ATI Engage Fubdamentals Tissue integrity

Skin

largest organ system in the body accounting for 15% of total body weight

The skin contains what 3 layers?

\-epidermis

\-dermis

\-subcutaneous layer of adipose tissue

Epidermis

outermost layer of the skin, made of squamous epithelial cells, which provide a barrier against the external environment

kartinocytes

cells formed in the basal layer of the skin that function to protect the skin from external environment

Melanocytes

cells that are produced in the epidermis and produce melanin

Melanin

a pigment that determines the color fo the hair & skin

Merkel cells

receptor cells in the epidermis that are specialized for detection of light touch

Langerhans cells

cells found in the epidermis that play a role in cutaneous immune system reactions

Dermis

Layer under the epidermis that is composed of connectiove tissue & provides strength & flexibility of the skin

Subcutaneous tissue

found under the epidermis & dermis mostly composed of adipose tissue insulates the body, absorbs shock, and pads internal organs & structures

Maceration

an irritation of the epidermis caused by moisture

Dermatitis

red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, & wound exudates (irritant dermatitis)

Skin tears

loss of the top skin layer caused by mechanical forces. Severity of skin tear defined bu the depth of the skin layer loss

Besides age what other conditions predispose clients to alterations in skin integrity?

Spina bifidia, cerebral palsy, chronic disease such as; liver failure, kidney disease, & cancer

Skin fragility

at-risk vulnerable skin

Pressure injuries

localized damage to the skin &/or the soft underlying tissue, which can be caused by prolonged contact with a firm surface that interferes with circulation to that area

Cellulitis

an infection of the superficial layers of skin

Skin aging diagram

\-hydration

\-exercise

\-diet

\-sleep

\-sun screen

\-cosmetics

Neonates and children skin changes & contributing factors

\-immature skin

\-prolonged duration of pressure

\-moisture/maceration

\-poor perfusion

Neonates & children skin problems

\-diaper rash

\-skin tears

\-pressure injuries

Older adults skin changes and contributing factors

Thinning for he skin resulting in decreased:

\-elasticity

\-subcutaneous tissue

\-blood supply

\-hydration

Older adults skin problems

\-skin tears

\-pressure injuries

\-itchy, dry, flaky skin

\-skin infections

Clients who have decreased mobility/paralysis (e.g., spina bifida) skin changes & contributing factors

\-reduced blood circulation

\-alterations in thermoregulation

\-incontinence

\-loss of collagen

\-muscles atrophy

\-impaired sensation

Clients who have decreased mobility/paralysis skin issues

\-skin tears

\-pressure injuries

\-skin infection

\-incontinence-associated dermatitis

Clients who are obese skin changes & contributing factors

\-decreased moisture

\-dry skin

\-maceration

\-elevated skin temperature

\-decreased blood & lymphatic flow

Clients who are obese skin issues

\-skin tears

\-pressure injuries

\-diabetic ulcers

\-0moisture lesions

\-skin-fold rashes

Clients who have cancer skin changes and contributing factors

Radiation resulting in:

Inflammation

\-skin surface damage

\-decreased blood supply

Clients who have skin cancer skin issues

\-pressure injuries

\-delayed wound healing

\-skin infections

\-radiation induced dermatitis

Clients who have chronic illnesses & other conditions skin changes and contributing factors

Skin changes due to:

\-hepatic diseases

\-renal diseases

\-cardiovascular diseases

\-malnutrition

\-stomas

\-psychological issues

Clients who have chronic illnesses and other conditions skin issues

\-skin tears

\-pressure injuries

\-infections

\-moisture associated lesions

How can nurses decrease the risks of client’s developing skin breakdown

\-regular skin assessments

\-observation of environmental factors

\-diligent implementation of prevention measures

Erythema

Redness of the skin due to dilation of the blood vessels

Blanchanble erythema

An area of reddened skin that temporarily turns white or pale when light pressure is applied, then reddens when pressure is relieved

Nonblanchable erythema

Redness of the skin that does not go away when pressure is applied indicating striuctural damage has occurred to the small vessels supplying blood to the underlying skin and tissues

Wound

A disruption in the normal composition and performance of the skin and its underlying structures

Intentional wounds

Created during a surgical procedure

Unintentional wounds

Develop as a result of a traumatic injury, such as burn, punctures, or gunshot wounds

Lacerations

Any tearing of the skin, usually caused by blunt/sharp objects

Clean & clean contaminated wounds

Have minimal bacterial loads & are closed at the completion of the procedure

Contaminated & dirty wounds

Have higher bacterial loads that’s may interfere with healing, these wounds may be left open after the procedure and recquire long-term wound management for healing

Surgical wounds should have?

