1. Anatomy of the skin

2. Aims and objectives
To understand the underlying structures of the skin
To gain a basic understanding of the process of wound healing.
To be able to identify different tissue types in areas such as the wound bed, wound edge and surrounding skin

3. Anatomy of the skin

4. Is it important to know the Structure and functions of the skin?

5. How many layers does the skin consist of?

6. Largest and most visible organ Made up of two main layers:
Epidermis – very thin layer and is firmly attached to the dermis at the dermo- epidermal junction.
Dermis- made up of two layers comprising of fibrous proteins, collagen and elastin which give skin its strength and elasticity.
Below dermis is subcutaneous layer , this provides support to the dermis and stores fat which protects the internal structures.
Epidermis is outer layer and varies in thickness 0.1mm-on eyelids and 1mm thick on Palms and soles
Acidic= PH 5.5
Has five layers corneum,lucidium,granulosum,spinosum, basale
Dermis – deeper layer composed of collogen fibres and elastin fibres( skins elasticity and stregnth)

7. Does the skin vary in depth?

8. Thinnest over eyelids -O.1mm
Thickest over palms and soles of the feet – 1mm
The skin is the largest organ of the body it weighs between 6-8 1bs
It has a surface area of 20 square feet.

9. What are the functions of the skin?

10. Acid PH helps to prevent infection
Protection of internal structures – physical barrier to microorganisms and foreign matter.
Acid PH helps to prevent infection
Damage to skin impairs ability to carry out these functions. Ordinary washing = 45 mins. to restore skin Ph
Prolonged exposure = up to 19 hours

11. Sensory perception-
Allows you to feel pain, pressure heat this helps us to identify potential dangers and avoid injury

12. Thermoregulation- Blood vessels constrict or dilate to raise or lower body temperature. Sweat production promotes cooling

13. Excretion –
Transmits small amounts of water and body waste via sweat
Helps to prevent dehydration.

14. Metabolism-Photochemical reaction in the skin produces Vitamin D essential for metabolism of calcium

15. Absorption-Some substances can be absorbed directly into blood stream

16. Communication

17. Functions of the skin that declines with age.
Flattening of the dermal-epidermal junction, increased susceptibility to friction/ shearing forces resulting in blistering.
Decreased sensitivity to pain perception
Epidermis becomes thinner and flatter , uneven distribution of melanocytes leading to uneven pigmentation.
Skin becomes wrinkled due to depletion of elastic fibres.
Skin becomes dry as a result of atrophy of sebaceous glands
Baraboski (2003) and Beldon (2006)

18. How do wounds heal?

19. Classification of wound healing
Wounds that heal by primary intention e.g. incisional wounds
Wounds that heal by secondary intention e.g. pressure ulcers
Wounds that heal by tertiary intention e.g. delayed suture

20. Wounds characterised by whether they are acute or chronic

21. Acute wounds Characterised by: No underlying aetiology i.e. trauma
Short duration
Normal inflammatory phase
Heal and do not breakdown

22. Chronic wounds Characterised by:
Underlying pathology e.g. venous insufficiency
Prolonged duration
Hyperactive state
Persistent state of inflammation

23. Wounds go through 4 distinct phases

24. Normal Wound Healing Response
Proteoglycans
Fibroblasts
Collagen
Angiogenesis
Collagen remodelling
Scar maturation
Neutrophils
Macrophages
Lymphocytes
MATURATION
PROLIFERATION
Platelets
Fibrin
0 – 3 days: The first phase of wound healing occurs immediately at the time of injury. During this phase, there is increased blood supply to the area, platelets aggregate to form a temporary plug & fibrin which forms a mesh as the body attempts to clot off any bleeding vessels allowing haemostasis to occur. This blood clot or scab is part of a natural covering mechanism creating a new barrier for the broken skin to protect the underlying tissues from harmful bacterial invasion.
1 – 6 days: Following this the natural inflammatory response occurs. It consists of widespread vasodilation, oedema formation and the migration of cells such as neutrophils (whose function is the phagocytosis of bacteria), macrophages (which also destroy bacteria but are also a rich source of biological regulators that are essential for the normal wound healing process) & lymphocytes (white blood cells involved in the immune response).
3 – 24 days: During the proliferation phase the extracellular matrix (the supporting structure of new tissue) is formed and remodelled, with angiogenesis (new blood vessel development), epithelisation (new skin cells) & wound contraction taking place. During this phase fibroblasts play an important role in the manufacture of collagen (protein responsible for holding the body together, skeleton included), along with other substances such as proteogylcans to form the ECM, which fills the wound space and provides a scaffold for the new tissue.
24 – 365 days: The maturation phase can last for many months after skin cover has been achieved. The initially formed ECM is remodelled, while collagen increases the tensile strength of the wound.
NB Stages overlap
INFLAMMATION
HAEMOSTASIS
MINUTES
DAYS
WEEKS
MONTHS / YEARS
(whru)

