2. This Photo by Unknown Author is licensed under CC BY-NC
3. Function of Skin
Primary Function: ACT AS A BARRIER
Protection from:
Mechanical Impacts & Pressure
Variations in temperature
Micro-organisms
Radiation
Chemicals
4. Skin Integrity
Skin health:
May be healthy, damaged, vulnerable to injury or unable to heal
normally.
Skin Assessment:
• Color
• Moisture
• Temperature
• Texture
• Mobility
• Turgor
• Lesions
5. Factors that affect skin
integrity
• Age
• Impaired circulation
• Fever
• Infection
• Lifestyle
• Mobility
• Medications
• Moisture of skin
• Nutrition/hydration
• Sensation/cognition
7. Pressure Injuries (Ulcers)
Pressure Injury – localized injury to the skin and other
underlying tissue, usually over a bony prominence as a
result of pressure or pressure in combination with
friction and/or shear.
Prolonged intense pressure affects cellular metabolism by
decreasing blood flow, resulting in tissue ischemia &
ultimately tissue death.
9. Causes of Pressure Injuries and
Skin Integrity Issues
Most Common Cause of is constant pressure to the skin.
Other Causes:
Sliding down a chair or bed
Pulling across a chair or bed
Irritation for sweat or other bodily fluids
Paralysis
Unable to feel pain or pressure
Braces, casts or wheelchairs
A lot of time in one position
Incontinence
Overweight or obese
Poor nutrition
13. Patients at risk for developing pressure
ulcers
Older Adults –thinning of underlying muscle and tissues,
reduced collagen, reduced elasticity
Patients with Spinal Cord Injuries – decreased sensation
Patients with hx of Fractured Hip – decreased mobility
Patients in long-term nursing facilities – decreased
mobility, nutrition, generally elderly
Patients with Diabetes – nerve damage and poor
circulation
Patients in Critical Care Settings – decreased mobility,
perfusion
14. Risk Factors include
Three pressure related factors that contribute to PU
development include
1) Pressure intensity – pressure applied > normal capillary
pressure leads to tissue ischemia
2) Pressure duration - low pressure long period, high pressure
short
3) Tissue tolerance – depends on integrity of tissue and
supporting structures
15. Braden Scale
• Risk Assessment to determine if a client is prone to a skin break down
related to
• Sensory Perception: Responsiveness
• Moisture: Dry skin is the most protected, ?incontinence
• Activity: Bedfast to walking frequently
• Mobility: Can pt adjust/reposition body by self
• Nutrition: The amount of nutritional support
• Friction and Shear: sliding movement of skin & subcutaneous tissues
while muscle & bone are stationary (e.g. transfer pt from bed to
stretcher & skin & subcutaneous layers adhere to bed surface & muscle
& bones slide in direction of body movement). Tissue damage to
dermis. Sliding across bed linens – damage epidermis
• Add up risks to get a number value.
• Mild Risk 16-18
• Moderate Risk: 13-14
• High Risk: 9 or less
16.
17. Staging/classification
Stage I
• Intact skin with nonblanchable redness
Stage II
• Partial-thickness skin loss involving epidermis, dermis, or both. Shallow,
open ulcer with red-pink wound bed. No slough. May be intact or open
blister.
Stage III
• Full-thickness tissue loss with visible fat. May have slough.
Stage IV
• Full-thickness tissue loss with visible bone, muscle, or tendon. Often includes
tunneling.
•Unstageable/Unclassified: Full thickness Skin or Tissue Loss, Depth Unknown –
completely obscured by slough or eschar
30. Deep Tissue Injury
• A deep tissue injury is a unique form of pressure ulcer. The
National Pressure Ulcer Advisory Panel defines a deep tissue
injury as “A pressure-related injury to subcutaneous tissues
under intact skin. Initially, these lesions have the appearance
of a deep bruise. These lesions may herald the subsequent
development of a Stage III-IV pressure ulcer even with optimal
treatment.”(NPAUP, 2005).
