Tissue Integrity

What is tissue integrity?

The ability of the human body to regenerate and maintain normal physiologic functioning.

What body structures act as defense mechanisms?

The skin, cornea, subcutaneous tissue, and mucous membranes.

What is the largest organ of the body?

The skin.

Approximately what percentage of body weight does the skin account for?

About 15% of total body weight.

What is the primary function of the skin?

Protection by providing a barrier from injury, infection, UV radiation, and heat.

What sensory functions does the skin provide?

Touch, pain, pressure, and vibration.

How does the skin help regulate the body?

It regulates temperature and protects against temperature changes.

What vitamin is synthesized by the skin?

Vitamin D.

What are the three layers of the skin?

Epidermis, dermis, and subcutaneous tissue.

What is the epidermis?

The outer layer of skin composed mainly of keratinocytes, melanocytes, Merkel cells, and Langerhans cells.

What is the dermis?

The largest portion of the skin that provides strength and flexibility and supports the epidermis.

What structures are found in the dermis?

Capillaries, blood vessels, lymph vessels, nerves, sweat glands, sebaceous glands, hair roots, elastic fibers, and collagen.

What is subcutaneous tissue?

Adipose tissue that insulates the body, absorbs shock, and cushions internal organs.

How can wounds be classified?

By underlying cause, wound description, wound depth, and presence or absence of infection.

What is a wound infection?

Contamination in a wound that may be acute or chronic.

What is an open wound?

A wound characterized by a break in the skin surface.

What is a closed wound?

A wound where the skin remains intact, such as a bruise.

What is maceration?

Softening of the skin caused by excessive moisture.

What is moisture-associated dermatitis?

Skin irritation or breakdown caused by prolonged exposure to moisture.

What is a surgical wound?

A wound intentionally created during surgery.

What is a surgical stab wound?

A puncture wound created surgically, often for drain placement.

What is a traumatic wound?

A wound caused by trauma such as a knife injury, gunshot wound, or motor vehicle accident.

What are examples of accidental wounds?

Cuts, burns, and hematomas.

What are chronic wounds?

Wounds that heal slowly, including venous stasis ulcers, diabetic foot ulcers, and pressure injuries.

What are common wound closure methods?

Sutures, Steri-Strips, and staples.

What are sutures?

Stitches used to hold wound edges together.

What are Steri-Strips?

Adhesive strips used to approximate wound edges.

What are staples?

Metal clips used to close surgical wounds.

What is the maturation phase of wound healing?

The remodeling phase that can last up to one year.

What occurs during the maturation/remodeling phase?

Collagen is deposited and remodeled while scar tissue forms and strengthens.

What is scar tissue?

An avascular mass of collagen that gives strength to the repaired wound.

What does avascular mean?

Without blood vessels.

What is primary intention healing?

Wound healing where edges are closely approximated with minimal tissue loss.

What type of wound heals by primary intention?

A clean surgical incision closed with sutures, staples, or Steri-Strips.

What is secondary intention healing?

The wound is left open and heals from the bottom and sides as new tissue fills in.

When is secondary intention used?

When there is significant tissue loss or the wound cannot be closed immediately.

What is tertiary intention healing?

Delayed primary closure.

What is another name for tertiary intention healing?

Delayed primary closure.

When is tertiary intention healing used?

When a wound has trauma, edema, or contamination and requires delayed closure.

How long is closure delayed in tertiary intention healing?

Usually 4–6 days.

What therapy may be used before tertiary closure?

Negative pressure wound therapy.

How is a tertiary intention wound eventually closed?

By primary closure, skin flaps, or grafts.

What is granulation tissue?

New red or pink tissue that forms during wound healing.

What does granulation tissue indicate?

Healthy wound healing.

What is dehiscence?

Partial or complete separation of tissue layers during healing, usually involving a surgical incision.

What is evisceration?

Complete separation of tissue layers with protrusion of internal organs through the wound.

Which complication is more serious: dehiscence or evisceration?

Evisceration.

What nursing interventions help prevent incision complications?

Abdominal binders and splinting.

What is an abdominal binder?

A supportive wrap placed around the abdomen to support an incision.

What is splinting?

Supporting an incision with a pillow or hands during coughing or movement.

What mnemonic helps remember factors affecting wound healing?

DIDN'T HEAL.

