Tissue Integrity Flashcards
Florence Nightingale quote
If the patient has a bedsore, it is not the fault of the disease, but the nursing
Skin
-Largest organ
-Protective barrier
-Nursing responsibility to assess and monitor skin integrity
Vitamin D synthesis
Calcitriol- activated form of vitamin D
Natural Flora
Staph, Strep, E.coli
Dermis
-Eccrine sweat gland
-Apocrine sweat gland
Assessment of the skin
-Inspect entire body
-ESPECIALLY BONY PROMINENCES
-Visual & tactile
-Assess any rashes or lesions
-Hair distribution
-Skin color
-Blanch test
Healthy skin should
Blanch
What light is the best for skin assessment?
Natural light
Assess the skin when?
On initiation of care, then a least once a shift
High-risk patients- assess every 4 hours or more
Friction
Skin dragging against surfaces
-can cause skin tears and blisters
Shear
Sliding movement of skin and subq tissue while the underlying muscle and bone are stationary.
Causes stretching and tearing of blood vessel which reduce blood flow increase blood pooling and can lead to cell damage
Avoid shearing when
Raising the HOB
Sensory perception
Ability to respond meaningfully to pressure-related comfort
Moisture
Degree to which skin is exposed to moisture
Activity
Degree of physical activity
Mobility
Ability to change and control body position
Nutrition
Usual food intake pattern
Braden Scale Low Risk
15-18
-Regular turning schedule
-Enable as much activity as possible
-Protect heels
-Manage moisture, friction, and shear
Moderate risk
13-14
-Position patient at 30 degree lateral incline using wedges or pillows
High risk
12 or less
-position patient at 30 degree lateral incline using wedges or pillows
-make small shifts in position frequently
-pressure redistribution surface
Tissue integrity interventions
-frequent-repositioning
-sitting in chair for 2 hour intervals
-keep HOB at 30º
HOB no higher than 30º for
Skin integrity purposes
If patient can’t breathe, raise higher
C.H.A.N.T
Cleanse
Hydrate (and protect) skin
Alleviate pressure
Nourish
Treat
Red/Excoriated Peri/Rectal area
-Cleanse
-Dry thoroughly
-Moisture barrier daily and prn
Redness/Excoriation between skin folds
-Cleanse
-Dry thoroughly
-Place inter dry or dry AG textile in skin folds
Red Heels
-Position pressure off of heels
-Elevate on pillows
-Sage boot
-Reduce friction
Red Sacral/Coccyx area
-Change positions q 1-2 hours
-HOB <30º unless contraindicated
-Avoid excess moisture
-Frequent peri care
-Wrinkle free linen
sequential response to cell injury
-Neutralizes and dilutes inflammatory agent
-Removes necrotic materials
-Establishes an environment suitable for healing and repair
Inflammation ≠ Infection
Inflammation is always present with infection, but infection is not always present with inflammation
Inflammatory response occurs with multiple conditions
-Surgical wounds, other skin injuries
-Allergies
-Autoimmune diseases
-Skin infections
Wound
Any disruption of the integrity and function of tissues in the body
What is important to wound healing
Wound assessment and classification
Mast cells
Secrete factors that mediate vasodilation and vascular constriction. Delivery of blood, plasma, and cells to injured area increases
Neutrophils
New white blood cells, secrete factors that kill and degrade pathogens
5 cardinal signs of inflammation
Pain
Heat
Redness
Swelling
Loss of function
Type of exudate
Serous
Purulent
Serosanguineous
Sanguineous
Serous
Clear, watery plasma
Purulent
Thick, yellow, green, tan, or brown
Serosanguineous
Pale, red, watery: mixture of serous and sanguineous
Sanguineous
Bright red, indicates active bleeding
Systemic response to inflammation
-Increased WBC count
-Malaise (Lethargic)
-Nausea and anorexia
-Increased pulse and respiratory rate
-Fever
Types of inflammation
-Acute
-Subacute
-Chronic
Acute inflammation
-Healing in 2-3 weeks, no residual damage
-Neutrophils predominant cell type at site
Subacute inflammation
Same features, but lasts longer
Chronic inflammation
-May last for years
-Injurious agent persists or repeats injury to site
-lymphocytes and macrophages
-May result from changes in immune system
Final phase of inflammatory process is
Healing
Regeneration healing
Replacement of lost cells and tissues with cells of the same type
Repair healing
A result of lost cells being replaced by connective tissue, results in scar formation
-more common
-more complex
-occurs by primary, secondary, or tertiary intention
Healing by primary intention
