Structure And Function Of Skin Health And Social Care Essay
Marty is a 2-year-old toddler brought into the Emergency Department by his distraught 16 year old single mother, Mandy.
Mandy had been heating some chicken soup in the microwave in their council flat in Whitechapel, when her friend Tracey had rung Mandy’s mobile. Mandy left the boiling soup on the kitchen table leaving Marty alone in the kitchen. Mandy, hearing Marty’s scream, rushed back into the kitchen to find that Marty must have reached up and tipped the soup over himself mainly over his chest and torso. Mandy immediately removed Marty’s clothes, and wrapped him in a damp towel, and called for an ambulance.
When Marty reaches the Royal London Accident and Emergency he is in considerable pain and is given an analgesic and started on intravenous fluids.
Marty is assessed and found to have second-degree partial thickness burns over both of his upper arms and lower abdomen and second degree deep partial thickness burns on his upper chest. At the periphery of these second degree burns are first-degree burns with large blisters developing some of which have burst. In total approximately 30% of Marty’s BSA is affected.
Mandy is distraught and wants to know if Marty will be scarred for life.
Learning Objectives:
The normal structure and function of skin
Normal wound healing
Burns
Classification
Treatments – Stem cells
Prognosis
Social/Ethical/Legal issues
Child abuse
Normal structure and function of the skin
Normal structure of skin
The structure of the skin is divided into three layers, the epidermis, the dermis and the hypodermis. (Bardia Amirlak, 2011) (Thomas H. McConnell & Kerry L. Hull, 2011)http://www.discovercosmeticsurgery.com/wp-content/uploads/2010/07/skin-structure.jpg
Source: (Discover Cosmetic Surgery, 2010)
Epidermis
Source: (Structure of the Skin)The epidermis is the uppermost layer of the skin and is avascular. It obtains its nutrients and oxygen from the underlying dermis through diffusion. The epidermis is subdivided into 5 layers – the stratum basale which consists of basal (stem) cells and melanocytes, stratum spinosum, stratum granulosum, stratum lucidum and the stratum corneum. It is made up of stratified squamous epithelial cells. (Thomas H. McConnell & Kerry L. Hull, 2011) (Bardia Amirlak, 2011)http://encyclopedia.lubopitko-bg.com/images/epidermal%20layer.jpg
Skin cells are being reproduced constantly to replace dead cells (Thomas H. McConnell & Kerry L. Hull, 2011). The process is as follows:
Each basal cell in the stratum basale
Mitosis
A cell that moves upwards to form part of the stratum spinosum.
Basal (Stem) cell. This remains in the stratum basale.
The basal cells found in the stratum basale divide repeatedly to produce a stem cell and another cell which matures and moves upwards towards the surface of the skin. They also become drier because they are moving away from the dermis which is the cells’ source of fluid. (Thomas H. McConnell & Kerry L. Hull, 2011)
The stratum corneum cells are shed on a daily basis and new cells reproduced by the process below replace them. (Thomas H. McConnell & Kerry L. Hull, 2011)
When the keratinocytes enter the stratum lucidum, they die due to apoptosis and the nucleus disappears. They form a layer of cells which is only observed in thick skin, for example, the palms of the hands. It is absent in thinner skin, for example, around the eyes. (Thomas H. McConnell & Kerry L. Hull, 2011)
By the time the original cell enters the stratum corneum, it is a dead, dry, flat packet of keratin which contain no nucleus. (Thomas H. McConnell & Kerry L. Hull, 2011)
