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BASIC HUMAN NEEDS ALTERATIONS IN SKIN INTEGRITY PRESSURE ULCERS

BASIC HUMAN NEEDS ALTERATIONS IN SKIN INTEGRITY PRESSURE ULCERS. Donna M Penn RN MSN CNE. Skin Integrity. Skin/Integumentary system is the body’s largest organ, 1/6 th of TBW Protects against disease causing organisms Sensory organ for temp, pain, touch Synthesizes Vitamin D

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BASIC HUMAN NEEDS ALTERATIONS IN SKIN INTEGRITY PRESSURE ULCERS

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  1. BASIC HUMAN NEEDSALTERATIONS IN SKIN INTEGRITYPRESSURE ULCERS Donna M Penn RN MSN CNE

  2. Skin Integrity • Skin/Integumentary system is the body’s largest organ, 1/6th of TBW • Protects against disease causing organisms • Sensory organ for temp, pain, touch • Synthesizes Vitamin D • Injury to skin poses a risk to safety and triggers a complex healing process

  3. Normal Integument • 2 principle layers in relation to wound healing • Epidermis • Dermis • Separated by basement membrane

  4. Epidermis • Outer layer has several layers within it • Stratum Corneum • Stratum Lucidem • Stratum Granulosum • Stratum Spinosum • Basal cell layer

  5. Dermis • Inner layer of skin • Provides tensile strength & mechanical support & protection to underlying muscle, bones, and organs • Contains mostly connective tissue • Also includes blood vessels, nerves, sensory nerve cells, lymphatics, collagen

  6. Skin Functions • Epidermis-functions to re-surface wounds & restore the barrier against bacteria • Dermis-functions to restore structural integrity-collagen& physical properties of skin

  7. Pressure Ulcers • New NPUAP terminology (2007) • A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. • A number of contributing factors are also associated with pressure ulcers

  8. Pressure Ulcers • Tissues receive oxygen and nutrients and eliminates metabolic wastes via the blood • Any factor that interferes with this affects cellular metabolism and cell life • Pressure affects cellular metabolism by decreasing or stopping tissue circulation resulting in tissue ischemia

  9. Causes of Pressure Ulcers • Pressure > ischemia > edema > inflammation > small vessel thrombosis > cell death • Shear – trauma caused by tissue layers sliding across each other, results in disruption or angulation of blood vessels

  10. Pressure Ulcer Contributing Factors • Friction • Poor Nutrition • Incontinence • Moisture • Co-existing Medical Conditions

  11. Pressure • Tissue damage occurs when pressure exerted on the capillaries is high enough to close the capillaries • Capillary closing pressure is the pressure needed to close the capillary > 32 mmHg • After a period of ischemia light toned skin undergoes 2 hyperemic changes

  12. Hyperemia • Normal Reactive Hyperemia-visible effect of localized vasodilatation (REDNESS) area will blanch with fingertip pressure and redness lasts less than 1 hour • Abnormal Reactive Hyperemia-excessive vasodilatation and induration (edema) in response to pressure. Skin appears bright pink-red. Lasts 1 hour to 2 weeks

  13. Risk Factors for Pressure Ulcer Development • Impaired Sensory Input • Impaired Motor Function • Altered Level of Consciousness • Orthopedic Devices

  14. Pathogenesis of Pressure Ulcers • Intensity of pressure and capillary closing pressure • Duration and sustenance of pressure • Tissue Tolerance

  15. Pathogenesis of Pressure Ulcers • Bony prominences are most at risk (sacrum, heels, elbows, lateral malleoli, greater trochanter, ischial tuberosities • Pressure ulcer forms as a result of time/pressure relationship • Greater the pressure and duration of pressure, the greater the incidence of ulcer formation

  16. Pathogenesis of Pressure Ulcers • Skin and subcutaneous tissue can withstand some pressure • Tissue will over time become hypoxic and ischemic injury will occur • If the pressure is above 32mmHg and remains unrelieved to the point of tissue hypoxia, the vessel will collapse and thrombose

  17. Pathogenesis of Pressure Ulcers • If circulation is restored before this critical point, circulation to tissue is restored (Reactive Hyperemia) • Skin has a greater ability to tolerate ischemia than does muscle, hence true pressure ulcers begin at bone with pressure related to muscle ischemia eventually coming through to epidermis (Shear injury) Sacrum and heels most susceptible

  18. Pressure Ulcer Staging • Depth of destroyed tissue • Does not indicate healing • Ulcer covered by necrotic tissue or eschar cannot be staged until debrided • NPUAP system used most clinically • Other staging systems exist

  19. Stage 1 Pressure Ulcer • Intact skin with non-blanchable redness of a localized area usually over a bony prominence. • Darkly pigmented skin may not have blanching: its color may differ from the surrounding area • The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. • Stage I may be difficult to detect in individuals with darker skin tones

  20. Stage I Treatment • Off-load pressure • Transparent film dressing • Hydrocolloid dressing • Moisture barrier

  21. Stage 2 Pressure Ulcer • Partial thickness skin loss involving the epidermis and/or dermis. • The ulcer is superficial and presents clinically as an abrasion, blister, or shallow open ulcer • Presents as shiny or shallow ulcer (red/pink wound bed) without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation

  22. Stage II Treatment • Hydrocolloid dressing: dressing of choice in minimally draining stage 2 ulcer • Absorptive dressings (Foam) draining wounds • Hydrogel: Healing wounds • Off-load pressure

  23. Stage III • Full thickness skin loss involving damage or necrosis to subcutaneous tissue that may extend down to, but not through underlying fascia • Ulcer presents as a deep crater with or without undermining or tunneling of adjacent tissue • Slough tissue may be present but does not obscure the depth of tissue loss • Depth varies by anatomical location

  24. Stage III Treatment • Requires physician order for Stage III or IV • Draining vs. Non-draining • Necrotic vs. Granulating • Draining wounds-Absorptive dressings • Granulating wounds-Hydrogel • Necrotic wounds-Require debridement (Chemical. Mechanical, Autolytic, Sharp)

  25. Stage IV • Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone , or supporting structures (tendons, joint) • Undermining and tunneling are often associated with Stage IV ulcers • Slough or eschar may be present in some on some parts of the wound bed • Depth of wound varies by anatomical location • Exposed bone or tendon is visible or directly palpable

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