ATI FUNDAMENTALS- TISSUE INTEGRITY Flashcards
LARGEST ORGAN SYSTEM OF THE BODY
SKIN
SKIN ACCOUNTS FOR WHAT % OF TOTAL BODY WEIGHT
15
The main function of the skin is
to provide a barrier against injury, infection, ultraviolet radiation (UV), and fluctuations in temperature changes.
The skin plays an important role in
the perception of touch, pain, pressure, and vibration.
3 LAYERS OF SKIN
the epidermis, the dermis, and a fatty subcutaneous layer of adipose tissue.
epidermis
The outer most layer of the skin, made of squamous epithelial cells, which provides a barrier against the external environment.
keratinocytes
Cells formed in the basal layer of the skin that function to protect the skin from the external environment.
WHEN KERATINOCYTES LEAVE THE BASAL LAYER, WHERE DO THEY MIGRATE
THE MORE SUPERFICIAL LAYERS WHERE THEY DIE IN TIME ARE REMOVED THROUGH SHEDDING
CELLS FOUND IN THE EPIDERMIS
MELANOCYTES
KERATINOCYTES
MERKEL CELLS
LANGERHANS
MELANOCYTES PRODUCE
MELANIN
MELANIN
a pigment that determines the color of the hair and skin. Melanin also absorbs radiant energy from the sun and protects the skin from harmful UV rays.
MERKEL CELLS
detect light touch, especially in the palms of the hands and soles of the feet.
LANGERHANS CELLS
ingest and package foreign antigens to be presented to lymphocytes, which then trigger an immune response in the epidermis.
DERMIS
UNDER THE EPIDERMIS
is composed of connective tissues along with capillaries, blood vessels, and lymph vessels.
FUNCTIONS OF THE DERMIS
sustains and supports the epidermis by providing strength, flexibility, and nourishment. The dermis also protects underlying structures from injury and assists with wound healing.
COLLAGEN AND ELASTIN FIBERS OF THE DERMIS
PROVIDE STRENGTH AND ELASTICITY
PROTECTS FROM COMPROMISED INTEGRITY
SUBCUTANEOUS LAYER
MOSTLY ADIPOSE TISSUE
INNERMOST LAYER
CONTAINS BLOOD VESSELS AND NERVES THAT ASSIST IN THERMOREGULATION AND SENSATION
FUNCTIONS OF THE SUBCUTANEOUS LAYER
insulates the body, absorbs shock, and pads the internal organs and structures
A nurse is teaching a group of older adults at a community center about the functions of the skin. Which of the following statements should the nurse include in the teaching? (Select all that apply.)
A
The skin plays an important role in the production of vitamin D.
B
The dermis contains cells that help prevent infection.
C
The skin protects against bacteria and viruses.
D
The skin helps regulate the body temperature.
A, C, D
Risk Factors for Impaired Tissue Integrity
TIME- EARLY AND LATE IN LIFE
IMPAIRED MOBILITY
OBESITY
CANCER
CHRONIC ILLNESSES
maceration
An irritation of the epidermis caused by moisture.
COMMON IN INFANCY
DERMATITIS
A red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates. This type of dermatitis is called an irritant dermatitis.
COMMON IN INFANCY
SKIN TEARS
Loss of the top skin layer caused by mechanical forces. The severity of a skin tear is defined by the depth of the skin layer loss.
DUE TO COLLAGEN STORES DECREASE, THIN SKIN, ELASTICITY LOSS
CONGENITAL CONDITIONS THAT PREDISPOSE CLIENTS TO TISSUE INTEGRITY ISSUES
SPINA BIFIDA
CEREBRAL PALSY
LIVER FAILURE
KIDNEY DISEASE
CANCER
SKIN FRAILTY
At-risk vulnerable skin.