Source: (Dreamstime)
Dendritic cells are found in the stratum spinosum which form an important part of the immune system. (Thomas H. McConnell & Kerry L. Hull, 2011)
Cells mature as they move towards the surface of the skin. (Thomas H. McConnell & Kerry L. Hull, 2011)
In the stratum spinosum, the cell amasses lots of keratin which is “a tough, fibrous protein” to become keratinocytes. They also become drier and flatter as they mature and move upwards to form part of the stratum granulosum. (Thomas H. McConnell & Kerry L. Hull, 2011)
The flat keratinocytes filled with protein granules form part of the stratum granulosum. (Thomas H. McConnell & Kerry L. Hull, 2011)
Cells divide by mitosis. (Thomas H. McConnell & Kerry L. Hull, 2011)
Melanocytes are also found within the stratum basale which produce melanin and this is responsible for a person’s skin colour. (Thomas H. McConnell & Kerry L. Hull, 2011)http://www.dreamstime.com/anatomy-of-the-epidermis-of-the-skin-non-labeled-thumb18513932.jpg
Dermis
The dermis is highly vascular and consists of many structures such as sweat glands, hair follicles, nerves, macrophages, dendritic cells and blood vessels. It is made up of collagen and elastic tissue. (Thomas H. McConnell & Kerry L. Hull, 2011)
The dermis is subdivided into the papillary dermis and the reticular dermis. (Thomas H. McConnell & Kerry L. Hull, 2011)http://virtual.yosemite.cc.ca.us/rdroual/Lecture%20Notes/Unit%201/FG04_07.jpg
Papillary dermis consists of the dermis between the folds of the epidermis to a short distance beneath the papillae. (Thomas H. McConnell & Kerry L. Hull, 2011)
Source: (Integumentary System)The reticular dermis includes the rest of the dermis and contains most of the structures listed above. As illustrated, this layer consists of dense fibrous tissue. (Thomas H. McConnell & Kerry L. Hull, 2011)
Hypodermishttp://www.maharshiclinic.com/images/hypodermis.gif
Source: (StudyBlue, 2010)The hypodermis lies underneath the dermis and is subdivided into two layers: a fat layer and a deep fascia layer. The deep fascia layer is made up of dense connective tissue and this encases the entire body. (Thomas H. McConnell & Kerry L. Hull, 2011)
Function of the skin
The skin has many important functions:-
Protection – The skin acts as a barrier to environmental effects, such as abrasions, and microbes. (Keith L. Moore, Anne M. R. Agur & Arthur F. Dalley, 2011)
Containment – It prevents dehydration by providing containment of all the tissues and organs of the body. (Keith L. Moore, Anne M. R. Agur & Arthur F. Dalley, 2011)
Heat Regulation – The skin regulates body temperature using sweat glands and blood vessels by a process known as homeostasis. (Keith L. Moore, Anne M. R. Agur & Arthur F. Dalley, 2011)
Sensation – Sensory nerve endings found in the skin provide sensation, for example, pain. (Keith L. Moore, Anne M. R. Agur & Arthur F. Dalley, 2011)
Vitamin D – When light energy is absorbed, cholecalciferol or Vitamin D is synthesised in the skin. This promotes bone growth when metabolised and activated. (Keith L. Moore, Anne M. R. Agur & Arthur F. Dalley, 2011) (R. Bowen, 2011)
Normal Wound Healing
When the skin is injured, for example, due to a burn, the cells undergo necrosis and die. They release enzymes which kill neighbouring cells and therefore, the damage spreads. (Thomas H. McConnell & Kerry L. Hull, 2011)
Wound healing consists of three phases (Clinimed, 2012):-
Inflammation (Clinimed, 2012)
Fibroblasts produce new collagen type III tissue. (Thomas H. McConnell & Kerry L. Hull, 2011) (SP Zinn)Proliferation (Clinimed, 2012)
Maturation (Clinimed, 2012)
