Maintaining Skin Integrity Research Articles

Maintaining skin integrity and preventing pressure damage

Early identification of patient risk is the first step in preventing pressure damage. Maureen Benbow discusses the importance of maintaining residents' skin integrity to ensure that damage is minimized.

Management of ileocutaneous fistulae using TNP after surgery for abdominal malignancy

Enteric fluids produced by enterocutaneous fistulae can cause severe inflammation in the surrounding skin. By removing these corrosive fluids, topical negative pressure can help maintain skin integrity and promote spontaneous closure.

Importance of Extracellular Matrix Protein 1 (ECM1) in Maintaining the Functional Integrity of the Human Skin

The extracellular matrix protein 1 (ECM1) is an 85 kDa glycoprotein first identified in 1994. The three- dimensional structure of ECM1 based on the third serum albumin domain was determined by in silico modelling in order to predict the most important binding site(s) of ECM1 with other protein partners in human skin. ECM1 consists of four domains: a first domain existing of � -helices (� D1), the serum albumin subdomain-like (SASDL) domain 2, the sequence homology comparable with the first subdomain of the third serum albumin domain, SASDL3 and SASDL4, resulting in four finger-like structures ideal for binding with different proteins. A role for ECM1 was proposed in endochondral bone formation, angiogenesis and skin differentiation. Increased evidence has emerged for a pivotal function of ECM1 in human skin; loss of function mutations in the ECM1 gene causes the autosomal recessive genodermatosis lipoid proteinosis and auto-antibodies against ECM1 in the auto-immune disease lichen sclerosus, sharing comparable skin pa- thology in the affected lesions. ECM1 is capable of binding variable skin structural and extracellular matrix molecules like perlecan, laminin 332, fibulin-1C/D, fibulin-3 and heparin, as well as dermal interstitial molecules like MMP-9, col- lagen type IV, fibronectin, hyaluronic acid and chondroitin sulphate. In this way, ECM1 could be one of the proteins ca- pable of connecting the basolateral surface of the epidermis through the basement membrane to the underlying dermis, which suggest a role for ECM1 as biological glue in maintaining skin integrity and function.

Unusual Prenatal Sonographic Findings of Epidermolysis Bullosa Mimicking an Amniotic Band Constriction Ring

pidermolysis bullosa (EB) refers to a group of heterogeneous diseases that are characterized by intraepidermal (simplex subtype), junctional (junctional subtypes), or subepidermal (dystrophic subtypes) blisters produced by minor degrees of trauma and heat.1–3 These disorders are the result of a variety of inherited defects of the proteins that maintain skin integrity. The clinical phenotypes vary according to the region within the skin where the defective protein is expressed and to the depth at which the resultant blister occurs. Extracutaneous features of some EB subtypes may include mucosal blistering, gastrointestinal involvement, urologic involvement, laryngeal involvement with airway obstruction, enamel hypoplasia, pyloric atresia, ureterovesicular obstruction, and hydronephrosis.4 So far, EB has been described during pregnancy with sonographic signs such as gastric dilatation associated with hydramnios as an expression of pyloric atresia,5,6 hydronephrosis and urethral stenosis,7 ear and nose deformities, and the “snowflake sign,” which may be a sign of in utero skin denudation syndromes.8 Amniotic bands are free strips of amnion that can form a focal ring around an extremity or digit, eventually producing enough constriction to cause damage or even amputation of the encircled structure.9 The aim of this report was to emphasize the importance of differential diagnosis in cases with sonographic findings thought to represent amniotic bands.

Can Henna Prevent Ulceration in Diabetic Feet at High Risk?