The most frequently occurring skin problems associated with skin frailty are
SKIN TEARS, PRESSURE INJURIES, AND INFECTIONS LIKE CELLULITIS
PRESSURE INJURIES
(localized damage to the skin and/or underlying tissue, as a result of a pressure or pressure in combination with shear
CELLULITIS
INFECTION OF THE SUPERFICIAL LAYERS OF SKIN
SKIN CHANGES
NEONATES/CHILDREN
Immature skin
Prolonged duration of pressure
Moisture/maceration
Poor perfusion
SKIN PROBLEMS
NEONATES/CHILDREN
Diaper rash
Skin tears
Pressure injuries
SKIN CHANGES
OLDER ADULTS
Thinning of the skin
Decreased
Elasticity
Subcutaneous tissue
Blood supply
Hydration
SKIN PROBLEMS
OLDER ADULTS
Skin tears
Pressure injuries
Itchy, dry, flaky skin
Skin infections
SKIN CHANGES
DECREASED MOBILITY/PARALYSIS
Reduced blood circulation
Alterations in thermoregulation
Incontinence
Loss of collagen
Muscle atrophy
Impaired sensation
SKIN PROBLEMS
DECREASED MOBILITY/PARALYSIS
Skin tears
Pressure injuries
Skin infection
Incontinence-associated dermatitis
SKIN CHANGES
CLIENTS WHO ARE OBESE
Decreased moisture
Dry skin
Maceration
Elevated skin temperature
Decreased blood and lymphatic flow
SKIN PROBLEMS
CLIENTS WHO ARE OBESE
Skin tears
Pressure injuries
Diabetic ulcers
Moisture lesions
Skin-fold rashes
SKIN CHANGES
CLIENTS WITH CANCER
Radiation resulting in:
Inflammation
Skin surface damage
Decreased blood supply
SKIN PROBLEMS
CLIENTS WITH CANCER
Pressure injuries
Delayed wound healing
Skin infections
Radiation-induced dermatitis
SKIN CHANGES
CLIENTS WITH CHRONIC ILLNESSES
Skin changes due to:
Hepatic diseases
Renal diseases
Cardiovascular diseases
Malnutrition
Stomas
Psychosocial issues
SKIN PROBLEMS
CLIENTS WITH CHRONIC ILLNESSES
Skin tears
Pressure injuries
Infections
Moisture associated lesions
doing what is key to promoting optimal skin health
Regularly assessing the skin of clients who are vulnerable to the development of alterations in skin and tissue integrity
major elements of a comprehensive skin assessment
athering the medical history, looking at factors that place clients at risk, and assessing the skin for abrasions, edema, moisture, rashes, and other abnormalities. Skin texture and temperature should also be assessed.
Assessment of the skin and soft tissue is also a key factor in
decreasing the risk of pressure injury formation, classifying wounds, and determining treatment modalities.
pressure injury
Localized damage to the skin and/or the soft underlying tissue, which can be caused from prolonged contact with a firm surface that interferes with circulation to the area.
when should clients undergo skin assessments
admission to a facility and then once daily or once per shift
erythema
Redness of the skin due to dilation of blood vessels.
blanchable erythema
An area of a reddened skin that temporarily turns white or pale when light pressure is applied. the skin then reddens when pressure is relieved.
nonblanchable erythema
Redness of the skin that does not go away when pressure is applied and indicates structural damage has occurred in the small vessels supplying blood to the underlying skin and tissues.
The skin should be palpated for
temperature changes, as inflammation will present as an increase in skin temperature, while areas with decreased blood flow will feel cool to the touch. also for edema
rythema is more difficult to detect in dark-skinned clients, which can lead to
delayed identification of pressure injuries.
special considerations to assessing the skin in obese
Due to the increased pressure caused by the weight of additional abdominal fat, the need to assess for the presence of pressure ulcers between the skin folds. also at risk for moisture related skin disordered and infections
If the client’s condition deteriorates, when should we assess the skin
If the client’s condition deteriorates, an increase in the frequency of skin inspections is recommended.
Pain at the site of pressure points is
a red flag and should be considered a warning sign of pressure injury formation.
wound
A wound is a disruption in the normal composition and performance of the skin and it s underlying structures.
how are wounds classified
acute or chronic based on their origin and healing progression.
intentional origination
acute wounds
created during a surgical procedure
unintentional wound
acute wound
develop as the result of a traumatic injury, such as burns, punctures, or gunshot wounds.
lacerations
traumatic wounds
tears in skin
usually by blunt or sharp objects
often irregular or jagged
classified as simple or complicated
skin tears
common in elderly
from mechanical forces like removing tape from skin
severity defined by depth of skin loss
most common on hands and extremities
classification of surgical wounds
clean
clean contaminated
contaminated
dirty
depends on suspected contamination
Clean and clean-contaminated wounds
ave minimal bacterial loads and are closed at the completion of the procedure.