Intact, well-approximated edges

Would healing colors

\-incision red on days 1-4 (day 4 epithelial closure)

\-bright pink days 5-14 (edema progressively decreases by day 5) (days 9-14 sutures/staples removed usually)

\-pale pink 15days - 1year

\-scar tissue white/silver on fair skin

\-scar tissue early pigmented skin pale pink to darker than normal skin tone

Exudate

Fluid secreted by the body during th inflammatory stage of healing and is made of plasma

Moisture-associated skin damage (MASD)

Form of dermatitis; a skin irritation that forms when the skin is exposed to the irritants like fecesm urine, stoma content, and wound exudates

Chronic wounds develop to which conditions?

\-chronic venous insufficiency

\-peripheral artery disease

\-diabetes mellitus

\-older clients/clients who smoke

\-malnourishment

\-immunosuppressed

\-immobilized

\-would infection

Venous ulcer

Neuropathic ulcer

Serous

thin, watery wound drainage

Serosanguineous

thin, watery wound drainage mixed with blood

Sanguineous

bloody wound drainage

Purluent

green/yellow wound drainage

Nurses most commonly use the following methods to measure wound size:

\-tracing the wound circumference & calculating the wound surface area using a see-through film

\-measuring the length and width of the wound using a ruler

Measurement of wound depth should be done with?

A sterile premoistened cotton tip applicator

Tunneling

a narrow channel or passage way extending in any direction from the base of the wound

Pressure injuries develop due to?

Prolonged pressure over an area of skin/ due to a combination of pressure and shearing

Shearing

a force parallel to the surface of the skin

What are the risk factors that predispose clients to pressure injuries?

\-immobility

\-malnutrition

\-reduced perfusion

\-altered sensation

\-decreased LOC

\-exposure to moisture

\-tearing

\-cuts

\-bruises

\-friction

Malnutrition

imbalance in a client’s intake, which can include deficiencies or excesses in nutrients, vitamins, or calories

Friction

the force created when two objects rub together

Each year in the United States approximately how many people due from complications of pressure injuries?

60,000

What areas are the moist susceptible to pressure injury formation?

Bony prominences

\-heels, toes, sacrum, hips, elbows, shoulders, and back of the head

Risk assessments fort pressure injury development includes:

\-immobility

\-malnutrition

\-perfusion

\-sensory loss

Immobility

one of the greatest factors contributing to the development of pressure injuries

malnutrition cause of pressure injury

malnutrition and low albumin levels place clients at a greater risk for developing pressure injuries

\-assessment of clients dietary intake and capacity it’s to maintain weight is one of the strongest nutritional measures for tissue integrity risk

Hypoperfusion

inadequate supply of blood circulation, which results in low oxygen level sin tissues

Sensory loss

in clients with certain neurological conditions such as dementia can have altered sensation to pain putting them at risk for pressure injuries

Braden scale

risk assessment tool for alterations in skin integrity

Categorized into 6 categories:

\-sensory perception

\-moisture

\-activity

\-mobility

\-nutrition

\-friction and shear

what is the lowest (worst outcome) score that can be received on a Braden scale?

6

What is the highest (best outcome) score that can be received on a Braden scale?

23

Undermining

an open area extending under the skin along the edge of the wound

Benchmarking

comparing results and outcomes to other sources of similarly retrieved data

Stage 1 pressure injury

\-skin is intact

\-non-blanchable edema present

Stage 2 pressure injury

\-partial-thickness skin loss

\-pink/red viable tissue in the wound bed

\-may also present as a ruptured serum-flies blister

Stage 3 pressure injury

\-full-thickness skin loss with visible adipose tissue

\-wound edges may be rolled

\-granulation/new skin tissue may form on the surface of the wound

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Granulation tissue

new skin that forms on the surface of the wound

stage 4 pressure injury

\-full thickness skin and tissue loss

\-fascia, muscles, tendons, ligaments, cartilage, and/or bone are visible

\-edges are rolled and undermining and tunneling may be present

\-dead tissue may also be seen

Unstageable pressure injury

\-obscured full thickness skin and tissue loss

\-covered with either slough, or eschar

Slough

yellow, stringy tissue found in the base of the wound

Eschar

hard nonviable black/brown tissue found in the wound bed

Deep tissue pressure injury

persistent nonblanchable tissue injury of the skin appearing deep red, maroon, or purple color

