Caring for clients w/ impaired tissue integrity-JZ

Tissue Integrity

• the ability of the body to regenerate & maintain normal physiologic functioning

Skin Integrity

• unimpaired condition of the skin

Impaired Skin Integrity

• altered dermis &/or epidermis indicated destruction of a skin layer(s)

Risk Factors for Impaired Tissue Integrity

• aging

• mobility/immobility

• nutrition

• chronic illness

• miscellaneous

Aging Risk Factors

• loss of skin elasticity & adipose tissue

• drying of the skin

Mobility/Immobility Risk Factors

• reducing circulation, atrophy, & impaired sensation

• pressure

• incontinence

Nutrition Risk Factors

• obesity malnutrition

Chronic Illness Risk Factors

• hepatic, renal, CV disorders

• altered elimination patterns

Miscellaneous Risk Factors

• smoking

• stress

• genetics

• previous injury

• medications

Assessing the Skin

• essential component of whole pt. assessment

Admission Skin Assessment

• head-to-toe skin assessment

• conducted by 2 nurses

  • admitting nurse

  • primary nurse

Shift Skin Assessment

• conducted by primary nurse

What are we Assessing?

• temperature

• turgor

• color

• moisture

• skin integrity

Special considerations

• bony prominences

  • occiput, scapula, sacrum, heels

• skin beneath & around devices

  • oxygen tubing (behind ears)

  • braces (shin, arms)

• skin to skin areas

  • back of knees, inner thighs, buttocks

• all areas where the pt.

  • lacks sensation

  • has skin folds

  • has had previous breakdown

Conducting A Risk Assessment: Braden Scale

• assesses for risk of 6 categories

  • sensory perception

  • moisture

  • mobility

  • nutrition

  • friction/shear

• lower the score = greater the risk

Braden Scale

Promoting Skin Integrity

• avoid skin trauma

  • while in bed

    • assess every 2 hours

    • HOB <30 degrees w/ knees bent; lower extremities elevated

    • pad bony prominences

    • offload/float heels

    • use specialty equipment

      • beds

      • padding (boots)

  • while in chair

    • chair/seat cushion

  • mobilization

    • ambulate, ears & often

    • encourage frequent weight shifting

    • do NOT slide - increases risk for shearing due to friction

Promoting Skin Integrity Healing

• maintain skin hygiene

  • use Braden Scale assessment tool Q shift

  • cleanse skin w/ pre-packaged wipes or warm water

  • cleanse immediately following incontinence

  • use barrier sprays/creams

  • do NOT massage bony prominences

  • ensure proper nutrition

    • protein intake

    • nutritional supplements

  • interprofessional collaboration

    • wound nurse

Types of Wounds: What to look for

• pressure injuries

• moisture associated skin damage

• venous ulcers

• arterial ulcers

• diabetic foot ulcers

• other wounds

  • abrasions

  • skin tears

  • lacerations

  • lesions

  • surgical wounds

  • burns

Pressure Injury

• injury to the skin & underlying tissue resulting from prolonged pressure or pressure & shear

• occurs over bony prominences (calcaneus, coccyx, elbow)

• HAPI = Hospital Acquired Pressure Injury

Pressure Injury: Staging

• Stage 1

• Stage 2

• Stage 3

• Stage 4

• unstageable

• deep tissue injury

Moisture- Associated Skin Damage (MASD)

• inflammation or skin erosion caused by prolonged exposure to a source of moisture

  • urine

  • stool

  • sweat

  • wound drainage

  • saliva

  • mucus

• treatment

  • exudate management

  • absorbent dressings

  • barrier creams

Venous Ulcers

• most commonly form around the ankles due to a problem w/ circulation (PVD)

• treatment

  • compression stockings/wrap

  • leg elevation

  • smoking cessation

  • weight loss

  • exercise

  • vascular referral for imaging

Arterial/Ischemic Ulcers

• caused by poor perfusion (delivery of nutrient-rich blood) to the lower extremities

• occur mostly on the lower legs & feet

• usually originate from a small traumatic injury (hitting shin against table)

• treatment

  • surgery

  • smoking cessation

  • blood sugar control

  • weight loss

Diabetic Foot Ulcers

• most occur on plantar aspect of foot

• occur due to combo of

  • neuropathy

  • poor circulation

  • foot deformities

  • pressure &/or friction

  • trauma

• increased risk w/ longer duration of diabetes

• treatment

  • surgery

  • offloading

  • blood sugar management

Other Wounds

• abrasion

• skin tear

• maceration

• lesion

• surgical

• burn

Types of Wound Healing

• primary intention

• secondary intention

• tertiary intention

Types of Wound Healing: Primary Intention

• 1st intention or primary healing

• little to no tissue loss

• edges well approximated

• low risk for infection

• minimal scarring

Types of Wound Healing: Secondary Intention

• 2nd intention or secondary healing

• loss of tissue

• edges poorly approximated

• heals from bottom up

  • granulation tissue

• increased risk of infection/scarring

Types of Wound Healing: Tertiary Intention

• delayed primary closure

• uses combination of primary & secondary

• used for dirty wounds at time of injury

Phases of Wound Healing

• hemostasis

• inflammation

• proliferation

• remodeling

Phases of Wound Healing: Homeostasis

• stop bleeding

Phases of Wound Healing: Inflammation

• prevention of infection

Phases of Wound Healing: Proliferation

• new tissue growth

Phases of Wound Healing: Remodeling

• wound closure

Complications of Wound Healing

• infection

• osteomyelitis

• necrosis / grangrene

• peri-wound dermatitis

• edema

• hematoma

• dehiscence

Risk for Impaired Wound Healing

• tissue perfusion

• immunocompromise

• infection

• medications

• malnutrition

• chronic disease

  • diabetes

• impaired oxygen deliveru

  • decreased hemoglobin

  • smoking

Wound Basics: Assessing the Wound

• measuring

  • L x W x D

    • length = head to toe

    • width = side to side

    • depth = straight down into wound bed

    • use concepts of analog clock & anatomical position

  • wound edges

    • tunneling

    • undermining

  • observe the wound bed for

    • granulation

    • slough

    • eschar

Wound Drainage

• exudate - fluid produced by the healing process

• assess

  • amount - none, scant, small, moderate, large/copious

  • odor

  • consistency - thin/watery vs thick/sticky

  • color

    • serous - clear, watery

    • sersosanguineous - pale, blood tinged

    • sanguineous - bloody

      • bright

      • dark

    • purulent - thick, various colors

Wound Closures

• sutures

• staples

• adhesives

• negative pressure wound therapy

Choosing the Right Dressing

• wound care = an order

• moisture consideration

  • a wet wound bed = risk for infection

    • need to dry

    • dressing will be wet when removed

    • ex: gauze, foams, alginates

  • dry wound bed = won’t granulate

    • need to keep it moist

    • ex: wet-to-dry, hydrocolloids, hydrogels

• goal: moist wound healing

Drains

• used to decrease the accumulation of fluid, reduced inflammation, or collect fluid

• classification

  • active or passive

  • open or close

• types

  • penrose

  • jackson pratt (JP)

  • hemovac

Drainage Care

• drainage

  • document: amount (mL), color, consistency, odor, & date/time

• insertion site

  • monitor for s/sx of infection

• cleaning

  • daily w/ NS unless order state otherwise

• miscellaneous

  • monitor for kinking of tubing

  • regularly empty drain to maintain suction

  • secure drain