• Even with proper treatment, deep tissue injuries can
deteriorate quickly
31. Deep Tissue Injury
• Here’s how NPUAP describes these ulcers:
• Localized area of maroon or purplish discoloration of intact
skin OR a blood-filled blister that forms due to shear and/or
pressure
• Prior to the identification of the discolored area, the skin may
feel boggy, firm, mushy, painful, cooler or warmer than the
surrounding skin
• The wound may progress to a thin blister overlaying a dark
wound bed, which may eventually be covered by eschar
• Additional tissue layers may become rapidly exposed even
with optimal treatment
32.
33.
34. Documentation/Description
• To describe a wound bed in pressure ulcers:
• Location of wound
• Size and shape
• Colors are often used: red-yellow-black
• Red-Granulation tissue – red moist, tissue composed
of new blood vessels. First step in healing OR exposure
of the underlying muscle
• Yellow - Slough is covering subcutaneous tissue or
deeper structure in the wound bed. Dead tissue.
Stringy/creamy substance.
• Black - Eschar- Can’t be staged until eschar is
surgically removed. (May be brown or tan or necrotic)
36. Nursing Diagnoses
Risk for Infection
Imbalanced Nutrition: Less than body requirements
Impaired Physical Mobility
Impaired (or Risk for Impaired) Skin Integrity (acute or chronic)
Ineffective Peripheral Tissue Perfusion
Impaired Tissue Integrity
Body Image Disturbance
Knowledge Deficit
Pain
37. Nursing Interventions
• Conduct a pressure assessment for ALL patients every
shift.
• Inspect skin at least daily.
• Reposition:
• In bed: every two hours. Keep HOB elevated at least
30 degrees
• In chair: every 20 minutes
• Manage moisture.
• Sweat, urine, stool, spills
• Optimize nutrition & hydration.
• Promotes healthy skin
• Minimize pressure & sheering.
• LIFT don’t pull!
38. Nursing interventions
• Barrier ointments & creams
• Special devices & air beds
• Assess skin around areas around medical devices
39. Goal
• PREVENTION!!!!
• Wound Goals: to maintain a moist wound bed that’s free of
infection and necrotic tissue and to keep the surrounding skin
dry. To prevent infection.
• Adequate Nutrition
• Adequate calories (30-35kcal/kg/day)
• Protein (1.25-1.5 g/kg)
• Vitamin C 1000 mg daily
• Vitamin A 1600-2000 retinol equivalents per day
• Zinc – 15-30 mg daily
• Fluid – 30-35 mL/kg/day
• Supplemental feedings may be necessary
40. Treatment
• Once the wound is staged, the treatment proceeds
• Wound Cleaning Normal Saline until MD order
• Application of appropriate dressing
• May need debridement
• Nutrition consult
• Wound care specialist prn
41. Ways to debride a wound
1. Biological debridement is the use of maggots.
2. Enzymatic debridement is performed by the
application of a prescribed topical agent that chemically
liquefies necrotic tissues with enzymes.
3. Autolytic debridement is the slowest, most commonly
used in the long-term care setting. This method uses the
body's own enzymes and moisture beneath a dressing.
4. Mechanical debridement is by irrigation, hydrotherapy,
wet-to-dry dressings, and an abraded technique.
5. Surgical sharp and conservative sharp
debridement is performed by a skilled practitioner using
surgical instruments such as scalpel, curette, scissors,
and forceps.
42. Documentation
• The size & location of the wound
• The amount, color, consistency and odor of exudate
• The presence or absence of necrotic tissue
• The presence of sinus tracts (tunneling)
• The presence or absence of granulation tissue (healing)
• The presence or absence of epithelialization (new
healthy skin)
43. Documentation
• Document any treatments and/or dressing
changes
• Document pain – before, during, after treatment
• Pt’s tolerance of procedure
• If a patient can’t talk
• OBSERVE for nonverbal expressions of pain
• Grimacing
• Increased moaning with examination