Device related pressure injury

occur as a result of prolonged pressure from devices worn by the client

\-MDRPI (oxygen masks, oxygen tubing, urinary catheters, cervical collars, and compression stockings)

Mucosal membrane pressure injury

Mucosal tissues: lining of respiratory tract, GI tract, genitourinary tract

Injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device

Assessing pressure injuries in clients who have darker-pigmented skin

\-skin temp and moisture in the wounds may be the first indicator of a pressure injury

\-edema, hardened skin, localized pain

\-nurse should apply light pressure ands then observe for an area that is darker than the surrounding skin

\-skin can also appear taut, shiny, or indurated

When documenting pressure injuries the nurse should include:

\-location

\-stage

\-size

\-description of the tissue

\-color of the wound bed

\-condition of surrounding tissue

\-appearance of wound edges

\-presence of undermining and tunneling

\-any foul odor present

\-wound drainage

\-pain at site

Debridement

process of surgically removing dead tissue and other debris (biofilm) that can cause infection

Wound irrigation

removes surface materials and decreases bacteria levels in the wound

\-most often 0.9% sodium chloride solution is used to irrigate wounds

Biological debridement

various enzymatic agents such as collagenase , papain (papaya extract) and bromelain (pineapple extract) can be applied to the wounds to clear dead tissue and debris

larvae therapy

larvae of green bottle fly and the Australian sheep blowfly secrete an enzyme that liquifies necrotic tissue

Sterile dressings

applied after surgery and are usually kept on the incision site for 24-48 hours

\-after 48 hrs wounds are managed using clean technique

Open dressings

gauze bandages

\-after being moistened with 0.9% sodium chloride gauze dressings are used to pack wounds to assist with the debridement process

\-also called wet-to-dry dressing

semi-open dressings

\-3 layers

\-bottom layers comprises a layer of knit gauze infused with therapeutic ointments

\-middle layer contains padding and absorbent gauze followed by a final layer of adhesive

\-do not control drainage well and place client at risk for poor wound healing

Films

advantages: include their ability to allow moisture to evaporate while still maintains a moist wound bed and the ability to woo oxygen to enter the wound wile decreasing the risk of micro-organism entrance into the wound

\-allows providers to visualize wound without removing dressing

\-not dressing of choice for wounds it’s significant exudate

Hydrocolloid dressings

\-used for small abrasions, superficial burns, pressure injuries, and postoperative wounds

\-gel-like dressings occlude the wound maintain moist wound bed, bacteriostatic properties, and stimulate growth of granulation tissue

\-comfortable and produce less maceration

Disadvantages: potential fro contact dermatitis, could smelling yellow gelatinous film that develops as bacteria are trapped on the underside of the dressing

Alginate dressings

recommended for moderate to highly exudative wounds

\-provide hemostasis, high absorption abilities, can remain for several days, variety of forms (ribbon, pads, and beads)

Disadvantage: secondary dressing is needed to cover the alginate increasing cost

Hydrofiber dressings

\-used for moderate and highly exudative wounds

\-provide high absorbency and can stay in the wound for several days

\-draw less fluid from the wounds edges resulting gin less maceration

Foams

used in wounds with mild to moderate exudate

\-requires more frequent dressing changes

\-may produce malodorous discharge

Polymeric membranes

used in mildly exudative wounds

\-stimulate the growth of new epithelium and do not stick to the wound bed, resulting in less trauma to the new granulation tissue

Hydrogels

Used in dry wounds for debridement of necrotized tissue and eschar

\-they can provide moisture to or draw moisture away from the wound depending on the needs

\-have soothing effect and cause little trauma

\-many require frequent changes

Staples

\-healing is faster with a stapled wound (7 to 14 days)

\-common complications are scarring and difficulty with removal

Sutures

made of synthetic materials such as nylon/polyester, or natural fibers such as silk, linen, or dried animal intestines

\-both synthetic and natural sutures can be absorbable/nonabsorbable

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