Skin

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.

Pressure Injuries

  • 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.

Clinical Manifestations (Staging) of Pressure Injuries

  • 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.

Pressure Injury Prevention

  • 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.

IV Infiltration

  • 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.

Extravasation

  • 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).