Contaminated and dirty wounds
have higher bacterial loads that may interfere with healing. In consequence, these wounds may be left open after the procedure and require long-term wound management for healing to occur.
surgical wounds
during surgical process
sterile conditions
mechanically closed
intact/well approximated edges
color of healing surgical wounds
red on days 1 to 4, changes to bright pink on days 5 to 14, and then appears pale pink from day 15 to 1 year after the procedure.
exudate
fluid consisting of plasma that is secreted by the body during the inflammatory phase of healing
scar tissue appearance
Scar tissue that forms on lightly pigmented skin will be white or silver, while scar tissue on darkly pigmented skin will change from pale pink to a darker than usual skin tone.
Moisture-associated skin damage (MASD) is
a form of dermatitis that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates. Excessive sweating, increased local skin temperature, abnormal skin pH, and deep skin folds all predispose clients to MASD.
clients with masd may also experience other clinical manifestations, including
pain, burning, and itching. MASD predisposes clients to pressure injury formation.
Chronic wounds
develop over time as a result of disruption in the wound healing process associated with acute wounds, or due to conditions that cause alterations in blood flow.
conditions attributed to chronic wound development
chronic venous insufficiency, peripheral artery disease, and diabetes mellitus
risk factors of chronic wound development
smoking
undernourished
immunosuppressed
immobilized
infection in the mound
three major categories of chronic lower extremity wounds with different etiologies:
venous disease wounds, arterial disease wounds, and neuropathic disease wounds.
Wound exudate may be
serous, serosanguineous, sanguineous, or purulent.
purulent
indicates infection
Green/yellow wound drainage.
wound documentation
changes in color/amount/odor of exudate
appearance
size
healing
serous
Thin, watery wound drainage.
serosanguineous
Thin, watery wound drainage mixed with blood.
sanguineous
Bloody wound drainage.
methods to measure wound size:
Tracing the wound circumference and calculating the wound surface area using a see-through film
Measuring the length and width of the wound using a ruler
either is fine but be consistent through the entire time and progression of healing
tunneling
development of a narrow channel or passageway extending in any direction from the base of the wound
Pressure injuries develop due to
prolonged pressure over an area of the skin or due to a combination of pressure and shearing
shearing
forces exerted parallel to the surface of the skin. Shearing occurs when clients are sitting or lying on an incline, such as sitting in high-Fowler’s position in bed.
how does shearing occur
While the client is sitting, gravity pulls deeper tissues, such as fat and muscles, downward while the top layers of the skin remain in contact with the surface on which the client is sitting.
what does shearing result in
stretching and trauma to the blood and lymphatic vessels. When pressure is added to shearing forces, the effect is additive and a more severe pressure injury may form
Most often pressure injuries occur
over bony prominences, but they can also develop where pressure is produced by medical devices, such as urinary catheters, oxygen tubing, endotracheal tubing, and surgical or wound drains.
pressure injury risk factors
immobility
malnutrition
reduced perfusion
altered sensation
decreased loc
exposure to moisture
tearing
cuts
bruises
friction
malnutrition
condition where there is nutritional deficit
friction
force created when 2 objects rub together
is friction a direct cause of pressure injuries
no, but it does cause trauma to the skin and tissues, thereby increasing the client’s risk for developing a pressure injury.
occipital pressure injury
Braids that are worn tightly to the scalp increase the risk
especially true if the client is immobile and not able to relieve the pressure placed on the scalp.
Occipital pressure injuries due to tightly braided hair can lead to
scarring, alopecia, and permanent hair loss.
Each year in the United States, approximately how many people die from complications of pressure injuries.
60,000
bony prominences common for pressure injury
including the heels, toes, sacrum, hips, elbows, shoulders, and back of the head.
A nurse is providing education about pressure injury development to a newly licensed nurse. Which of the following points should the nurse include in the teaching? (Select all that apply.)
A
Shear forces occur when the skin and muscles are pulled in opposite directions.
B
Pressure injuries most often develop over bony prominences.