Inflammatory cells accumulate on the surface and water evaporates from the extracellular fluid causing a scab to arise. (Thomas H. McConnell & Kerry L. Hull, 2011)
Granulation tissue is the accumulation of blood vessels, such as capillaries, and fibroblasts. (Thomas H. McConnell & Kerry L. Hull, 2011)
Collagen type III is remodelled into collagen type I which is much stronger. (CliniMed, 2012)
Source: (Wound Care Solutions Telemedicine)
During inflammation, there is an increased flow of blood to the injury site which brings white blood cells to destroy bacteria and remove any dead remains of cells. (Thomas H. McConnell & Kerry L. Hull, 2011)
Occurs over a long period of time. (SP Zinn)http://www.woundcaresolutions-telemedicine.co.uk/images/WoundHealingProcess.jpg
A clot forms due to red blood cells and platelets being released. (Thomas H. McConnell & Kerry L. Hull, 2011)
Tissue healing takes place in the proliferative stage. It can result in complete regeneration if the stroma of the tissue is left intact. This means that a scar is not formed and the tissue can be restored to complete normalcy. However, if the stroma is distorted or damaged, then a mixture of regeneration and scarring will occur as the regenerating cells are not supported or directed appropriately. (Thomas H. McConnell & Kerry L. Hull, 2011)
Regeneration is also determined by the location of the injury. Tissue cells, for example, have many stem cells which allow them to undergo more successful regeneration compared to muscle cell which have a lower number of stem cells. (Thomas H. McConnell & Kerry L. Hull, 2011)
Maturation involves the remodelling of collagen fibres. This occurs over a long period of time and is only initiated after the wound has been closed. (CliniMed, 2012)
Source: (CliniMed, 2012)Phases of Wound Healing
Burns
Classification
A burn is defined as an “injury resulting from exposure to heat, chemicals or radiation”. (WordNet Search – 3.1)
The classification of burns according to the layers affected is as follows (Thomas H. McConnell & Kerry L. Hull, 2011): –
Type of Burn
Regions Affected
Sensation
Appearance
Example
Time to Heal
Superficial(First Degree) Burns
Epidermis
Painful
Erythema, Swelling
Sunburn
<1 week
Superficial Partial Thickness (Second Degree) Burns
Epidermis and Papillary Dermis
Painful, Sensitive to touch
Formation of blisters
Scalding due to boiling water
2-3 weeks
Deep Partial Thickness (Second Degree) Burns
Epidermis, Papillary Dermis and Reticular Dermis
Painless (due to nerve endings being damaged)
White or pale (due to lack of blood vessels)
Fire burn
3-6 weeks
Full Thickness (Third Degree) Burns
All the layers of the skin
Painless(due to nerve endings being damaged)
Dry and leathery
Directly exposed to flame
Skin grafting needed to heal
Fourth Degree Burn
Skin and underlying muscle and bone
Painless
Dry and leathery, black or purple
Electrical and severe thermal burns
Hospital admission is required
Source: (Medical Student LC), (Thomas H. McConnell & Kerry L. Hull, 2011) (Marieb & Hoehn, 2012)
Burns can also be classified by the total body surface area affected:
The rule of nines can be used to estimate the total body surface area affected by a burn. (Thomas H. McConnell & Kerry L. Hull, 2011)
The total body surface area affected together with the patient’s age is used to calculate the severity of the burn and the volume of body fluid lost. (Thomas H. McConnell & Kerry L. Hull, 2011) (Marieb & Hoehn, 2012)
Source: (Thomas H. McConnell & Kerry L. Hull, 2011)
Treatments
First Aid
The first aid for treatment of burns is as follows:
