Why Skin Matters. Pressure ulcer/injury incident rates: Overview of Why Skin Matters. Patient s Need to Be Informed!

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1 Overview of Why Skin Matters Why Skin Matters?! TCHP Class Skin Assessment Wound Ostomy Continence Team Cost of HAPU $$$$ Pressure ulcers cost $9.1-$11.6 billion per year in the US. Cost of individual patient care ranges from $20,900 to $151,700 per pressure ulcer. Minnesota Adverse Health Care Events Reporting Law in st in Nation Center for Medicare and Medicaid Services Oct 1, 2008 Legal: More than 17,000 lawsuits related to PU/ year 87% of verdicts from NH cases goes to Plaintiff Average award is $13.5 million Highest award is $312 million in one case! It is the second most common claim after wrongful death and greater than falls or emotional distress. Pressure ulcer/injury incident rates: Number of HAPU nationwide Estimated 2.5 million patients in U.S. acute-care facilities suffer from pressure ulcer/injuries and 60,000 die Pressure ulcer/injury incidence rates vary considerably by clinical setting 0.4 to 38 percent in acute care 2.2 to 23.9 percent in long term care 0 to 17 percent in home care 29 percent in cardiac surgeries percent in orthopedic surgeries percent in spine surgeries. The most common locations: Heel (14-52 percent) Sacrum (22-41 percent) Buttocks (11-47 percent) Why Skin Matters Over 100 people die every day because of pressure sore injuries. According to the Center for Disease Control, more than 1 out of 10 nursing home patients have a pressure sores, an estimated 11% 2 nd leading reason for NH admission Complications: pain, infection, quality of life, death Patient Education Patient s Need to Be Informed! Why is it important? Ethical promotes quality of life Regulatory expects it Financial implications Fines for not doing it! Good communication Across settings of care Patient education is CRITICAL!! They need to know: Who is at risk and why??? What causes pressure ulcers? Why compliance is so important!! Where to look?? What are prevention strategies? 1

2 Tools for Patient Education Anatomy and Physiology of Skin Formal and Informal Largest organ of the body! Weight: 6-8 pounds Size of adult skin: 3000 square inches Thickness varies: 0.5mm 6mm Eyelids vs palms or soles of feet Receives 1/3 of the blood supply in the body Anatomy and Physiology of Skin Anatomy and Physiology of Skin Has the ability to self-regenerate every 4-6 weeks This is a defense mechanism against infection Skin is constantly exposed to changing environments ph is (average is 5.5) This is called the acid mantle Protects against bacteria The more basic ph = more prone to bacteria Soap and water = alkaline Dry skin, DM, CV diseases = increased ph Seen here in a scanning electron micrograph, the epidermis is a tough coating formed from overlapping layers of dead skin cells, which continually slough off and are replaced with cells from the living layers beneath. -National Geographic Skin ph Skin Layers: Epidermis Skin ph is with mean of 5.5 Depends on area of body Urine, stool, soap and frequent cleansing will increase ph to more basic levels Pooled urine changes ph to 7.1 or alkaline shift = this contributes to overgrowth of bacteria Patients with fecal incontinence are 22x more likely to develop pressure ulcers Outermost layer made of epidermal cells Thin and avascular Repairs and regenerates itself 2

3 Skin Layers: Epidermis Skin Layers Function of Epidermis: Protective barrier Organization of cell content Synthesis of Vitamin D Division and mobilization of cells Maintain contact with dermis Pigmentation (contains melanocytes) Allergen recognition Differentiates into hair, nails, sweat glands and sebaceous glands Dermis Thicker layer Contains a network of: blood vessels hair follicles lymphatic vessels sebaceous glands sweat and scent glands nerve endings Skin Layers: Dermis Made up of Protein: Collagen and Elastin Collagen: major structural protein that gives skin its strength Elastin: responsible for skin recoil and resiliency Allows skin to be stretched and released Skin Layers: Dermis Function of the Dermis: Supports structure Interlocking dermal-epidermal junction Mechanical strength Supplies nutrition Resists shearing forces Inflammatory response Collagen anchors dermis to hypodermis (subcutaneous tissue) which covers fascia, muscle and bone Skin Layers: Hypodermis Subcutaneous Tissue Composed of adipose and connective tissue Filled with major blood vessels, nerves and lymphatic vessels Attaches dermis to underlying structures Holds skin in place to cover bones and muscles Provides thermal insulation and cushioning to body Acts as a ready reserve of energy Mechanical shock absorber Body Image Maintenance of body form Appearance Attributes Expression 3