25. Haemostasis Starts immediately after injury.
Blood vessel contraction (vasoconstriction)
Vasoconstriction minimises blood loss

26. Inflammatory phase Occurs between 0-3 days
Vascular permeability increases and serrous fluid ( comprising of cell and plasma protein) accumulates in surrounding tissue causing swellling redness and warmth

27. Proliferation
0-24 days
During this phase growth factors prompt fibroblasts to migrate to the wound. They make new fibres and ground substnaces (ECM) provides support to cells
Fibroblasts start at wound edge then spread over surface. – require o2 to perform this task

28. Maturation 20 days – 2 years Closure of wound and re-epithelisation.
Scar maturation

29. What factors may affect wound healing?
ASK AUDIENCE

30. Factors Affecting Healing Systemic
Age
Anaemia
Nutrition
Medications e.g.: Anti inflammatory, Cytotoxic drugs, steroids
Chronic health conditions eg :Diabetes Mellitus
Systemic infection (Bowler & Davies, 1999)
Oxygenation
Smoking
Psychological factors
Temperature
Age – in old age the inflammatory response, proliferation phase and maturation are diminished.
Anaemia – lack of red blood cells
Anti-inflammatory – suppress the normal inflammatory response to injury.
Cytotoxic drugs – interfere with cell proliferation and severely impair healing. Also neutropenia makes the patient more susceptible to infection. Nausea / vomiting leads to poor nutritional intake and dehydration.
Diabetes – many factors are thought to impair wound healing, though no single factor alone is responsible.
Hormones -
Jaundice - excess of bilirubin (bile) from the liver Nutritional status – despite malnutrition healing has been demonstrated to take place, improved nutrition would reduce the complications and length of hospital stay. There are discrepancies in the literature relating to obesity and wound healing. Problems such as performing surgery are very high.
Temperature - Any substance used should be at body temperature as it takes 40 mins for the wound to return to normal body temp after cleansing and Mitotic cell division can be delayed for up to 3 hours
Uraemia – excess of urea (waste products from the kidneys in the urine)
Vitamins – Vit A deficiency inhibits the keratinisation process; Vit C deficiency causes wound dehiscence, reduces tensile strength and adversely affects angiogenesis.
Zinc is essential in fibroblast epithelialisation, cofactor for protein synthesis & for metalloproteinase production in the ECM.
Stress & anxiety can affect the immune system, can disturb sleep, which is important for healing and tissue repair. Altered body image due to disfiguring wounds or surgery can adversely affect patients’ psychological state.

31. Factors affecting healing Local Factors
Blood supply
Denervation
Haematoma
Local Infection
Duration
Wound bed condition
Anatomical site
Size of wound
Classic infection – clearly infected, red, hot, smelly and bleeding. 5th toe already amputated. 4th toe sausage shaped. Neuropathy
Eventually had a below knee amputation.
Denervation – interruption of the nerve supply to the muscles and skin.

32. Assessment of a wound is the responsibility of the qualified member of staff
You should ensure that this has been undertaken and a treatment plan has been established.

33. Remember
The selection of dressings or bandages without accurately undertaking a wound assessment taking into account underlying factors that may delay wound healing may result in costly treatments that are inappropriate and are not successful!

34. Clinical appearance of wound bed
Colour Physiological State
Black Necrotic
Yellow Sloughy
Red Granulating
Pink Epithelializing
Green Infected?

35. Characteristics of granulation tissue
Healthy tissue
Bright red
Moist
Shiny
Does not bleed
Unhealthy tissue
Dark red
Dehydrated
Dull
Bleeds easily S

36. Granulating
(WHRU)

37. Necrosis
(WHRU)

38. Slough

39. Clinical appearance of surrounding skin

40. Maceration

41. Excoriation

42. Erythema and oedema

43. Eczema and dry skin

44. Exudate
Quantity – Small , moderate copious is dressing containing exudate?
Colour – Green? serous?, haemoserrous?
Consistency – Thick?Thin,

45. Pain When does it occur? How bad (intense) is it? How does the patient
describe it?
What makes it better?

46. If there are any changes in the wound report immediately to your nurse in charge
Any delay in a reassessment may result in inappropriate treatment