C
Friction is a continuous force exerted on or against an object.
D
Factors contributing to pressure injury development include immobility, malnutrition, reduced perfusion, and sensory loss.
a, b, d
To optimize maintenance of skin integrity, nurses should
identify individual client preferences and determine the specific risk factors that might increase the client’s risk for skin breakdown.
common risk factors assessed for pressure injury
immobility, malnutrition, perfusion, and sensory loss.
hypoperfusion
Inadequate supply of blood circulation, which results in low oxygen levels in tissues.
braden scale
rates a client’s risk for alterations in tissue integrity using six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear
lowest is 6–> most at risk
highest is 23
When staging pressure injuries, the nurse should observe for
non-blanchable erythema, the amount and depth of skin and tissue loss, the condition of tissue in the wound bed and surrounding areas, the presence of dead tissue, and tunneling and undermining
undermining
an open area extending under skin along the edge of the wound
benchmarking
involves comparing results and outcomes to other sources of similarly retrieved data, and it can show the facility if its overall pressure injury prevention initiatives are successful.
Stage 1 Pressure Injury: Non-blanchable Erythema
skin is intact with a localized area of non-blanchable erythema. Sensation, temperature, and changes in consistency of the skin and tissues may precede color changes. Stage 1 pressure injuries may be difficult to detect in darker-pigmented skin.
Stage 2 Pressure Injury: Partial-Thickness Skin Loss
present as a partial-thickness skin loss, with pink or red viable tissue in the wound bed. The tissue is moist, and deeper tissues are not visible. A stage 2 pressure injury may also present as a ruptured serum-filled blister.
Stage 3 Pressure Injury: Full-Thickness Skin Loss
full-thickness skin loss with visible adipose tissue. Granulation tissue, or new skin tissue that forms on the surface of the wound, is often present, and wound edges may be rolled. Dead tissue may have formed. Undermining and tunneling may also be present. The fascia, muscles, tendons, bone, ligament, and cartilage are not visible in this stage.
granulation tissue
New skin tissue that forms on the surface of the wound.
Stage 4 Pressure Injury: Full-Thickness Skin and Tissue Loss
full-thickness tissue loss. The fascia, muscles, tendons, ligaments, cartilage, and/or bone are visible. Edges are rolled, and undermining and tunneling may be present. Dead tissue may also be seen.
Unstageable Pressure Injury: Obscured Full-Thickness Skin and Tissue Loss
damage cannot be determined owing to the obscured full-thickness skin and tissue loss injury. Such a wound is covered with either slough, a yellow, stringy nonviable tissue found in the base of the wound, or eschar, a hard nonviable black/brown tissue. Once the eschar is removed, the wound will reveal a stage 3 or 4 pressure injury.
unstageable pressure injury
Obscured full-thickness skin and tissue loss injury.
slough
Yellow, stringy nonviable tissue found in the baase of the wound.
eschar
Hard nonviable black/brown tissue found in the wound bed.
deep tissue pressure injury (DTPI)
Persistent nonblanchable tissue injury of the skin appearing deep red, maroon, or purple color.
Device-Related Pressure Injury
devices worn caused by devices, equipment, furniture, or objects left in contact
assumes shape of device
usually from o2 masks or tubing, urinary catheters, cervical collars, compression stockings
Mucosal Membrane Pressure Injury
Injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device.
cannot be staged because doesn’t have same layers as skin
Classifying Pressure Injuries in Darkly Pigmented Skin
skin temp
level of moisture
edema
hardened skin
localized pain
look for darker area after light pressure
may appear taught, shiny, or indurated
If pressure injury wound begins to deteriorate, the exudate changes, manifestations of infection appear, or other complications emerge, what happens
treatment plans will need to be adjusted. If the wound is not healing according to expectations, the nurse should consider recommending to the provider further diagnostic testing, such as a tissue biopsy.
When documenting pressure injuries, the nurse should include
the location, stage, and size; a description of the tissue; the color of the wound bed; the condition of the surrounding tissue; the appearance of the wound edges; the presence of undermining and tunneling; and any foul odor present.
also drainage, pain
Older adults, especially who have dementia, are at risk for
under-assessment and under-treatment of pain when they are unable to advocate for themselves.
debridement
The process of surgically removing dead tissue and other debris that can cause infection.
