Tissue Integrity (Class 17)

Partial Bed Bath

Nurse assists the patient to bathe inaccessible body parts.

Complete Bed Bath

Reserved for patients who are completely dependent and require total assistance.

Edentulous

Without teeth

Cheilitis

Cracked lips

Gingivitis

Inflammation of the gums

Glossitis

Inflamed tongue

Halitosis

Bad breath

Maceration

Softening and breaking down of skin from prolonged moisture

Perineal Care

Cleaning and care of the perineal area. More frequent care needed for patients at a greater risk for infection.

Stomatitis

Sore or inflammation of the mucous membrane of the mouth. (Ex. cheeks, tongue, gums) Also called “canker sore.”

Xerostomia

Dry mouth. Ex. Cracked tongue.

Chlorohexidine Gluconate (CHG)

* For oral and topical use
* Broad-spectrum microorganism coverage
* Reduces cross contamination and colonization of multidrug-resistant organisms
* Continues antimicrobial activity up to 24 hours after application
* ICU patients and those wit central lines require this every day.

Denture Care

* Performed on a daily basis
* Handle with care as they can easily break
* Place a towel in the sink during cleaning
* Do NOT clean with toothpaste
* Remove at night
* Store in a cup with a patient label
* Do not:
* Place in a napkin
* Place on a food tray
* Use toothpaste to clean dentures

True

True or False: Remove a patient’s dentures at night to prevent gum irritation and bacteria build up.

Paralysis/Immobilization Impact on Hygiene

Dependent body parts are exposed to pressure from underlying surfaces. The inability to turn or change position increases the risk for pressure injuries.

Diabetes Impact on Hygiene

Patients are prone to dryness of mouth, gingivitis, periodontal disease, and loss of teeth.

Excessive Secretions/Moisture Impact on Hygiene

Creates a medium for bacterial growth and causes local skin irritation, softening of epidermal cells, and skin maceration. Increases risk for pressure injuries.

Obesity Impact on Hygiene

Patient cannot visualize skin properly and keep it clean and dry. Excessive adipose tissue creates pressure from weight, lack of air circulation, and an increase in moisture with poor tissue perfusion.

Considerations for Caring for an Unconscious Patient

* Reduced gag reflex leads to the pooling of secretions.
* Microorganisms can grow.
* If secretions are aspirated, pneumonia can develop.
* CHG should be used topically and orally.
* Always have suction set up and the patient in semi-fowlers.
* Reduced blinking reflex distribution of tears leads to dry eyes, corneal abrasions, and infection.
* Apply lubricating eye drops.
* Apply an eye patch if the eye does not close completely.

Considerations When Caring for an Incontinent Patient

* Change when the incontinence occurs.
* Take measures to prevent incontinence associated dermatitis (IAD.)
* Exposure to urine, bile, and stool is common.
* Use urinary diversion methods like condom catheters or purwicks.
* Do NOT use briefs on a patient while they are in bed.

False

True or False: If a patient is incontinent, contacting the provider for a Foley catheter is an acceptable solution.

Shear

The sliding movement of skin and subcutaneous while the underlying muscle and bone are stationary.

Friction

The force of two moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface.

Pressure Intensity

Capillary closing pressure as the minimal amount of pressure required to collapse a capillary.

Pressure Duration

Low pressure over a prolonged period and high-intensity pressure over a short period are two concerns related to this.

Tissue Tolerance

The inability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures.

Top Down Damage (Superficial)

Stage I-II

Bottom-Up Damage (Deep)

Stage III-IV

Stage I Pressure Injury

Intact skin with non-blanchable erythema redness of a localized area. Usually over a bony prominence. The area may be painful, firm, soft, warmer, or color compared to adjacent tissue.

Nonblanchable Erythema

* Indicated compromised circulation
* The erythematous area does not blanch

True

True or False: Nonblanchable erythema appears blue or violet in patients with darker skin.

Pressure Injury

Localized damage to the skin and underlying soft tissue developing over a bony prominence or related to pressure from a medical device.

Stage II Pressure Injury

Partial thickness loss of dermis presenting as a shallow open ulcer with a pink/red open wound bed without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister.

Skin Function

* Protection
* Temperature
* Sensation
* Regulation

Stage III Pressure Injury

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss.

Stage IV Pressure Injury

Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often undermining or tunneling. Can extend into muscle and/or supporting structures. (Ex. fascia, tendon, or joint capsule.)

Slough

Wet necrotic tissue. Tan or yellow.

Eschar

Dry necrotic tissue. Black.

Deep-Tissue Pressure Injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Unstageable Pressure Injury

Full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough or eschar in the wound bed.

Acute Wound

Wounds that proceed through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity. Caused by trauma or incision.

Chronic Wound

Wound that fails to proceed through an orderly and timely process to produce integrity.

Primary Wound Closure

* Surgical incision with sutures or staples
* Minimal scar formation

Secondary Wound Closure

* Wound edges are not closed
* Intentional for wounds that have tissue loss
* Heals by granulation tissue formation, wound contraction, and epithelialization

Tertiary Wound Closure

* Wound that is left open for several days; then wound edges are approximated.

Partial Thickness Wound Repair

1. Inflammatory response
2. Epithelial proliferation and migration
3. Reestablishment of the epidermal layers

Full-Thickness Wound Repair

1. Hemostasis
2. Inflammatory phase
3. Proliferation
4. Remodeling

Inflammatory Response

Damaged tissue/mast cells secrete histamine resulting in vasodilation. Redness and swelling with moderate serous exudate. Generally limited to 24 hours.

