Skin Flashcards
What is SSKIN Bundles?
Assessment of skin integrity
Used in adult nursing care
S - surface
S - skin inspection
K - keep moving (assessment, repositioning schedule, prevention)
I - incontinence/moisture (moisture damages Stratum Corneum)
N - nutrition
What things are you looking for in a skin assessment and when identifying risks?
Observe - colour, dry, loose, oedematous, wound - history, erythema (redness), self hygiene
Touch - clammy/moist, soiled/wet, sensitive, CRT
Positioning - ability to re-position, pain on movement
Clothing - loose, restrictive, soiled
Medications - creams, steroids, allergies
Skin conditions - chronic, infectious
Malnutrition- alongside SSKN bundle
Skin map - document, photograph
What is the definition of a pressure ulcer?
A localised injury to the skin and/or underlying tissue as a result of pressure
What is the definition of medical device related pressure ulcer (MDRPU)?
A pressure ulcer that developed due to sustained pressure from a medical device like plaster cast, O2 therapy masks, tracheostomy tubing etc
What is the definition of moisture associated skin damage (MASD)?
Reactive response of the skin to chronic exposure to excessive moisture from sweat, urine, faecal matter which could be observed as inflammation and erythema. Loss of epidermis and skin appears macerated, red, broken and painful
What is a stage 1 pressure ulcer?
Intact skin with an area of non-blanchable erythema
Changes in sensation, temperature, or firmness
Colour changes do not include purple or maroon (these may indicate deep tissue)
What is a stage 2 pressure ulcer?
Partial thickness loss of skin with exposed dermis
Wound bed is viable, pink or red, moist, intact or ruptured serum-filled blister
Subcutaneous/adipose is not visible and deeper tissues are not visible
Granulation tissue, slough and Escher are not present
What is a stage 3 pressure ulcer?
Full thickness skin loss
Subcutaneous fat may be visible but bone, tendon or muscle and not exposed
Slough may be present but does not obscure the depth of tissue loss
What is a stage 4 pressure ulcer?
Full thickness tissue with exposed bone, tendon or muscle
Slough or eschar may be present on some parts of the wound bed
Includes undermining or tunnelling
Can extend into muscle and/or supporting structures (tendon or joint capsule) making osteomyelitis (infection of the bone) possible.
What is an unstageable pressure ulcer?
Depth unknown
Full thickness tissue loss
Base of ulcer is covered in slough in the wound bed
Until slough and/or eschar (necrotic tissue which is dryer than slough) is removed to expose base of the wound, the true depth and category cannot be determines
Stable eschar on heels serves as the body’s natural cover and should not be removed
What is a deep tissue injury?
DTPI
They are persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to underlying soft tissues
They can deteriorate quickly
What are the preventative measures or pressure ulcers?
Moisture lesions
Pressure-relieving devices - mattresses, beds
Skin massage/repositioning
Nutritional interventions as preventative strategies for people with and without deficiencies
Patient and career education
Assessment and grading of ulcers
Management such as debridement
What are the 3 stages of wound healing?
Inflammation
Proliferation
Maturation
How does the first step of wound healing progress?
1-5 days
Vasodilation and release of histamine
Primary defence
The wound will become red, swollen and hot, with tenderness for 1-3 days
Neutrophils, macrophages and lymphocytes- debris and bacteria + secrete cytokines and growth factors
Diabetes - macrophages are reduced. Hypoxic wounds and malnourished wounds = delayed healing
Debris = osmolality increase and swelling increases, chronic wounds don’t progress from this stage and increase infection and higher levels of exudate.
How does the second stage of wound healing progress?
3-24 days
Macrophages initiate fibroblasts and to divide and produce collagen
Angiogenesis - formation of new blood vessels, joining existing blood vessels forming loops. Fragile and held within a collagen matrix
Granulation tissue - angiogenesis, granulation and collagen = wound edge contraction
Mitosis and epithelial migration - re-epithelialisation occurs and spans the granulating wound bed. Keratinocytes change polarity and span the wound
O2, optimal nutritional levels, protein, carbs, iron, Vit 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
