SKIN INJURY

dr. Imam Firmansyah

Skin is the largest, most important organ
16% of total body weight
Function
Protection
Sensation
Temperature Regulation
etc
Introduction to
Skin Injury
Skin Injuries
Skin is the bodys first layer of defense against
injury
Most frequently injured body tissue
Different Types of Skin Injuries
Abrasions
Blisters
Skin Bruises
Incision
Laceration
Puncture Wound
Epidemiology
Open Wounds
Over 10 million wounds present to ED
Most require simple care and some suturing
Up to 6.5% may become infected
Closed Wounds
More Common
Contusions
Introduction to
Skin Injury
Anatomy
Skin Layers
Epidermis
Outermost, avascular layer of dead cells
Helps prevent infection
Sebum
Waxy, oily substance that lubricates surface
Dermis
Upper Layer (Papillary Layer)
Loose connective tissue, capillaries and nerves
Lower Layer (Reticular Layer)
Integrates dermis with SQ layer
Blood vessels, nerve endings, glands
Sebaceous & Sudoriferous Glands
Subcutaneous
Adipose tissue
Heat retention
Langers Line
Tension Lines
Natural patterns in
the surface of the
skin revealing tension
within
Type of
Injury
Closed Wounds
Contusions
Erythema
Ecchymosis
Hematomas
Crush Injuries
Open Wounds
Abrasions
Lacerations
Incisions
Punctures
Impaled Objects
Avulsions
Amputations
Abrasions
Minor skin injuries
Caused by a shear force
Skin is scraped with sufficient force, usually in
one direction, against a rough surface
The greater the applied force, the more layers
of skin that are scraped away
Blisters
Minor skin injuries
Caused by repeated application of shear in
one or more directions
Occurs when a shoe rubs back and forth
against foot
Result is the formation of a pocket of fluid
between the multiple layers of skin
Skin Bruises
Contusion
Injuries resulting from compression sustained
during a blow
Damage of the underlying capillaries
Causes the accumulation of blood within the
skin
Incision and Laceration
Incision
Clean cut
Produced by the
application of a tensile
force to the skin as it is
stretched along a sharp
edge
Laceration
Irregular tear in the skin
Typically results from a
combination of tension
and shear
Puncture Wound
Formed when a sharp object penetrates the
skin and underlying tissues with tensile
loading
Puncture wound can come from:
Shoe spike
Nail

Burns
Burns are a type of injury caused by thermal,
electrical, chemical, or electromagnetic
energy.
Smoking and open flame are the leading
causes of burn injury for older adults, while
scalding is the leading cause of burn injury for
children.

Classification
First-degree (superficial) burns
First-degree burns affect only the epidermis, or outer layer of
skin. The burn site is red, painful, dry, and with no blisters.
Mild sunburn is an example.
Second-degree (partial thickness) burns
Second-degree burns involve the epidermis and part of the
dermis layer of skin. The burn site appears red, blistered, and
may be swollen and painful.
Third-degree (full thickness) burns
Third-degree burns destroy the epidermis and dermis. Third-
degree burns may also damage the underlying bones,
muscles, and tendons. The burn site appears white or
charred. There is no sensation in the area since the nerve
endings are destroyed.


Hemostasis
Bodys natural ability to stop bleeding & the ability
to clot blood
Begins immediately after injury
Inflammation
Local biochemical process that attracts WBCs
Epithelialization
Migration of epithelial cells over wound surface
Wound Healing
(continued)
Neovascularization
New growth of capillaries in response to healing
Collagen Synthesis
Fibroblasts: Cells that form collagen
Collagen: Tough, strong protein that comprises
connective tissue
Cont
Infection
Most common and most serious complication of open wounds
1:15 wounds seen in ED result in infection
Delay healing
Spread to adjacent tissues
Systemic infection: Sepsis
Presentation
Pus: WBCs, cellular debris, & dead bacteria
Lymphangitis: Visible red streaks
Fever & Malaise
Localized Fever
Complication
Infection
Risk Factors
Hosts health & pre-existing illnesses
Medications (NSAIDs)
Wound type and location
Associated contamination
Treatment provided
Infection Management
Antibiotics & keep wound clean
Gangrene
Deep space infection of anerobic bacteria
Bacterial Gas and Odor
Tetanus
Lockjaw

Other Wound Complications
Impaired Hemostasis
Medications
Anticoagulants
Aspirin
Warfarin (Coumadin)
Heparin
Antifibrinolytics
Re-Bleeding
Delayed Healing
Compartment Syndrome
Abnormal Scar Formation
Pressure Injuries
Cont
Careful initial and repeat assessment of the patient and the wound will help the clinician in
selecting treatment modalities and evaluating progress. The examination includes notation
of the location, depth, and dimensions of the wound, evaluation of the wound bed and the
surrounding skin, and analysis of any odor or exudate that may be present. Important
wound characteristics to be documented are:

