Tissue Integrity

Functions of the Skin?

Protects underlying tissues / structures

Enables sensation perception

Temperature regulation

Psychosocial

Assists with vitamin D production

Absorbs medications and eliminates

water/lytes/waste

Types of Skin Assessment?

Quick peek assessment

Systematic head-to-toe skin assessment

Wound assessment (for ongoing wound monitoring)

Skin Assessment- Color?

Normal: appropriate for ethnicity; even tone

Generalized color changes

(systemic):

Pallor means decreased

perfusion/anemia

Cyanosis means decreased oxygenation

Erythema means

inflammation/pressure

Jaundice means liver dysfunction

Localized pigmentation changes:

Vitiligo means loss of pigment patches

Skin Assessment Cues?

•Moisture

- Dry skin may indicate dehydration

- Excess moisture may be related to fever or infection

•Temperature

- Warm skin may indicate inflammation

- Cool skin may indicate decreased perfusion

•Turgor

- Delayed return suggests dehydration

- Less reliable in older adults

•Edema

- Assess for swelling and degree of pitting

•Texture

- Thin or fragile skin increases risk for

breakdown

•Lesions (describe)

- Document size, shape, color, and drainage

Skin Risk Factors?

Immobility

-prolonged pressure

Moisture

-incontinence, perspiration, drainage

Friction & shear

-repositioning, sliding in bed

Poor nutrition

-low protein, weight loss

Decreased perfusion

-diabetes, vascular disease

Decreased sensation

-neuropathy, spinal cord injury

Advanced age

-thin, fragile skin

Skin Changes with Aging?

• Decreased skin thickness, collagen, and

circulation: skin becomes thinner, less elastic, and more fragile

• Decreased epithelial cell turnover: delayed healing and increased risk for skin breakdown

• Loss and redistribution of subcutaneous fat: decreased insulation and protection

• Decreased fibroblast activity in the dermis: increased wrinkling

• Thinning of dermis and subcutaneous layers: increased risk for injury and pressure injuries

• Decreased dermal blood flow: delayed wound healing

• Increased risk for skin cancer (especially

basal cell carcinoma)

Hemoglobin A1C normal?

< 6%

Nursing Interventions for skin?

Skin care and hygiene:

Mechanical loading and support devices:

Proper positioning: Reposition at least every 2 hours;

Local wound care / drains

Adequate nutrition:

Patient education: Teach skin inspection, repositioning, and wound care at home

Braden Scale: Assess risk for pressure injury;

Heat / cold therapy: Apply as prescribed;

30 degree lateral position recommended to prevent what?

reduce pressure and shearing force to the skin

Positioning: Chair?

• Educate client to weight shift every 15 min

• Limit sitting up in chair to 2 hours

• Use foam, gel or air cushions

Foam Beds?

pressure reduction measure

o Reduces pressure, friction/shear

Low Air Loss Beds?

pressure relief measure

o Overlay or bed

o Constant inflation with air loss at the surface

Static air-filled overlays Bed?

pressure relief or reduction

o Pressure is maintained at a certain level

Air-fluidized Bed?

pressure relief

o A bed frame with beads that become fluidized

when air is pumped through the beads

o Use with burns, multiple stage 3 or 4, flaps

Kinetic Bed?

o Provides continuous passive motion

o Helps to promote the mobilization of respiratory

secretions

Protein?

Rebuilds epithelial tissue and promotes wound healing.

Calories?

Provide energy for tissue repair and cell regeneration.

Vitamin C?

Promotes collagen synthesis and strengthens capillary walls.

Fortified Diets & Oral Supplements?

Supply additional calories and protein when intake is inadequate.

Braden Scale?

• Looks at Sensory perception, moisture, activity,

mobility, nutrition, friction & shear

• Scoring

• Minimum score = 6

• Maximum score = 23

Hemostatic and Inflammatory Stages?

The damaged tissue releases cytokines which

trigger a process called hemostasis; blood

coagulates, and the wound starts to heal. In

addition, plasma leaks into surrounding

tissue and causes swelling. (onset of injury -

6 days)

Proliferative Stage?

New collagen fibers are

formed, a new wound bed is created, and

capillaries start growing. The wound edges

begin pulling closer and new granulation

tissue grows. (3 days to 24 days)

Remodeling Stage?

