two layers of the skin
- epidermis (thin outer layer; mainly connective tissue and few skin cells
- dermis (inner layer; provides protection of underlying muscles, bones and organs)
examples of skin-associated issues
- age related changes (decreased collagen/elasticity)
- attachment of dermis and epidermis become flat in older persons
- aging causes diminishes inflammatory response
- reduced nutritional intake
pressure injury
localized damage to the skin and/or underlying soft tissue usually over a bony
prominence or related to a medical or other device
Three pressure related factors that contribute to pressure ulcer development
pressure intensity
pressure duration
tissue tolerance
pressure intensity
-pressure exceeds normal capillary pressure (15-32mm)
-vessels occlude and tissue ischemia develops
-tissue may be damaged or tissue death may result
characteristics of dark skin at risk of skin breakdown
- colour remains unchanged
- localized area may turn a purplish colour rather than red
- look in a natural light
- compare to surrounding skin
- warm to touch
- edema may occur
- area may be sensitive and tender to touch
pressure duration
- Low pressure over prolonged period of time &/or High pressure over a short period of
time
-pressures occur quickly (1-2hrs)
- occludes blood flow and nutrients and contributes to cell death
tissue tolerance
- the ability of tissue to endure pressure depends on the integrity of the tissue and the
supporting structures
- extrinsic factors: shear friction and moisture
- poor nutrition, age and low blood pressure affect tissue tolerance
, risk factors for pressure injury development
- factors directly related to disease like decreased consciousness, aftereffects of trauma
and presence of cast
- braden scale helps to determine appropriate interventions
impaired sensory perception
Patients with altered sensory perception for pain and pressure are at risk because they
cannot feel their body sensations
-may not feel prolonged pressure and are at risk
impaired mobility
patients who are unable to independently change position are at risk because they
cannot change or shift off of bony prominences
alteration in level of consciousness
- Patients who are confused or disoriented and those who have expressive aphasia or
other inability to verbalize or changing levels of consciousness are unable to protect
themselves from pressure ulcer development.
- Patients who are confused or disoriented are sometimes able to feel pressure but are
not always able to understand how to relieve it or communicate their discomfort.
- Patients in a coma cannot perceive pressure and are unable to move voluntarily to
relieve pressure.
shear
- force exerted parallel to the skin resulting both from gravity and from resistance
(friction) between the patient and a surface, such as that created when a patient slumps
in a chair
- underlying tissue capillaries are stretched and angulated by the shear force
- impact dermis
friction
-the force of two surfaces moving across one another such as mechanical force exerted
when skin is dragged across a coarse surface like bed linens
- friction injuries impact epidermis
moisture
- presence and duration of moisture on the skin
- increases the risk of ulcer formation
- moisture reduces the skins resistance to other factors like pressure and shear force
- prolonged moisture softens the skin (prone to damage)
nutrition
- adequate nutritional intake is essential for wound healing
- alternative feedings are recommended for patients unable to maintain normal food
intake
-use nutritional supplements to help improve nutrition status
nutrients that are good for wound healing
calories
protein
vitamin c
vitamin a
vitamin e
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