD

Answer 11

Damage to peristomal skin d/t effluent exposure
- internal (perspiration)
- external (stool or urine)

Presentation
- Macerated/erythema of peristomal skin
- Patchy areas of skin loss
- Burning/itching

Prevention + Treatment
- Secure pouching system to reduce skin exposure
- Correct sizing for pouch application
- Use of ostomy paste or liquid barrier fold
- Appropriate pouch change frequency
“crust” if indicated

Question 12

Hospital-Acquired Pressure Injury - Role of the RN

Answer 12

• Support surfaces/chair cushions
• Heel offloading boots
• Turning + repositioning patients
• Skin protection products
• Moisture management products
• Staff education

Question 13

Key Elements of Pressure Injury Prevention

Answer 13

• Pressure redistribution surfaces
• Routine repositioning
• Measures to reduce friction and shear
• Measures to manage moisture
• Padding/repositioning for medical devices
• Nutritional assessment/intervention
• Routine skin care/assessment

Question 14

Support Surfaces - Contributory Factors

Answer 14

• Weight
• Falls risk
• Mobility
• Exposure to moisture
• Existing breakdown

Question 15

Pressure relief

Answer 15

: total offloading of surface (ie. Heels off bed)

Question 16

Pressure redistribution

Answer 16

surface that evenly distributes pressure and reduces interference to blood flow

Question 17

Constant low pressure

Answer 17

constant redistribution of pressure via immersion and envelopment

Question 18

Immersion

Answer 18

extent to which patient “sinks” into surface

Question 19

Envelopmentt

Answer 19

conformability of the surface

Question 20

Alternating pressure (AP)

Answer 20

surface with air chambers that is alternatively inflated and deflated

Question 21

Reactive

Answer 21

surface “reacts” to patient’s weight and position changes but conforming to body contours but NOT changing pressure points

Question 22

Active

Answer 22

powered surface with alternating pressure due to presence of air chambers

Question 23

Low air loss

Answer 23

microperforations in mattress to permit low volume air flow

Question 24

Air fluidized

Answer 24

tank filled with beads that creates a fluid medium to device is powered on

Question 25

Continuous lateral rotation therapy

Answer 25

surface designed to counteract pulmonary effects of immobility via constating oscillation of upper body

Question 26

Bariatric support surfaces:

Answer 26

for patients >300 lbs. or who’s girth prevents effective repositioning