Skin

The skin is the largest organ system in the body.
- Comprises 10-15% of body weight.
- Receives 1/3 of circulating blood volume, indicating its importance.
Functions:
- Protective barrier against the external environment.
- Maintains water balance.
- Regulates temperature.

Occur when the skin's vascular supply is compromised.
Definition: Localized injury to the skin and underlying tissue, usually over a bony prominence.
Cause: Pressure or pressure combined with shear.
Common Sites:
- Sacrum and heels (most common).
- Occiput in young children (due to proportionally larger head size).
Influencing Factors:
- Amount of pressure applied.
- Duration of pressure.
- Tissue's ability to tolerate shearing force (pressure exerted when surface layer adheres to bedding while deeper layers slide).
Risk Factors:
- Immobility.
- Excessive moisture (e.g., incontinence).
- Inadequate nutrition.
- Medical devices (device-related pressure injuries).
  - Examples: face masks, trach tubes/ties, endotracheal tubes, oxygen cannulas, monitoring probes.
Skin Failure:
- Distinct from pressure injuries but interrelated.
- May occur simultaneously with pressure injuries in critically ill children due to multiple organ dysfunction syndrome (MODS).
- Blood is shunted away from the skin to protect vital organs.
- Associated with hemodynamic changes:
  - Pale, cool skin.
  - Poor capillary refill.
- Impaired thermoregulatory control.
- Metabolic complications (e.g., acidosis).
- Pressure injuries preventable; injuries from skin failure may not be.

Staged based on visible/palpable tissue in the injury bed.
Stage 1:
- Intact skin with non-blanchable erythema (redness).
- Localized area, usually over a bony prominence.
Stage 2:
- Partial thickness loss of dermis.
- Red-pink wound bed without slough.
Stage 3:
- Full thickness skin loss.
- Subcutaneous fat may be visible.
- Bone, tendon, or muscle are not exposed.
Stage 4:
- Full thickness tissue loss.
- Exposed bone, tendon, or muscle.
- Slough or eschar may be present.
- May include undermining and tunneling.
Unstageable:
- Full thickness tissue loss, but depth obscured by slough or eschar.
Suspected Deep Tissue Injury:
- Purple or maroon localized area of discolored intact skin or blood-filled blister.
- Damage to underlying soft tissue from pressure or shear.

Perform thorough skin and risk assessment on admission and each shift, using a validated tool (e.g., Braden QD scale considering device-related risks).
Keep skin clean and dry, especially perineal and perianal areas.
Ensure adequate nutrition.
Apply preventative dressings over bony prominences.
Relieve pressure through frequent repositioning (even small changes are beneficial).
Avoid wrinkles under the patient.
Use appropriate mattress surfaces (low air loss or alternating pressure).
Be aware of medical devices and rotate them to different sites when possible.

Definition: Leakage of IV fluids or medications into surrounding tissue.
Causes: Improper catheter placement or dislodgement, patient movement.
Prevention:
- Select appropriate IV site (avoid flexion areas).
- Follow hospital policies for securing the IV catheter.
- Observe IV site frequently.
- Instruct patient to report swelling or tenderness.
Signs/Symptoms:
- Swelling.
- Discomfort.
- Burning.
- Tightness.
- Cool skin.
- Blanching.
Management:
- Stop infusion and remove device.
- Elevate limb.
- Apply cold or warm compress.
- Monitor pulse and capillary refill time.
- Assess site frequently.
- Document findings and interventions.

Definition: Leakage of vesicant drugs into surrounding tissue.
Consequences: Severe local tissue damage, delayed healing, infection, tissue necrosis, disfigurement, loss of function, potentially amputation.
Signs/Symptoms:
- Blanching.
- Burning and discomfort.
- Cool skin.
- Swelling at/above IV site.
- Blistering and skin sloughing.
Management:
- Same as infiltration.
- Administer antidote per facility protocol (e.g., hyaluronidase to increase tissue permeability and promote absorption).