Wound irrigation
removes surface materials and decreases bacterial levels in the wound. Wound irrigation may be performed at the bedside or in the surgical suite, depending on the amount of pressure needed to irrigate the wound.
Biological Debridement
Various enzymatic agents, such as collagenase, papain (papaya extract), and bromelain (pineapple extract), can be applied to wounds to clear dead tissue and debris.
collagenase
agent that only targets necrotic tissue
larvae therapy
Larvae therapy can be used for debridement of chronic wounds when surgical debridement is not an option.
Careful selection of the correct dressing does what
facilitates wound healing, minimizes scarring, and strengthens tissue as it heals.
For healing to occur, a moist—not wet—wound bed is required. Ideally, the dressing should
pull excessive moisture from the wound, decreasing the probability of maceration of surrounding tissue, while leaving adequate moisture for the wound to heal.
Sterile dressings
are applied after surgery and are usually kept on the incision site for 24 to 48 hours. If the dressing becomes saturated or loose, the dressing is changed using sterile technique.
After 48 hours, wounds are managed using
clean technique during dressing changes, as the wound is considered to be colonized from the client’s environment. In most cases, if a client requires dressing changes in the home environment, clean technique will be used.
Gauze bandages are considered
open dressings.
wet to dry dressing
After being moistened with 0.9% sodium chloride, gauze dressings are used to pack wounds to assist with the debridement process. As the gauze dries, it clings to tissue inside the wound. When the gauze is removed, the tissues that have clung to the gauze are removed along with the dressing.
removes necrotic and healthy tissues
Semi-open dressings
3 layers
The bottom layer comprises a layer of knit gauze that is more closely woven than traditional gauze; it is infused with therapeutic ointments. The middle layer contains padding and absorbent gauze, which is followed by a final layer of adhesive.
semi-open dressings do not
control drainage well and place the client at risk for poor wound healing and breakdown of tissue adjacent to the wound.
Semi-occlusive dressings
have more diverse properties than open and semi-open dressings. These dressings vary in their abilities to cover wounds and control moisture and bacteria
films
semi occlusive dressings
Due to their reduced ability to absorb moisture, self-adhesive transparent dressings are used for covering superficial wounds that have minimal exudate.
Hydrocolloid Dressings
Semi-Occlusive Dressings
used for small abrasions, superficial burns, pressure injuries, and postoperative wounds. When placed over wounds, these gel-like dressings occlude the wound, maintain a moist wound bed, have bacteriostatic properties, and stimulate growth of new granulation tissue.
alginate dressings
Semi-Occlusive Dressings
recommended for moderate to highly exudative wounds. These dressings provide hemostasis, have high absorptive abilities, and can remain in a wound for several days, so they require less frequent dressing changes. They also come in a variety of forms, including ribbons, pads, and beads, making them very versatile in terms of wound coverage and packing.
hydrofiber dressings
Semi-Occlusive Dressings
Used for moderate and highly exudative wounds, hydrofiber dressings provide high absorbency and can stay in the wound for several days. These dressings draw less fluid from the wound edges, resulting in less maceration around the wound compared to alginate dressings.
foams
Semi-Occlusive Dressings
used in wounds with mild to moderate exudate, but require more frequent dressing changes as compared to those dressings previously discussed. Foam dressings may produce a malodorous discharge.
polymeric membranes
Semi-Occlusive Dressings
used in mildly exudative wounds. These dressings stimulate the growth of new epithelium and do not stick to the wound bed, resulting in less trauma to the new granulation tissue.
hydrogels
Semi-Occlusive Dressings
used in dry wounds for debridement of necrotized tissue and eschar. They work differently than other dressings, in that they can provide moisture to or draw moisture away from the wound depending on the needs of the wound. Hydrogels have a soothing effect and cause little trauma to the wound bed.
sutres and staples
wound closures
Abdominal wounds, chest wounds, and wounds without infection are treated with this type of wound closure.
The type of wound and its location on the body will determine whether sutures or staples are used. In general, staples are not used for face or neck wounds.
