skin integrity and wound care

• ·       Protective barrier against the disease-causing organism

  ·       Sensory organ for pain

  ·       Temperature and touch

  ·       Synthesize vitamin d


  skin
• • Is a complex cellular and biochemical processes and is affected by systemic and local factors

  wound healing
• • is the thin outermost layer of the epidermis, It consist of flattened, dead, keratinized cells

  stratum corneum
• • cells in this layer divides, proliferate, and migrate towards epidermal surface after they reach the stratum corneum the flattened and die

  basal layer
• ·       protect underlying cells and tissues from dehydration and prevents entrance of certain chemical agents

  ·       allows evaporation from the skin and permits absorption of certain topical medication

  thin stratum layer
• inner layer of the skin, provides tensile strength and mechanical support

  protection from underlying muscle, bones and organs

  blood vessels and nerves are found in this layer

  dermis
• tough fibrous protein


  collagen
• responsible for collagen formation, are the only distinctive cell type within the dermis

  fibroblast
• impaired skin integrity related to unrelieved, prolonged pressure

  pressure ulcers
• localized damage to the skin and underlying soft tissue, usually developing over a bony prominence or related to pressure from a medical device or other device

  pressure injury
• microclimate

  nutrition

  perfusion

  comorbidities

  condition of soft tissues


  the tolerance of soft tissue for pressure and shear may also be affected
• individual who have experience trauma

  individual with SCI

  Individual who have sustained a fractured hip

  Individual with diabetes mellitus


  patient who are at risk in developing pressure injury
• major elements of pressure injury

  pressure
• receive oxygen and nutrients and eliminates metabolic wastes via the blood

  tissue
• when the pressure applied over a capillary exceeds the normal capillary pressure and the blood vessel occluded for prolonged period

  tissue ischemia
• if the pressure is relieved and the blood flows return, the skin turns red. the effects this redness is cause by vasodilation, called hyperemia
• if you press finger over affected area and if it turns lighter in color the when you remove it, erythema returns

  blanchable hyperemia
• if the erythematous does not blanch when you apply pressure, deep tissue damage is probable

  nonblanchable erythema
• occurs when the normal red tones of the light-skinned patient are absent

  blanching
• ability of tissue to endure pressure depends on the integrity of the tissues and supporting structures

  tissue tolerance
• affects the ability of the skin to tolerate pressure

  extrinsic factors of shear, friction, and moisture
• patient with altered sensory perception for pain and pressure are more at risk for impaired skin integrity. They are unable to feel when a part of their body undergoes increased prolonged pressure or pain . Thus a patient who cannot feel or sense that there is pain or pressure is at risk for the development of pressure injury

  impaired sensory perception
• patient who are unable to independently change positions are at risk for pressure injury

  impaired immobility
• sliding movement of skin and subcutaneous tissue while the underlying muscle are stationary

  shear force
• patient who are restless, in those who have uncrontrollable movements such as spastic conditions, and in those whose skin is dragged rather than lifted from the bed surface during position changes o transfer to a stretcher

  friction
• reduces the resistance of the skin to other physical factors such as pressure, friction, or shear

  moisture
• prolonged moisture softens the skin, making it more suspectable to damage
• inflammation and erosion of the skin caused by prolonged exposure o various sources of moisture, including wound drainage, urine or stool, perspiration, wound exudate, or saliva

  moisture-associated skin infection
• describe the pressure injury depth at the time of the assessment

  pressure injury staging
• intact skin, color changes do not included purple or maroon discoloration

  Stage1 pressure injury
• partial-thickness skin-loss with exposed dermis. the wound is viable, pink or red and moist and may also present as an intact or raptured serum-filled blister

  Stage 2 pressure injury