4 Sensation Abundant nerve receptors in skin Touch Heat/Cold Pain/ Itch Pressure Moisture Lack of sensation = HIGH risk for pressure ulcers!!!! Regulation of body temperature 98.6 F / 37 C Thermoregulatory mechanisms: Circulation Blood vessels dilate to dissipate heat Blood vessels constrict to shunt heat to body organs Sweating 2-5 million sweat glands Most sensitive areas = increased nerve endings: Lips Nipples Fingertips Protection Safety against sunburn Melanin in the epidermal cells protects against ultraviolet light Metabolism Vitamin D formation Presence of sunlight This activates the metabolism of calcium and phosphate and minerals (important in bone formation) Protection Barrier to germs and poisons Normal floral = Staph Aureus Diphtheroids Gram neg bacilli NOT Candida Chemical defenses Sweat, oils, wax from skin glands contain lactic acid and fatty acid These acids make skin ph acidic to kill bacteria and fungi Healthy Skin Maintenance of water balance Prevents loss of water through evaporation < 10% moisture cells shrink = increase invasion of bacteria > 30-40% moisture level = maceration Increased permeability Increased risk of injury from friction Protect from Sun Wear sunscreen Don t smoke Narrows blood vessels to skin Depletes of oxygen and nutrients Damages collagen and elastin Increase in wrinkles Be gentle on skin Moisturize Nutrition Eat fruits, vegetables, whole grains and lean proteins Drink plenty of water Manage stress 4

5 Skin Changes with Aging Age-Related changes: Functions decline Epidermal/dermal junction flattens Decreases skin strength Increases risk for tearing 20% loss of dermal thickness = paper thin skin Reduction of collagen fibers, blood vessels, nerve endings Reduction of hormones = delayed wound healing Melanocytes shrink (decrease in volume) Increases sensitivity to sun Skin Changes with Aging Age-Related changes: Decreased sweat production Leads to increased dryness and flaking Less able to retain moisture = risk of dehydration Reduction in pain perception Vulnerable to trauma from shoes/stepping on objects Nutrition changes Medications steroids, antibiotics can change skin flora SCALE: Skin Changes at Life s End Skin Changes at End of Life Patient Centered Concerns: Answer the 5 P s: Prevention? Prescription Is wound treatable? Preservation Maintenance plan? Palliative Comfort and Care? Preference- What does patient desire? Risk factors Aging Dry and fragile skin Poor healing Prone to injury Immobility Tissue ischemia Poor nutrition/hydration Impaired oxygenation Skin Challenges with Bariatric Population In , the prevalence of obesity was 39.8% in adults and 18.5% in youth. Changes in skin physiology: Greater skin to weight ration Reduced vascularity and perfusion Increase moisture Skin folds are source of redness, moisture, pressure ulcers Watch for cellulitis, skin infections, lymphedema, intertrigo and pressure ulcers Skin Challenges with SCI Population 450,000 persons are living with SCI in USA 8000 NEW SCIs every year 82% Males Ages Causes: Motor vehicle accidents (44%) Acts of violence (24%) Falls (22%) Sports (8%) (2/3 of sports injuries are from diving) Other (2%) Average age = 33.4 years old Quadriplegia is slightly more common than paraplegia. 5

6 Skin Challenges with SCI Population Start Seeing Skin! Risk factors for pressure ulcers Immobility Urinary incontinence Severe spasticity Preexisting conditions Advanced age, smoking, lung/cardiac disease, diabetes, impaired cognition Residence in a nursing home Malnutrition and anemia Remember to look at the WHOLE patient and not just the HOLE in the patient!!!! Temperature Normally warm to touch Warmer = inflammation Cooler = poor vascularization Color Intensity: Pale = poor circulation Normal color tones: light ivory to deep brown Yellow to olive Light pink to dark ruddy pink Hyperpigmentation or Hypopigmentation Variation is melanin deposits? Blood flow concerns? Moisture Dry or moist to touch Hyperkeratosis (flaking, scales) Eczema Dermatitis, psoriasis, rashes Edema 6

7 Turgor Normally returns to original state quickly Slow return = dehydration? Aging? Integrity No open areas Types of skin injury Trauma/burns Pressure/ neuropathic ulcers Vascular wounds Arterial wounds Surgical wounds Refer to wound assessment/ documentation Watch out for Look under devices! FLT s. Funny Little Things Comprehensive Skin Assessment How Skin Heals 7

