Lesson 3: Skin Loss Via External Factors Flashcards
Friction Injury
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
Skin Tears
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
Medical Adhesive Related Skin Injury (MARSI)
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
Incontinence-Associated Dermatitis
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
Dimethicone
- Non-occlusive and nongreasy
- Level I treatment
- For urine + formed stool
Petrolatum
- For urine + formed stool
- Must be thin
Zinc Oxide
For liquid stool
Liquid Barrier Films
- For urine + formed stool
- Daily application
Intertriginous Dermatitis
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
Periwound MASD
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
Peristomal MASD
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
Hospital-Acquired Pressure Injury - Role of the RN
- Support surfaces/chair cushions
- Heel offloading boots
- Turning + repositioning patients
- Skin protection products
- Moisture management products
- Staff education
Key Elements of Pressure Injury Prevention
- 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
Support Surfaces - Contributory Factors
- Weight
- Falls risk
- Mobility
- Exposure to moisture
- Existing breakdown
Pressure relief
: total offloading of surface (ie. Heels off bed)
Pressure redistribution
surface that evenly distributes pressure and reduces interference to blood flow
Constant low pressure
constant redistribution of pressure via immersion and envelopment
Immersion
extent to which patient “sinks” into surface
Envelopmentt
conformability of the surface
Alternating pressure (AP)
surface with air chambers that is alternatively inflated and deflated
Reactive
surface “reacts” to patient’s weight and position changes but conforming to body contours but NOT changing pressure points
Active
powered surface with alternating pressure due to presence of air chambers
Low air loss
microperforations in mattress to permit low volume air flow
Air fluidized
tank filled with beads that creates a fluid medium to device is powered on