Diabetic foot infections are one of the most dreadful and costly complications of diabetes. Efforts have recently focused on preventive measures. The balance of moisture in the neuropathic foot is critical and challenging. Whilst the interdigital areas should be kept dry to prevent maceration and subsequent softening and thinning of the skin other areas of the foot should be managed for optimal moisture to avoid dry skin and resulting cracks. Oftentimes, the primary cause of infection is a breakdown of skin integrity. Several factors may cause a break in healthy skin, however some parts of the foot, notably the interdigital area, are more prone to compromise. The interdigital area, which usually provides entrance points for infectious agents, is a rather closed environment and may therefore be subject to more moisture than any other part of the foot. Excess moisture may in turn cause maceration which increases the likelyhood of skin breakdown and microbial colonisation and invasion. Indeed, it has been shown that the skin in interdigital areas of the diabetic patients has higher PH levels which promotes susceptibility to candidal infections [1]. Many products have been developed for the protection of skin integrity. Topical henna is an extract of the lawsonia plant. Some experimental and clinical studies have reported antibacterial and antifungal effectiveness and wound healing activity of this product [2–4]. Henna is an easily accessible, inexpensive product which, to our best knowledge, has not been studied so far in the diabetic foot at risk. The henna extract may be prepared by mixing 1 gr of powdered leaves to 10 mL of distilled water which will subsequently be applied to the interdigital space. It is then kept wrapped with a dressing for 4–6 hours before it is washed. This procedure will provide a long-term barrier against moisture in the problematic interdigital area (1 to 3 months) and thus will not require frequent application. Henna may also improve wound healing in fissures and cracks in diabetic feet. As prevention is of paramount importance, studies should focus more on intensive preventive strategies that are promising in maintaining healthy skin. In this context, henna could be a valuable, inexpensive, and readily accessible product that does not require frequent application to maintain skin integrity in the interdigital area.

Riding the Research Roller Coaster

Evidence-based practice drives nursing procedures and standards of care. Supporting practice with valid research can be a challenge. After identifying a knowledge- and problem-focused trigger, a group of WOC nurses began a research journey. Our purpose was to determine the effectiveness of the rectal trumpet compared to the fecal collector in maintaining skin integrity in patients with fecal incontinence. The methodology included a convenience sample of 100 patients randomized to rectal trumpet or fecal collector versus standard care. Data were collected on signs of increased skin breakdown or healing, stool leakage around device, dislodgement, and discomfort from device. This article will reveal our journey in conducting this clinical research. After many challenges, the study was terminated, but the experiences and lessons learned during our efforts were invaluable. Even well-planned studies can encounter problems that prevent completion. It is important to evaluate these problems so that lessons can be learned and shared. This is our roller coaster ride in the research world.

Using emollients to restore and maintain skin integrity

Emollients are an essential treatment option for the reduction of dry skin conditions and the maintenance of healthy skin. These functions are dependent on complex interactions within the upper layers of the epidermis, designed to maintain the skin's dynamic but intact barrier function. Choice of emollient is dependent on several factors, including the variability of skin by location and age, as well as individual choice regarding the patient's preferred emollient routine.

To what extent is cyanoacrylate useful to prevent early wound infections in hernia surgery?

Prolene graft infection still occurs at an unacceptably high rate, despite many preventive measures with suggested effectiveness against infection. We assessed the efficacy of cyanoacrylate as a tissue adhesive and barrier against early and late contamination through the skin. Thirty-two Wistar albino rats weighing between 250 and 300 g were randomised into four groups with eight animals in each. Group I: N-butyl 2-cyanoacrylate and early local contamination; group II: N-butyl 2-cyanoacrylate and late local contamination; group III: prolene suture and early contamination; group IV: prolene suture and late contamination. Prolene graft material 1 x 0.5 cm was implanted in mice above the fascia. Local contamination with 75 x 10(6) cfu/ml Staphylococcus aureus ATCC 25923 was carried out in groups III and VI within a postoperative period of 24 h. On the seventh day, the animals were killed and the grafts were explanted. The microscopic, histological and microbiological evaluation of the graft material and the surrounding tissues were performed. All of the graft cultures from group III (8/8) were positive for S. aureus, whereas all of those from group I (0/8) were negative. This difference was significant (P < 0.001). Histological examination revealed denser inflammatory cell infiltration in group III than in group I. On the other hand, there was no difference between groups II and IV. Maintaining skin integrity after closure is very significant, as contamination during the first few hours of the procedure may result in prolene graft infection. Cyanoacrylate appears to be a promising molecule within the first few hours of the operations for two reasons, namely, its bacteriostatic effects and ability to seal the barrier effectively and immediately.