Stronger collagen replaces the

soft gelatinous collagen; however, this tissue

is much weaker than the original tissue and

is susceptible to re-injury. (day 21 to > 1 yr)

Primary Intention?

wound margins are approximated,

occur in clean lacerations and surgical incisions, closed

with skin adhesives or sutures

Secondary Intention?

have irregular margins, heal from the

base/edges inward

Tertiary Intention?

delayed primary healing. Need to

control the infection first, then suture.

Wound left open for several days to allow edema or

infection to resolve

Goals of Wound Management?

• Prevent and manage infection

• Cleanse the wound

• Remove nonviable tissue

• Manage exudates

• Protect the wound

Penrose Drain?

Soft, flexible rubber tube placed in the

wound to allow passive drainage by

gravity. No collection device

—drainage absorbed by dressing.

Small amount of

serosanguinous fluid.

- Keep dressing dry and secure; use

sterile technique; monitor skin for

irritation; change dressing

frequently.

Jackson-Pratt (JP) Drain?

Closed suction system with a bulb that

provides gentle, constant suction. Used

for post-op abdominal, breast, or orthopedic surgery.

- Moderate amount of serosanguinous drainage.

- Compress bulb before closing to maintain suction; empty and measure output; maintain sterile closure; document color/amount.

Hemovac Drain?

Closed suction system with a spring-loaded container that provides stronger suction than JP. Common after

orthopedic or major abdominal surgery.

- Moderate to large amount of serosanguinous fluid.

- Keep drain compressed to maintain suction; measure and record output; monitor for loss of suction or increased bleeding; maintain sterile technique.

Debridement methods include?

•Sharp/Surgical - using sterile instruments

•Enzymatic - topical agents that dissolve necrotic tissue

•Autolytic - moisture-retentive dressings to allow body's enzymes to soften tissue

•Mechanical - wet-to-dry dressings or irrigation

General recommendations for wound dressing?

Keep wound base moist: primary principle to adhere to

Wet or dry depending on the wound base, healing rate,

and amount of exudate

Control exudate

Keep surrounding tissue intact

Eliminate wound dead space by loosely filling all cavities with dressing materials

Wound Vac?

Assists in healing by:

o Pulling fluid which decreased swelling

o Removing bacteria from wound bed

o Increased wound approximation

o Stimulate new tissue growth

Factors that Delay Healing?

Nutritional

Vitamin C

Protein

Zinc

Blood supply

Corticosteriods

Autoimmune disease

Smoking

hypoxia

Obesity

Diabetes Mellitus (DM)

Anemia

Infection

Tissue necrosis

Increased age

Friction:

Rubbing of two surfaces

• Ex: moving up and down in bed, rubbing against sheets

Shear:

• Two forces are pulling in different directions

• Ex: elevating HOB too high and the patient slides down

Risk Factor: Malnutrition?

• Protein

• Calories

• Vitamin C

Assessing Pressure Injuries?

o Location

o Measure size

o Color of wound bed

- Red (granulation)

- Yellow (slough)

- Brown/black (eschar)

o Odor

o Condition of the surrounding skin

o Exudate/Drainage:

- Serous: thin, watery, clear

- Purulent: thick, various colors

- Serosanguineous: thin, watery, blood-tinged

- Sanguineous: bloody

o Undermining/Tunneling

Measurements of Wound?

length, width, depth

Stage 1 Wound?

• Intact skin, epidermis

• Nonblanchable

• Erythema

Stage 2 Wound?

• Partial thickness skin loss involving epidermis, dermis, or both

• Injury is superficial

• Injury presents clinically as an abrasion, blister or shallow crater

Stage 3 Wound?

• Full-thickness skin loss involving damage to, or necrosis

of, subcutaneous tissue that may extend down to, but not

through, underlying fascia

• Ulcer presents as a deep crater with or without

undermining of adjacent tissue

Stage 4 Wound?

• Full-thickness skin loss with extensive destruction, tissue

necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, capsule)

• Undermining and sinus tracts

Unstageable Wound?

• Deep purple color, perhaps covering a stage 4 injury

• Full-thickness loss

• The base of ulcer is covered by slough and/or eschar tissue

• Unable to tell the depth of the ulcer

Deep Tissue Injury?

• Persistent non- blanchable deep red, purple or maroon localized area of discolored intact skin

• Painful

• Firm or mushy/boggy

• Warmer or cooler

• DTI may appear initially as a bruise, but it connects to a pressure-related injury

TIME Acronym for Wounds?

T= Tissue Integrity; Describe how the tissue looks

I= Inflammation or infection

M= Moisture

E= Edge of wound