The person must be removed from the source of burn as soon as possible. (NHS Choices,2012)(Dr Hayley Willacy, Dr Tim Kenny, Prof Cathy Jackson, 2012)
Clothes or jewellery must be removed from the burning area. (NHS Choices,2012)(Dr Hayley Willacy, Dr Tim Kenny, Prof Cathy Jackson, 2012)
The burn must be cooled for approximately 10-30 minutes using cool or lukewarm water only. It should then be covered but not wrapped, with clingfilm because it is sterile and doesn’t stick to the burn. (NHS Choices,2012)(Dr Hayley Willacy, Dr Tim Kenny, Prof Cathy Jackson, 2012) (Bupa, 2011)
The person must be kept warm to prevent hypothermia. (NHS Choices,2012)
The pain can be managed with paracetamol or ibuprofen. (NHS Choices,2012) (Dr Hayley Willacy, Dr Tim Kenny, Prof Cathy Jackson, 2012) (InjuryInformation.com, 2009)
First aid must be given to the patient as soon as possible to minimise the damage caused by the burn. (NHS Choices, 2012)
Treatment for different types of burns
The treatment given depends on the type of burn it is:
Superficial (First Degree) burns
Superficial burns are treated by cooling the burn with clean water and managing the pain with the use of analgesics (painkillers) or topical solutions such as aloe vera. (InjuryInformation.com, 2009)
Superficial burns do not result in deep wounds and blisters therefore, there is only a slim chance of infection. (InjuryInformation.com, 2009)
Partial thickness (Second degree) burns
Partial thickness burns are treated in the same way as superficial burns. The first step in treating partial thickness burns is cleaning the wound with water and reducing pain and swelling with the use of analgesics. The next step is to use sterile gauze to cover the burn without breaking the blister to minimise the chance of infection. (InjuryInformation.com, 2009) (Bupa, 2011) The skin layers can still regenerate after a partial thickness burn due to the stem cells present in hair follicles. (Thomas H. McConnell & Kerry L. Hull, 2011)
However, severe partial thickness burns, for example, burns covering a significant proportion of the body, require medical attention and are treated using (InjuryInformation.com, 2009):
First Aid – to clean the burn and prevent the chance of infection. (InjuryInformation.com, 2009)
Intravenous fluids – to prevent excess heat and fluid loss which could lead to a decrease in blood pressure and shock. (Bupa, 2011)(Thomas H. McConnell & Kerry L. Hull, 2011)
Prophylactic antibiotics – if the patient is suspected of being infected, prophylactic antibiotics are given to treat the infection. (Saunders Comprehensive Veterinary Dictionary, 2007) (Bupa, 2011)
Analgesics – Analgesics will be given, for example, ibuprofen, aspiring, paracetamol, to manage the pain. (InjuryInformation.com, 2009) (Bupa, 2011) (NHS Choices, 2012)
Skin grafts – to reduce scarring. This is carried out for patients with severe partial thickness, full thickness and fourth degree burns to re-establish the surface of the skin because most of the basal cells have been destroyed. (InjuryInformation.com, 2009) (Thomas H. McConnell & Kerry L. Hull, 2011) (Bupa, 2011) (Shabir Bhimji, VeriMed Healthcare Network & David Zieve, 2011)
There are four different types of skin grafts (Leah DiPlacido, 2010):
Autografts – The skin is taken from any part of the part of the patient’s body, for example, the buttocks. This is then spread over the wound and held in place using staples or stitches. (Shabir Bhimji, VeriMed Healthcare Network & David Zieve, 2011) (Bupa, 2011) (Leah DiPlacido, 2010)The main advantage of autografts is that it is no issue of rejection because it is the patient’s own skin.
