Tissue Integrity PPT

What is tissue integrity?

the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes

Assessment of Wounds and Ulcers

• Acute wound or chronic wound

• Location

• Size (length, width, depth), Tunneling?

• Color (red, yellow, black)

• Cleanliness (clean, contaminated)

• Odor

• Presence of wound drains

• Presence of drainage and exudate

• Serous, serosanguineous, sanguineous, purulent

• Staging pressure ulcers-Stages I, II, III, IV, non -stageable

• Normal reactive hyperemia- Indicates when pressure relieved,  no lasting damage

Wound Complications

• Infection

• Hemorrhage

• Dehiscence & Evisceration

• Fistula Formation

What should the nurse do if a wound becomes eviscerated (organs come out)?

• DO NOT ATTEMPT TO PUSH ORGANS BACK INTO PLACE – THIS IS THE JOB OF THE SURGICAL TEAM!

With total separation of wound layers, evisceration (protrusion of visceral organs through a wound opening) occurs. The condition is an emergency that requires surgical repair. When evisceration occurs, a nurse places sterile gauze- soaked in sterile saline -over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues. If the organs protrude through the wound, blood supply to the tissues can be compromised. The presence of an evisceration is a surgical emergency. Immediately place damp sterile gauze over the site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery.”  Since the client is going into emergency surgery, the nurse should attempt to initiate IV access if the client does not already have patent IV access.

How should the patient be positioned while waiting for the surgical team to come for an eviscerated wound?

While waiting for the surgical team to arrive, the client should stay in bed and the head of the bed should be raised to 15-20 degrees.

Drainage Connected to Suction

• If evacuator is unable to maintain vacuum on its own, notify surgeon who then orders a secondary vacuum system (such as wall suction)

• Nurse’s role: Ensure that suction is exerted at ordered pressure and that the connection points between evacuator and tubing are intact

• If a sudden unexpected decrease in drainage occurs and suction is working and connections are intact, suspect clogged/blocked tubing and notify provider

• Assess volume and character of drainage every shift

Montgomery Straps/Ties

Montgomery straps/ ties are hypoallergenic straps or ties used to help facilitate frequent dressing changes without having to repeatedly remove and reapply tape, which can be very traumatic to fragile skin. 

Healthy Skin - General

• Limit bath / shower length - temperature

• Moisturize immediately after showering (jojoba oil, olive oil, shea butter, coconut oil)

• (CWON also recommends Eucerin or petroleum jelly).

• Apply hand cream frequently after washing (nurses!)  :)