Tissue Integtrity

Question 1

What is tissue integrity?

Answer 1

State of structurally intact and physiologically functioning epithelial tissues such as the integument (skin) and mucous membranes

Question 2

What is impaired skin integrity?

Answer 2

-focused on damage to the epidermal and dermal layers of epithelial tissue, deep damage to skin integrity is associated with disruption of under lying tissues

Question 3

What is impaired tissue integrity?

Answer 3

-varying levels of damage to one or more of those groups of cells

Question 4

What is the scope of tissue integrity?

Answer 4

• intact skin and tissue
• partial thickness injury
• full thickness injury

Question 5

What is Debridement?

Answer 5

Remove dead or infected tissue, usually from a wound

Question 6

What is granulation?

Answer 6

-new connective tissue and blood vessel that form on the surface of a wound during the healing process (from base of wound)

Question 7

What is turgor?

Answer 7

-sign of fluid loss (dehydration)

Normal=snap back

Question 8

What is an emollient?

Answer 8

Agent that softens and smooths the skin

Question 9

What are age related changes in skin?

Answer 9

• epidermis less proliferative (slow healing)
• dermis losses elasticity, strength, moisture
• dermis becomes less vascular
• dermis slow to clear foreign material
• decline in melanocytes
• decrease in subcutaneous fat
• less pacinian and Meissen receptors
• decreased sebaceous glands (skin touch, dry, itchy)
• hair and nail growth slows

Question 10

What is trauma and injury to skin?

Answer 10

-superficial abrasion or scrape to a deep wound penetrating the skin and subcutaneous layers

Question 11

What is loss of perfusion to skin?

Answer 11

-could lead to necrosis

Question 12

What is immunologic reaction of skin?

Answer 12

-redness, rash hives, allergies

Soap, detergents, cleaning products acute slough

Question 13

What are types of infections/infestations of the skin?

Answer 13

• bacterial (cellulitis, impetigo (streptococci)
• fungal infections (candida), like moist areas, skin folds, tines capitis (head), Inet pedis (althetes foot)
• viral infections: wart, HSV, HSV2
• infestations: mites, lice

Question 14

What are thermal radiation injuries?

Answer 14

-sunburn, scald burn, radiation burns

Question 15

What is the process of wound healing?

Answer 15

Primary: margins well approximated
Secondary: ulcer action, distinct edges, granulation tissue fill in gap wound
Tertiary: sutured closed much later, scarring
Inflammatory (3-5)
Granulation (vascular pink wound)
Maturation (fibre remoulding and scar contraction may continue)

Question 16

What happens when tissue integrity is impaired?

Answer 16

-thermoregulation, elimination, fluid/electrolyte balance, protection from infection, safety, comfort affected

Question 17

What are individual factors for skin integrity?

Answer 17

Poor peripheral perfusion
Malnutrition/obesity 
Dehydration/Edema 
Impaired mobility
Immunosuppression
Exposure to irritants 
Radiation, temp extremes 
Tissue trauma

Question 18

What are factors for dermal ulcer risk?

Answer 18

• impaired cognition
• sensory perception
• immobility
• friction/sheering
• poor nutrition
• impaired perfusion
• oxygenation
• impaired sensation
• incontinence /moisture

Question 19

What are diagnostic tests?

Answer 19

Patch testing: allergies
Wound cultures
Tissue biopsy
Woods lamp: magnification/special lighting

Question 20

What are dermal ulcers?

Answer 20

-localized area of necrosis over a honey prominence caused by pressure for a sufficient period causing tissue ischemia
(Greater risk: decreased mobility or sensation)

Question 21

What is a stage 1 pressure ulcer?

Answer 21

• erythema not resolving within 30mins of pressure relief
• epidermis intact
• IS REVERSIBLE AT THIS STAGE

Question 22

What is stage 2 ulcer?

Answer 22

-partial thickness loss of skin layers, involving epidermis and penetrate into but not through dermis
-blistering with erythema
-wound base moist and pink
-painful,
FREE of necrotic tissue

Question 23

What is stage 3 pressure ulcer?

Answer 23

• full-thickness loss tending though dermis to involve subcutaneous tissue
• shallow crater unless covered by Escher
• necrotic tissue, undermining, sinus tact formation, exudate, infection
• wound base not usually painful

Question 24

What is stage 4 pressure ulcer?

Answer 24

• deep tissue destruction extending through subcutaneous tissue to fascia, involve muscle layers, joint and bone.
• deep crater
• necrotic tissue, undermining, sinus tract formation, educate, infection
• wound base not painful

Question 25

What is an upstageable pressure ulcer?

Answer 25

-a wound that is covered by Escher or slough, preventing visualization of wound bed

Question 26

What are the components of the Braden scale?

Answer 26

• sensory perception
• moisture
• activity
• mobility
• nutrition
• friction and shear

Question 27

What does 15-18 mean on Braden scale ?

Answer 27

At risk

Question 28

What does less than 9 mean on Braden scale?

Answer 28

Very high risk

Question 29

How often should assessments be at high risk for low risk?

Answer 29

High: minimum monthly
Low: q6months

Question 30

What are key aspects of a pressure ulcer?

Answer 30

• stage/size
• location, SA
• odour
• sinus tracts
• exudate
• condition of surrounding tissue
• wound edges
• wound bed

Question 31

How can we prevent pressure ulcers?

Answer 31

• Use devices to relieve pressure
• change position every 2 h
• avoid shearing forces
• keep skin dry
• apply moisturizing agents, no massage over Bonney prominences
• good nutrition; high in protein

Question 32

What are risk factors for pressure ulcers?

Answer 32

• severity of illness
• involuntary weight loss
• less than 9 score, assess every month