Tissue Integrity Flashcards
What is tissue integrity?
Tissue integrity is the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes
Scope of tissue integrity
- Intact skin and tissue: beautiful skin with no problems
- Partial thickness injury: partial injury where it may be injured under epidermis
- Full-thickness injury: injury all the way to the bone
Define epithelium
Elastic state of skin and tissue
Define debridement
Removal of dead, damaged, or infected tissue
Define granulation
Connective tissue that forms on the surface of a healing wound
Define turgor
Elastic state of skin and tissue
Define emollient
Agents that soften skin or treat dry skin
Physiological Processes: Skin Function
Epithelial cells cover all internal and external body surfaces
Functions are: protection, absorption, secretion, excretion
What is primary intention?
think of a surgical wound where there is a straight cut with a nice, clean wound; can be sutured or stapled; cleaner healing; may have a small scar
- Wound margins well approximated
- Lacerations and surgical incisions.
- The most rapid healing.
What is a secondary intention?
pressure ulcers; almost like a crater; think of a road rash; granulation tissue forms on the bottom and works its way up; leads to big scars because it is a lot of scar tissue and granulation
- Wound margins not well approximated.
- Larger wound area requires the formation of granulation tissue to fill gap.
- Longer period of time needed to heal.
What is a tertiary intention?
dirt biking and you crash into the cactus and all the dirt so you have a dirty wound full of dirt, sand, cactus, etc. and cant close wound up right away, let it drain, flush it, let it heal, and LATER we will close it with a suture if it is still not coming together
- Wound healing delayed and occurs when wound previously open is now closed.
- Usually associated with large infected/contaminated wounds.
What populations are at greatest risk for impaired tissue integrity?
- Infants: cannot move as much when they’re new and have sensitive skin; recommend to parents draft baby detergent; less subq fat so they have thinner skin; get pee and poop all over them leading to diaper rash; change their diaper as soon as you notice
- Children: are at risk because they get into everything, fall, climb on things they are not supposed to; don’t know boundaries yet; more prone to accidents
- Older adults: are at risk because they may be incontinent, less skin elasticity; thinner skin; 65+ community; reduced mobility; fall risks; long term meds (corticosteroids) that can thin out the skin a lot
Risk factors for impaired tissue integrity
- Health conditions: poor peripheral perfusion, malnutrition or obesity, dehydration or edema, impaired mobility, immunosuppression
- Exposure to irritants: Radiation, temperature extremes, chemical, mechanical trauma, medical treatments, occupation (miners), detergents and softeners
- Tissue trauma: Friction, shearing, moisture, pressure, sun exposure (tanning)
Health History
General health history: past and current conditions, family history, allergies, current and recent medications, history of skin disorders
- Problem-based history: Changes in skin condition and color, new rash or lesion; changes in previous lesions, excessive bruising, loss of hair; changes in condition of nails, wounds slow to heal
Examination
Inspection: General color and condition of skin
Lesions: location, size, shape, color, pattern, characteristics (e.g.,raised versus flat, dry versus exudate)
Palpation: feel skin for surface characteristics, temperature, and texture, pinch skin for turgor
- Pink tinge to skin, look at mucous membranes
- Always look for lesions, is there a pattern, how deep is it, something abnormal on skin
- Perfusion!! Cap refill on both extremities
- Take off socks when doing pedal pulses