Sutures are made from
wound closure
synthetic materials such as nylon or polyester, or from natural fibers such as silk, linen, and dried animal intestines. Both synthetic and natural sutures can be absorbable or nonabsorbable. Synthetic absorbable sutures dissolve within days to weeks, sometimes lasting up to 2 months.
skin adhesives
wound closures
save time in terms of placement, and the wound infection rates and cosmetic look of the incisions are comparable to those achieved with other techniques. Skin adhesives form a protective waterproof covering over the wound. Skin adhesives are used for small, minor wounds and wounds that have straight edges. They are suitable for wounds on the face, head, parts of arms, legs, and torso, but are not used over joints.
Negative Pressure Wound Therapy
wound closure
by reducing edema surrounding the wound and increasing granulation tissue formation. In this therapy, a foam dressing is applied over the wound and covered by a semi-porous occlusive dressing, to which suction is applied.
Suction during NPWT can be applied
constantly or intermittently, depending on the wound and the client’s needs.
drains
Drains are used to decrease accumulation of fluid, reduce accumulation of air, and collect wound drainage for testing and identification. Surgical procedures that often require drain placement include those involving the chest, breast, abdomen, and thyroid, and plastic surgeries utilizing flap procedures.
Passive drains, such as Penrose drains, rely on
gravity to remove accumulated fluid from a body cavity or wound.
Active drains, such as portable wound bulb suction devices, use
negative pressure to suction drainage from wounds or body cavities.
Open drains
remove fluids to the air
closed drains
send fluids to a closed containment system. Closed systems require smaller incisions and are less likely to become contaminated with bacteria.
hematoma
(accumulation of blood in the body)
seroma (collection of serious fluid) formation.
(collection of serious fluid)
Penrose Drain
flat, pliable passive drain that uses gravity to drain accumulated fluids
open drain- no collection chamber
Portable Wound Bulb Suction Device
bulb suction drain, is an active, closed system drain that uses negative suction to drain fluid from the wound.
Large Bottle Drainage
if a large amount of fluid is expected, a higher-pressure, large bottle is used. The bottle is changed when half-full and the nozzle is expanded.
Circular Portable Wound Suction Device
pecial type of wound drainage system that is designed to continuously suction drainage from a wound by providing a low vacuum pressure.
The nurse should monitor the amount of drainage and
document the drainage type, amount, consistency, and odor.
when should a provider be contacted regarding a drain
If a significant increase or decrease in the amount of drainage occurs, blood clots are observed, the client develops manifestations of infection, or the drain is accidentally removed
In addition to monitoring wound drainage, the nurse should monitor
the skin around the drain site for maceration as well as the client’s lab work for manifestations of fluid and electrolyte imbalances.
Prevention of pressure injuries consists of two main components:
identification of clients at risk and implementation of interventions that are designed to reduce risk.
Interventions for Minimizing Risk
Clients should be kept clean, dry and repositioned frequently. If the client is at high risk for pressure injury development, supportive surfaces, preventive dressings, toileting schedules, hydration, and nutritional interventions are implemented along with a mobilization plan, as applicable.
Repositioning and Early Mobilization
Repositioning involves changing the position of clients at regular intervals to relieve or redistribute pressure points. Clients should be repositioned based on their individualized needs.
Early mobilization involves
assisting and encouraging clients to move or shift into a new position to increase activity and mobility as rapidly as the client can tolerate it.
Correct position of the bed:
minimize pressure and shearing forces by keeping the head of the bed lower than 30°
Flexing the client’s knees and placing pillows under the arms helps prevent sliding down in the bed.
Supportive surfaces:
Clients at risk of pressure injury should be placed on a special mattress and, if needed, on special pressure-relieving beds.
protection of bony prominences, skin, and mucosa under drains and other medical devices:
Positioning devices such as pillows or foam wedges should be used to offload pressure points.
Universal Measures for Prevention and Treatment of Tissue Injuries
nutrition
hydration
hygiene
circulation
Factors Influencing Wound Healing
diabetes, infection, presence of a foreign body in the wound, medications, malnutrition, tissue necrosis, hypoxia, and the presence of multiple wounds.
Diabetes mellitus
decreases peripheral perfusion and impairs sensation, placing clients at greater risk for delayed wound healing.
The infectious process
breaks down collagen, making tissues more vulnerable to damage.