-Initial phase: acute inflammatory response
-Granulation phase: wound pink & vascular, resistant to infection
-Maturation phase: scar formation: 7 days after injury, mature scar forms
Eschar
Dead tissue
Wound approximation
Edges of wound able to be pulled together
Healing by secondary intention
-Wounds from trauma, ulceration, & infection have large amounts of equate and wide, irregular wound margins
-Edges cannot be approximated
-Wound may need to be derided before healing can take place
Healing by tertiary intention
-Delayed primary intention due to delayed suturing of wound
-Occurs when contaminated wound is left open and sutured close free infection is controlled
Factors that affect wound healing
-Nutrition
-Tissue perfusion
-Infection
-Age
Complications of wound healing
Hemorrhage
Hematoma
Infection
Dehiscence
Evisceration
Dehiscence
Separation/splitting open layers of surgical wound
Hemorrhage
Bleeding
Hematoma
Bleeding under skin (bruise)
Evisceration
Extrusion of visceral or intestine through a surgical wound
Wounds are classified by
Cause: Surgical or non-surgical, acute or chronic
Depth: Superficial, partial thickness, full thickness
Skin tear
Wound caused by shear, friction, and/or blunt force
Wound assessment, include:
Location
Size
Condition of surrounding tissue
Wound base
Any drainage (consistency, color, odor)
Factors that could delay healing
What is the enemy of wound healing
Dryness
Never use __________ on a wound
Peroxide
Granulating
Tissue that is in the process of healing
Goal is for wound to be as moist as
Healthy skin
Surgical wounds may have a drain placed to
Help remove excess fluid
(Jackson-Pratt drain is common)
Purpose of dressings
-Protects from microorganisms
-Aids in hemostasis
-Promotes healing by absorbing drainage or debrieding a wound
-Supports wound site
-Promotes thermal insulation
-Provides moist environment
Types of dressings
-Gauze
-Transparent film
-Hydrocolloid
-Hydrogel
-Foam
-Composite
What do you need to do to dressings?
Put date and time
Removing sutures
-Remove every other suture
-Document how many
-Clip near skin
-Steri strips
Pressure ulcer/injury
-Localized injury to skin and/or underlying tissue (usually over bony prominences)
-Results from prolonged pressure or pressure in combo with shearing
-Will generally heal by secondary intentio
Pressure ulcer/injury influencing factors
Pressure intensity
Pressure duration
Tissue tolerance factors
Shearing forces
Moisture
Pressure ulcer/injury risk factors
-Age
-Anemia
-Diabetes
-Increased temp
-Friction
-Impaired circulation
-Low BP
-Obesity
-Shear
Slough
Thick yellow/white/grey covering of the wound bed
Stage I
-Intact skin — non-blanchable redness of a localized area
-most common over bony prominence
Stage II
-Partial thickness loss of dermis
-Shallow open ulcer with red/pink wound bed
-May also present as intact or ruptured blister
Fat and deeper tissues not visible
Stage III
-Full thickness skin loss
-Subq tissue may be visible,but bone, tendon, or muscle are not
-Presents as deep crater
Stage IV
-Full thickness loss, extends to muscle, bone, or supporting structures
-Bone, tendon, or muscle may be visible or palpable
-Slough or eschar may be present
-Undermining and tunneling may also occur
You cannot stage a wound if
Slough is covering it
Unstageable ulcer
-Full thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
Suspected deep tissue injury
-Purple or maroon localized area of discolored intact skin or blood filled blister
Cellulitis
Systemic infection caused by localized skin injury
Stage III and IV pressure injuries acquired after admission
NEVER want to happen
Venous leg ulcrs
-Poor blood return to heart
-Surrounding skin may be red, scaly, weepy, and thin
-Shallow, irregular shape
Diabetic ulcers
-Located on sole of floor, under heels and on toes
Cellulitis
-Inflammation of subq tissue, often following break in skin
-Treatment:moist heat, immobilization, elevation
The most important treatment for infection is
Prevention!
Psoriasis
-Common, chronic autoimmune inflammatory disorder characterized by plaque formation with varying degrees of severity
Mild psoriasis
red patches covered with silvery scales on scalp, elbows, knees, palms, and soles
Severe psoriasis
May involve entire skin surface and mucous membranes, superficial pustules, high fever, painful fissuring of the skin
Psoriasis treatment
Avoid:
-Scrubbig
-Long exposures to water
-Trying to remove scales