What does D stand for in DIDN'T HEAL?

Diabetes.

What does I stand for in DIDN'T HEAL?

Infection.

What does the second D stand for in DIDN'T HEAL?

Drugs.

What does N stand for in DIDN'T HEAL?

Nutritional problems.

What does T stand for in DIDN'T HEAL?

Tissue necrosis.

What does H stand for in DIDN'T HEAL?

Hypoxia.

What does E stand for in DIDN'T HEAL?

Extensive tension.

What does A stand for in DIDN'T HEAL?

Another wound.

What does L stand for in DIDN'T HEAL?

Low temperatures.

What is a pressure injury?

Local damage to the skin and/or underlying tissue caused by pressure or pressure combined with shear.

Where do pressure injuries most commonly occur?

Over bony prominences.

What medical devices can cause pressure injuries?

Urinary catheters, oxygen tubing, endotracheal tubes, and drains.

What are common sites for pressure injuries?

Heels, toes, sacrum, hips, elbows, shoulders, and the back of the head.

What are risk factors for pressure injuries?

Age, weight, decreased mobility, poor nutrition, neuropathy, inability to respond, moisture exposure, and poor hygiene.

How does decreased mobility increase pressure injury risk?

The patient cannot reposition independently, causing prolonged pressure.

How does neuropathy contribute to pressure injuries?

The patient cannot feel pain or pressure, so injuries go unnoticed.

What is the Braden Assessment Tool?

A tool used to identify risk for skin breakdown.

When should the Braden Scale be completed?

On admission, every shift, at discharge, and before or after transfers or procedures.

What Braden score indicates severe risk?

Less than 9.

What is a Stage 1 pressure injury?

Intact skin with nonblanchable erythema or persistent redness over a pressure area.

What is nonblanchable erythema?

Redness that does not disappear when pressure is applied.

What is a Stage 2 pressure injury?

Partial-thickness skin loss with exposed dermis that does not extend below the dermis.

Does Stage 2 extend below the dermis?

No.

What is blanchable erythema?

Redness that temporarily fades or turns white when pressure is applied.

What does nonblanchable erythema indicate?

Structural damage to the skin has occurred.

What is a Stage 3 pressure injury?

Full-thickness skin loss extending into subcutaneous tissue but not exposing muscle, bone, or connective tissue.

What is a Stage 4 pressure injury?

Full-thickness skin and tissue loss with exposed muscle, bone, or connective tissue.

Why is exposed bone concerning in Stage 4 pressure injuries?

It increases the risk of osteomyelitis.

What is osteomyelitis?

Bone infection.

Which stage involves intact skin?

Stage 1.

Which stage involves exposed dermis?

Stage 2.

Which stage extends into subcutaneous tissue?

Stage 3.

Which stage exposes muscle or bone?

Stage 4.

What is an unstageable pressure injury?

A full-thickness injury covered by necrotic tissue or eschar that prevents determination of wound depth.

Why can't an unstageable wound be staged immediately?

Because necrotic tissue or eschar obscures the wound bed.

What must be done before an unstageable wound can be staged?

The dead tissue covering the wound must be removed.

What is eschar?

Dead, thick, leathery tissue that is usually black or brown.

What is a deep tissue injury (DTI)?

Intact skin that is purple, burgundy, or a blood-filled blister due to underlying pressure damage.

Is DTI considered a pressure injury?

Yes.

Why is DTI difficult to assess?

The true depth of injury is not immediately visible.

How does DTI differ from Stage 1 pressure injury?

DTI is purple/burgundy or blood-filled with deeper damage suspected; Stage 1 is nonblanchable redness with intact skin.

What is undermining?

Tissue destruction under intact skin around the wound edge, forming a lip.

What stage of pressure injury commonly has undermining?

Stage 3.

What is tunneling or a sinus tract?

A narrow passageway extending outward from the wound edge.

How is undermining or tunneling measured?

Using a cotton-tipped applicator (Q-tip).

How does tunneling differ from undermining?

Tunneling is a narrow channel; undermining is a wider area under the wound edges.

What is surgical debridement?

Removal of dead tissue and debris using a scalpel or scissors.

Why is debridement performed?

To reduce bacteria and stimulate wound healing.

What does debridement remove?

Biofilm, debris, and necrotic tissue.