Allografts – The donor skin is from another person, usually a cadaver. However, the cells in the skin need to be alive when transplanted. The disadvantage of allografts is that the patient’s immune system will attack the allografts leading to rejection. Therefore, this is only a temporary form of cover. (Leah DiPlacido, 2010)
Xenografts – The skin used is from a different species, for example, a pig. It has the same disadvantage as allografts and eventually results in rejection, therefore, xenografts are also used as a temporary cover. (Leah DiPlacido, 2010)
Synthetic Tissue – Burns can also be covered using synthetic tissue which is synthesised in a laboratory. It is made of collagen and carbohydrate and is placed over the wound to allow the patient’s own cells to grow into this engineered skin. (Leah DiPlacido, 2010)
Full thickness (Third Degree) and Fourth degree burns
Immediate emergency attention is required for these burns as all the layers of the skin are destroyed. This also increases the likelihood of an infection and therefore, these burns are treated in a sterile environment. (InjuryInformation.com, 2009)
All full thickness and fourth degree burns require full-thickness skin grafts in which the transplanted skin includes the underlying muscle and blood supply. (InjuryInformation.com, 2009) (Shabir Bhimji, VeriMed Healthcare Network & David Zieve, 2011)
An escharatomy is also performed in severe burns where the skin and tissue becomes inelastic and damages blood vessels thereby preventing circulation. Surgical incisions are made along the area of the burn to release the pressure of the skin and tissues so circulation can resume. (Jennifer Heisler, 2012) (Jama, 1968)
There is a definite chance of scarring in full thickness and fourth degree burns because all the stem cells in the skin have been destroyed and regeneration cannot take place. (InjuryInformation.com, 2009) (Thomas H. McConnell & Kerry L. Hull, 2011)
Prognosis
The prognosis for burn patients is dependent on the severity of the burn and the total body surface area affected. (Considerations for burn patients)
Social/Ethical/Legal issues
Child abuse – Responsibilities
Child abuse is defined as the mistreatment of a child either physically, emotionally or sexually. (Supreme Court of Newfoundland and Labrador)
There are four categories of child abuse which are recognised:
Physical abuse – This form of abuse involves physical mistreatment of the child, for example, hitting, burning, poisoning, etc. (Dr Colin Tidy, Dr Naomi Hartree & Dr Tim Kenny, 2010)
Emotional abuse – This form of abuse involves the emotional mistreatment of a child which could result in child’s emotional development being affected. Some examples of this include: bullying, frightening a child, etc. (Dr Colin Tidy, Dr Naomi Hartree & Dr Tim Kenny, 2010)
Sexual abuse – This form of abuse involves forcing a child to participate in sexual activity and also forcing him/her to look at sexual images etc. (Dr Colin Tidy, Dr Naomi Hartree & Dr Tim Kenny, 2010)
Neglect – Neglect is defined as the failure of the parent or guardian to meet the “basic physical and psychological needs” of the child, for example, emotional neglect, failure to protect the child from danger, etc. (Dr Colin Tidy, Dr Naomi Hartree & Dr Tim Kenny, 2010)
Some of the symptoms of child abuse include:
Withdrawal of child (Dr Colin Tidy, Dr Naomi Hartree & Dr Tim Kenny,2010)
Physical marks and bruises which indicate towards physical abuse or neglect (Dr Colin Tidy, Dr Naomi Hartree & Dr Tim Kenny,2010)
Overdose of toxic substances could indicate towards physical abuse (Dr Colin Tidy, Dr Naomi Hartree & Dr Tim Kenny,2010)
The child might be afraid of physical contact, etc. (Dr Colin Tidy, Dr Naomi Hartree & Dr Tim Kenny,2010)
If a child is suspected of being abused, the doctor should discuss the case with their colleagues and if necessary, the child and family should be referred to social services. If possible, consent should try to be obtained and the carer involved. However, if the doctor feels that the child is at immediate risk, then the emergency services must be informed immediately. (Dr Colin Tidy, Dr Naomi Hartree & Dr Tim Kenny, 2010)
Conclusion
Looking at the scenario, it can be seen that Mandy carried out the correct first aid procedure by wrapping Marty in a damp towel as this will cool the burn and prevent the risk of infection. (InjuryInformation.com, 2009)
In A & E, Marty was given the treatment required for the above burns, for example, analgesics and intravenous fluids. However, for the second degree deep partial thickness burns on his upper chest, he might require skin grafts from another part of his body such as the buttocks to minimise scarring and re-establish the growth of epidermis. (InjuryInformation.com, 2009) (Bupa, 2011)
In conclusion, I think that Marty will recover fully with some scarring on the upper chest; however, he might need psychological support and counselling to help deal with the scars.
Source: (Natalie Verney, 2012)As this is the first case of neglect, Marty must be observed to see if any such incident happens again. The social services can also be involved to help Mandy take care of Marty. She can also be advised to join support groups, for example, Netmums to help cope physically and mentally. http://www.heart.co.uk/u/apps/asset_manager/uploaded/2012/23/netmums-logo-1339067868.jpg
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