Talocrural Dislocation With Associated Weber Type C Fibular Fracture in a Collegiate Football Player: A Case Report

To present the case of a talocrural dislocation with a Weber type C fibular fracture in a National Collegiate Athletic Association Division I football athlete. The athlete, while attempting to make a tackle during a game, collided with an opponent, who in turn stepped on the lateral aspect of the athlete's ankle, resulting in forced ankle eversion and external rotation. On-field evaluation showed a laterally displaced talocrural dislocation. Immediate reduction was performed in the athletic training room to maintain skin integrity. Post-reduction radiographs revealed a Weber type C fibular fracture and increased medial joint clear space. A below-knee, fiberglass splint was applied to stabilize the ankle joint complex. Subtalar dislocation, Maisonneuve fracture, malleolar fracture, deltoid ligament rupture, syndesmosis disruption. The sports medicine staff immediately splinted and transported the athlete to the athletic training room to reduce the dislocation. The athlete then underwent an open reduction and internal fixation procedure to stabilize the injury: 2 syndesmosis screws and a fibular plate were placed to keep the ankle joint in an anatomically reduced position. With the guidance of the athletic training staff, the athlete underwent an accelerated physical rehabilitation protocol in an effort to return to sport as quickly and safely as possible. Most talocrural dislocations and associated Weber type C fibular fractures are due to motor vehicle accidents or falls. We are the first to describe this injury in a Division I football player and to present a general rehabilitation protocol for a high-level athlete. Sports medicine practitioners must recognize that this injury can occur in the athletic environment. Prompt reduction, early surgical intervention, sufficient resources, and an accelerated rehabilitation protocol all contributed to a successful outcome in the patient.

Experimental observations of an 8 m/s drop test of a metallic helicopter underfloor structure onto water: Part 2

This is the second part of a two-part paper that describes the experimental observations for two similar sections of floor that were dropped onto both hard and water surfaces at 8 m/s, as part of one experimental campaign. The current paper provides an assessment of a simple box-beam under floor structure typically found in metallic helicopters and provides an overview of the failure modes and the collapse mechanism observed when dropped onto water at 8 m/s, as well as providing quantitative data for the skin deflections observed. The results demonstrate that the lack of frame and intersection joint collapse is a common feature, which is caused by the high failure strength of the existing construction, together with the inability of the skin to generate membrane loads that are sufficiently large to trigger progressive collapse within the structure. It is therefore recommended to reduce the collapse force of the structure through the use of geometry, material type, and inclusion of triggers. However, the caveat with this approach is that if the failure strength is optimized for a water impact, a poor crashworthy response may occur during a hard surface impact. The current paper discusses three main limitations with the design, which are heavily interrelated, as improvements in frame and joint collapse cannot be achieved without considering developing the ductile behaviour of the skin. However, maintaining skin integrity will be critical to maintain the floatation capabilities of the helicopter. The current paper recommends that a next generation design should encompass a passive dual role capability for both hard and soft surface impacts, by being able to degrade the localized strength depending upon the type of surface encountered. This will significantly improve the crashworthy response of a metallic under floor structure and have a significant impact on improving occupant survivability for an impact on water.

Anaesthesia for reconstructive surgery

Skin or tissue defects that cannot be closed primarily with simple suturing require skin grafts or flaps to maintain skin integrity and prevent infection. Tissue defects may be covered using skin grafts, tissue-expanded skin, local skin flaps, pedicled flaps or free flaps. This article describes the different methods. The causes of flap failure are discussed. In general they are the result of poor blood flow or oedema. Flap tissue has no lymphatic drainage and is therefore susceptible to oedema, which reduces flow to the flap. The practical conduct of anaesthesia for reconstructive surgery is also explained.

Cyanoacrylate for Wound Closure in Prosthetic Vascular Graft Surgery to Prevent Infections Through Contamination

Prosthetic vascular graft infection (PVGI) still occurs at an unacceptably high rate, despite the many measures that have proven effective against infection. The major cause of PVGI is perioperative contamination, which usually occurs before a histological barrier is completed and may threaten graft viability. We assessed the efficacy of cyanoacrylate as a tissue adhesive and barrier against early contamination through the skin. A 1 x 0.5-cm Dacron graft was placed subcutaneously under sterile conditions in 16 Sprague-Dawley rats. The skin was closed with polypropylene sutures in eight rats (group A) and with N-butyl 2-cyanoacrylate in eight rats (group B). The closed incisions were then contaminated with 75 x 10(6) cfu/ml methicillin-sensitive Staphylococcus aureus. Microbiological and histopathological assessments were done 7 days later, after the rats were killed. All of the graft cultures from group A (8/8) were positive for S. aureus whereas all of those from group B (0/8) were negative. This difference was significant (p < 0.001). Histological examination revealed denser inflammatory cell infiltration in group A than in group B. Maintaining skin integrity after closure is of the utmost importance because contamination during the first hours of the procedure may cause PVGI. Cyanoacrylate seems to be a promising molecule not only because of its bacteriostatic effects, but also because it seals the barrier effectively and immediately.