1. Location
Anatomic location of the wound is important. The time required for complete healing is affected by the
blood supply to the region. For this reason, wounds on the face generally heal faster than a similar
wound in a peripheral area where the blood supply is poorer. The rate of healing is also affected by the
extent to which the skin is tightly adherent to the underlying fascia. For example, wounds on the shin
generally heal slower than comparable wounds anywhere else because skin adherence is so tight over
the shin (Baranoski,S., Ayello, E.A., 2004).


Wound Assessment
and Documentation

WOUND
ASSESSMENT


SIZE AND DEPTH
Measure or trace
wound area.
Measure depth




WOUND EDGES
Assess for undermining
and condition of margins

SURROUNDING SKIN
Assess for color, moisture, suppleness

WOUND BED
Assess for
necrotic and
granulation
tissue,
fibrin slough,
exudate

2. Wound Dimensions
Size: the initial size of a wound is an important factor in noting the rate of healing. Large deep wounds
take longer to heal than small deep wounds. By contrast, large shallow wounds, like skin-graft donor
sites, are covered with new epithelium at about the same rate as small shallow wounds, especially when
kept moist. Measure and document the wound upon admission and every Monday using centimeters as
follows:
1. Length - longest point on wound, from head to toe.
2. Width - widest point on wound, from side to side. 3. Depth- the
deepest point in the wound

Length x width x depth

3. Depth The depth of a wound profoundly affects time to healing. Wounds left to heal by formation of
granulation tissue are classified by depth. To measure the depth of deep wounds, gently insert a gloved
finger into the deepest part of the wound bed. Mark and measure against a centimeter ruler (Kerstein,
1997). Document findings in the medical record.

4. Undermining Tissue destruction that occurs around the wound perimeter under intact skin where edges
have pulled away from wound base. Document the location and amount. (Baranoski & Ayello, 2004)

5. Wound Bed The condition and appearance of the wound bed provides information about the progress of
healing and the effectiveness of treatment. The presence of granulation tissue indicates that healing is
progressing. A significant amount of fibrin slough or necrotic tissue in the wound bed suggests
inadequate wound debridement. Document appearance of the wound bed.


6. Necrotic Tissue Dead devitalized avascular tissue and may impede wound healing. It may be present in
the wound as yellow, gray, brown or black. Yellow or tan stringy tissue is referred to as slough. Black
devitalized tissue is eschar. Document color, type and percentage of tissue in the wound bed.
(Baranoski & Ayello, 2004)

7. Exudate Visual appraisal of the amount and character of wound drainage is generally regarded as an
important parameter in wound assessment. One study showed the healing rate of wounds was slowed
by two-thirds when exudate was present at baseline. The amount of exudate may be an important
indicator of healing. (Xakellis & Chrischilles, 1992). Document exudate color, consistency, odor and
amount.

8. Surrounding Skin Monitor and document wound margins for signs of inflammation (erythema, swelling,
pain) or maceration (waterlogged). Inflammation may be caused by unrelieved pressure, infection or
adverse reactions to wound care treatments. Skin maceration, caused by prolonged contact of wound
fluid with the skin, may be a sign that the topical wound treatment is inappropriate for the patient.
Document periwound condition.

9. Induration Induration is an area of hardened tissue that can be palpated around a pressure ulcer or
wound. Use fingertips to palpate for induration on intact skin surrounding a pressure ulcer or wound.
Document induration and extent of wound margin.

10. Infection Occurs in viable tissue beneath the wound surface. Clinical signs of wound infection are the
presence of warmth, pain, erythema, swelling, induration, and/or purulent drainage. Infection occurs
when the bacterial burden overwhelms the host. Assess the peri-wound tissue for cellulitis. A tissue
biopsy should be obtained to confirm infection. Document signs of infection and contact APN /
CWOCN and/or physician.


Sterile & Non-sterile Dressings
Sterile: Direct wound contact
Non-sterile: Bulk dressing above sterile
Adherent/Non-adherent Dressings
Adherent: stick to blood or fluid
Absorbent/Non-absorbent
Absorbent: soak up blood or fluids
Wet/Dry Dressings
Wet: Burns, postoperative wounds (Sterile NS)
Dry: Most common
Dressing & Bandage Materials
Gauze bandage
Single ply, non-stretch: 1-3
Adhesive bandages
Elastic (Ace) Bandages
Triangular Bandages
Dressing & Bandage Materials
TERIMA KASIH