8 Partial Thickness Damage Repair of Skin Damage Partial thickness skin damage Damage is confined to the epidermis and superficial dermis skin layers Shallow wounds Wounds are moist and painful (due to exposure of nerve endings) Wounds are bright pink or red Wound edges are often torn in appearance Vulnerable to further damage from moisture or friction Repair of partial thickness skin damage Regeneration Damage is confined to epidermal and superficial dermal layers collagen matrix of dermis is intact Epithelial cells will reproduce Trauma triggers inflammatory response Erythema, Edema, Serous exudate Epidermal resurfacing begins Day 7 - new blood vessels sprout Day 9- Collagen fibers are visible Collagen synthesis continues until about day Full Thickness Damage Full thickness skin damage Damage involves total loss of skin layers (epidermis and dermis and deeper layers) Ischemic changes from pressure can damage tissue deep inside Repair of Skin Damage Repair of full thickness skin damage Scar formation Damage is deeper to deeper dermal structures (hair follicles, sebaceous glands and sweat glands), subcutaneous tissue, muscle, tendons, ligaments, bone Damage is permanent. Healing is done by primary or secondary intention Primary intention surgical closure Secondary intention scar formation Repair of Skin Damage Scar formation process is complex with several phases: Hemostasis phase Clot formation Inflammatory phase Clean up phase Takes 3-4 days usually Proliferation phase Vascular integrity restored New connective tissue is growing Granulation tissue growth Wound contraction Maturation / Remodeling phase Strength remains less than normal Example: 30 after injury coagulation Disruption in blood vessels Bleeding is controlled by clot formation Clot is mix of fibrin mesh and platelets This provides scaffold for migration of clean up cells 8

9 Example: 2 days after injury inflammation Example: 17 days Epithelialization Tissue trauma stimulates inflammatory response Break down of torn tissue and bacteria Clean up has begun! Process of regrowth Cell differentiation Mitosis Migration Proliferation Example: 30 days Collagen synthesis Prolonged Inflammatory Phase Major function now is protein synthesis Filling in the wound Elastin is not synthesized in response to injury so there is an absence of elasticity in scar tissue. Stuck in Inflammatory phase Colonization to Infection When host resistance fails to control the growth of microorganisms, localized wound infection results! Prolonged Inflammatory Phase Contaminated and Colonized Bacteria are present within the wound There is a steady state of replicating organisms that maintain a presence in the wound but do not cause delayed healing 9

10 Prolonged Inflammatory Phase Prolonged Inflammatory Phase Critically Colonized The bacterial burden in the wound bed is increasing. This burden initiates the body s immune response locally but not systemically The wound is no longer healing at the expected rate Infected Bacteria are present within the wound and are multiplying There is an associated host immune response locally and then systemically The wound is painful and may increase in size. Patient presents at ill fever, chills, elevated inflammatory labs, wound culture positive Risk Factors for a Non healing Wound Poor perfusion and oxygenation Glycemic control Comorbidities CAD, COPD Nutritional status Protein levels Vitamin C Zinc Tobacco use- Vasoconstriction Skin Is Oriented to Healing We need to: Catch it early!. Frequent skin inspections!!! Create the environment to promote wound healing!!!! References References Essentials, Sharon Baranoski and Elizabeth Ayello Health Research & Educational Trust (2017, April). Hospital Acquired Pressure Ulcers/ Injuries (HAPU/I): Chicago, IL: Health Research & Educational Trust. Accessed at Acute and Chronic Wounds: Current Management Concepts, 3 rd Edition, Ruth Bryant and Denise Nix Overview. Content last reviewed October Agency for Healthcare Research and Quality, Rockville, MD. oolkit/puover.html The Joint Commission. Quick Safety 43: Managing medical devicerelated pressure injuries, July 2018 National Pressure Ulcer Advisory Panel (NPUAP). NPUAP Pressure Injury Stages (accessed Oct 8, 2018) Are we ready for this change?. Content last reviewed October Agency for Healthcare Research and Quality, Rockville, MD. oolkit/putool1.html 10

11 References Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, NCHS data brief, no 288. Hyattsville, MD: National Center for Health Statistics. 201 National Spinal Cord Injury Association Resource Center Fact Sheets Spinal Cord Injury Information Pages. #2: 11