Continent or Incontinent? That is the Question

A qualitative, emergent, case study design guided the description of care provided to nursing home residents with urinary incontinence in three Midwestern nursing facilities. Participants included 17 residents and 16 family members or friends of the respective residents. Staff and managers involved in the planning and delivery of care to the participating residents also were included. The three facilities represented variation in size, location, ownership, and Medicare certification. Data were collected via observation, resident record audit, and semi-structured interview. Definitions of incontinence varied among staff. A collectively held expectation that residents would be toileted every 2 hours was not met. Maintaining skin integrity was the primary motivation for keeping residents clean and dry. Medical directors viewed incontinence as a nursing problem. Staff described situations in which incontinence was improved for specific residents, but there was little evidence of formal programs to maintain continence or improve incontinence.

Calcium pump disorders of the skin.

The causes of Darier disease (DD) and Hailey-Hailey disease (HHD) have eluded clinicians and scientists for more than 60 years. DD is characterized by loss of adhesion between suprabasal epidermal cells associated with abnormal keratinization, while loss of epidermal cell-to-cell adhesion is predominant in HHD. The genes for both conditions have recently been identified using candidate positional cloning approaches. The gene for DD (ATP2A2) encodes a calcium transport ATPase of the sarco (endo)plasmic reticulum (SERCA2) Verboomen et al. [1992: Biochem J 286(Pt 2):591-595], while the gene for HHD (ATP2C1) codes for a secretory pathway for calcium and manganese transport ATPase of the Golgi apparatus (SPCA1) Hu et al. [2000: Nat Genet 24:61-65]. These results have provided completely new insights into the role of calcium and/or manganese in maintaining skin integrity. Although the precise disease mechanisms remain to be understood, these discoveries open a new field in research for the understanding and the treatment of these distressing disorders.

Skin Health Improvements Associated with Use of Nitrile Exam Gloves with Dermal Therapy Coating

BACKGROUND: The association between irritated, damaged skin on the hands of healthcare workers (HCWs) and increased risk of transmission of healthcare-associated infections has led the Centers for Disease Control and Prevention to recommend the use of products that help maintain skin integrity. METHOD: Nitrile exam gloves coated with ingredients involved in skin repair, moisturization, and protection of the skin's barrier properties were studied to determine the effect use of these gloves has on the hands of HCWs with compromised skin. Twenty-six HCWs with dry skin wore a nitrile exam glove with a coating comprised of ingredients proven to have beneficial effects on skin health on one hand and an equivalent nitrile exam glove without the coating on the other. RESULTS: After 12 successive 15-minute wear periods (each time with new gloves), measurements of skin moisture, erythema, transepidermal water loss, and overall skin dryness were taken from both hands of each subject at baseline and following the final wear period. Nitrile exam gloves with dermal therapy coating produced quantifiable improvements in the skin of clinicians with dry, compromised skin. Wearing exam gloves with the dermal therapy coating resulted in a greater improvement in skin moisturization, produced less erythema, reduced skin flaking, and did not increase water loss through the skin. CONCLUSIONS: Routine use of exam gloves with this dermal therapy coating has the potential to improve clinicians' skin and contribute to a reduction in the number of healthcare-associated infections by reducing scaliness of the skin and improving overall skin wellness.

Unplanned Extubation in Adult Critical Care

Unplanned Extubation in Adult Critical Care

Skin Care Provided in an Aged Care Facility

Objective The objective of this systematic review is to determine what are the most effective and safe topical skin care regimens for maintaining skin integrity, in an aged population in long term care. Questions What are the best methods of providing skin care in an elderly population in long term care prevent or reduce the occurrence of: 1. skin tears? 2. dry skin and irritation? 3. Development of open sores (not pressure sores) Inclusion criteria for effectiveness Patients: Adults 65 years of age or over residing in an aged care facility. If these studies are not available, studies using adults aged 65 years and over who are hospitalised or in long term care in the community will be considered. Intervention: Any topical intervention or program that aims to prevent the development of adverse skin conditions (not repair) in older institutionalised adults. Comparators: The most appropriate comparators would be a no care protocol, or existing practice related to maintaining skin integrity. Outcomes: Incidence of adverse skin conditions such as rash, skin irritation, haematoma or tears during the treatment or control, study period. Pressure ulcer prevention will not be considered. Patient satisfaction will also be considered. Inclusion criteria for safety Patients: Adults 65 years of age or over residing in an aged care facility. If these studies are not available, studies using adults aged 65 years and over who are hospitalised or in long term care in the community will be considered. Intervention: Any non-medical intervention or program that aims to maintain or improve the integrity of skin in older adults. Comparators: The most appropriate comparators would be a no care protocol, or existing practice related to maintaining skin integrity. Outcomes: Adverse physical health outcomes associated with the treatment/management options.

Perianal skin integrity and wound management

The management of patients with perianal skin loss and/or perianal wounds presents a challenging clinical situation. Although the goal is to maintain skin integrity in a patient undergoing a surgical procedure in the perianal area, the nature of the area—moist mucosa, bacteria from the stool as well as generalized moisture, and uneven skin and tissue planes—make care of the patient with perianal disease challenging. This article will present options to protect and heal the perianal skin from moisture or drainage and review principles of wound management related to wounds in the perianal area.

Transcriptional control of the mouse Col7a1 gene in keratinocytes: basal and transforming growth factor-beta regulated expression.

Anchoring fibrils at the cutaneous basement membrane zone of the stratified squamous epithelia are essential to maintaining skin integrity, as absence of these structures leads to the chronic blistering disease, dystrophic epidermolysis bullosa. Type VII collagen, the major component of anchoring fibrils, is synthesized primarily by basal keratinocytes and to a lesser degree by dermal fibroblasts. To elucidate the transcriptional control elements of the type VII collagen gene (Col7a1), 3 kb of 5' flanking sequence of the mouse gene was cloned, sequenced, and fused to the chloramphenicol acetyltransferase reporter gene. Promoter deletion analyses revealed that 560 bp of Col7a1 5' flanking sequence was sufficient and necessary for basal level of transcription in cultured murine keratinocytes. Mutagenesis of DNA sequences with similarity to consensus binding sites for transcription factors, including Sp1/Sp3, AP2, AP1, and Smads, within the p-560Col7a1 promoter/chloramphenicol acetyltransferase construct, coupled with DNA binding assays, revealed the importance of these sites for basal Col7a1 expression. The effect of transforming growth factor beta, an activator of Col7a1 expression in keratinocytes and dermal fibroblasts, was examined using the same Col7a1 promoter/chloramphenicol acetyltransferase constructs. These analyses demonstrated that transforming growth factor beta1 stimulation of Col7a1 transcription is dependent on a putative interaction between Smads and AP1. Interestingly, the Smad-like binding site was essential for both basal and transforming growth factor beta1 stimulated Col7a1 transcription. Collectively, these findings attest to the complex regulation of Col7a1 transcription in epidermal keratinocytes.

Skin Care Intervention for Patients Having Cardiac Surgery

Pressure ulcers are a major problem after cardiovascular surgery, occurring in 9.2% to 38% of patients. To determine the effectiveness of a skin care intervention program in preventing development of ulcers or progression from one stage to another and to determine the extent to which selected risk factors were associated with development and progression of pressure ulcers. A simple interrupted time series design was used. The protocol involved interrelated assessment, staging, and type of intervention provided. The Braden Scale was used to determine risk for skin breakdown. Of the 351 patients in the study, 327 (93%) maintained skin integrity and 24 (7%) had skin breakdown. Breakdown by stages was as follows: stage 1, 62% (n = 15); stage 2, 29% (n = 7); stage 3, 4% (n = 1); and stage 4, 4% (n = 1). Age, sex (female), and heart failure were statistically significant risk factors for breakdown (P = < .001, .02, and .02, respectively). The mean scores on the Braden Scale of the breakdown group differed significantly from those of the skin integrity group from days 2 through 5 after surgery (P = .01). Seventeen (71%) of the breakdowns occurred during the first 4 days after surgery. Skin assessments and nursing interventions should be increased on the day of surgery and the first to fifth postoperative days, including multiple assessments and skin care focused on maintaining skin integrity.