Epithelial Proliferation and Migration

Start at wound edges, cells migrate across the wounded soon after the wound occurs.

Hemostasis

Controls blood loss, establishes bacterial control, and seal the defect. Blood vessels constrict and platelet gather to stop bleeding.

Reestablishment of the epidermal layers

Cells slowly reestablish normal thickness and appear as dry pink tissue.

Proliferation

Occurs 3-4 days after injury and can last for two weeks wound fills with granulation tissue, wound contraction, and wound resurfacing by means of epithelialization.

Remodeling

Collagen scar continues to reorganize and gain strength. Begins several weeks post-injury and depends on depth/extent.

Partial Thickness

Shallow, involving loss of epidermis and possible loss of dermis.

Full Thickness

Extend into the dermis and heal by scar formation because deeper structure. Do not regenerate. Ex. Stage III and IV pressure injuries.

Internal Hemorrhage

* Hematoma-collection of blood
* Large bruise (ecchymosis)

External Hemorrhage

* Blood-soaked dressing
* Pooling underneath the patient

Dehiscence

* Partial or total separation of the wound layers
* Occurs after coughing, vomiting, straining
* Patient ports a pop sensation or something “gave way”
* Possible serosanguineous drainage.

Evisceration

* Emergency
* Protrusion of visceral organs
* Caused by poor wound healing or suturing
* Notify the provider, keep the patient NPO, and cover site with sterile saline gauzes.

Infection

* A wound that has excessive exudate (drainage) provides an environment that supports bacteria growth, macerates the peri-wound skin, and slows the healing process.
* Signs and Symptoms:
* Erythema
* An increased amount of wound drainage
* Change in appearance of wound drainage (purulent and odorous)
* Fever and an increase in WBC count
* Wound culture

Surgical Drain Function

* Provide a means for fluid or blood that accumulates within a wound bed to drain out of the body
* Surgeon inserts it into or near a surgical wound if there is a large amount of drainage
* Removes excess wound fluid and promotes wound healing in the wound bed allowing it to heal from the inside out.

Jackson Pratt Drain

Hemovac

Penrose Drain

Debridement

* Removal of nonviable, necrotic tissue
* Necessary to rid the wound of a source of infection
* Enables visualization of the wound bed
* Provides a clean base necessary for healing

Autolytic Debridement (Slow Method)

* Adding moisture to the wound to make the dead tissue liquify and easy to remove with dressing changes.
* Hydrocolloids, hydrogels, and transparent films.

Mechanical Debridement

* Can damage healthy tissue as well
* Wet to dry dressing technique (wet gauze first and layer with dry gauze)
* Pulls off viable and nonviable tissue with each dressing change.
* PAINFUL

Chemical Debridement

* Application of a prescribed topical agent that chemically liquefies necrotic tissues with enzymes.
* Some enzymes dissolve and engulf devitalized tissue within the wound.
* Dakin solution breaks down and loosens dead tissue in a wound.

Biological Debridement

* Sterile maggots eat the dead tissue only.

Surgical Debridement

* Removal of tissue with a scalpel, scissors, or other sharp instrument.

High Pressure Wound Irrigation

* Type of debridement
* Pulse lavage
* Whirlpool treatments

Incontinence Associated Dermatitis

Skin irritation caused by prolonged exposure to feces or urine.

Gauze Dressing

* Oldest and most common dressings.
* Absorbent and wicks away wound exudate.
* Can be used to clean or pack wounds.
* Purpose is to provide moisture to the wound, yet allow wound drainage to be wicked into the dry cover pad.

Self Adhesive Transparent Film Dressing

* Traps moisture over a wound, providing a moist environment to ensure epithelial cell growth.
* Ideal for small, superficial wounds. (Ex. Stage 1)
* Serves as a barrier to external fluids and bacteria but still allows the wound surface to breathe as oxygen passes through.

Hydrocolloid Dressing

* Dressings with complete formulations of colloids and adhesive components. Support healing in clean granulating wounds and automatically debride necrotic tissue.
* Impenetrable to bacteria ad other contaminants.
* Self-adhesive and mold to the wound.
* Good for shallow to moderately deep wounds.

Hydrogel With Foam

* Gauze/sheet dressings with gel.
* Indicated for use in partial thickness wounds, deep wound with exudate, necrotic wounds, burns, and radiation damaged skin.
* Softens necrotic tissue, soothing, and does not adhere to the would.
* May require a secondary dressing.

Negative Pressure Wound Therapy

* Application of negative pressure wound through suction to facilitate healing and collect fluid.
* Draws edges of the wound together.

Wound Irrigation

* Using irrigation syringe to flush the wound with a constant, low-pressure flow of solution.
* Cleanses the wound of exudate and debris.
* Good for deep, open, or inaccessible wounds.
* Requires sterile technique.

Nutrition for Wound Healing

* More calories
* Protein
* Vitamin C
* Vitamin A
* Zinc
* Fluid

Binders and Bandages

* Support underlying muscles and incisions, lessening muscle stress.
* Promote early ambulation, controlling pain, and recovery experiments.

Hot Therapy

* Vasodilation
* Reduces blood viscosity
* Reduced muscle tension
* Increased tissue metabolism
* Increased capillary permeability
* Improves blood flow to injured body part
* Promotes delivery of nutrients and removal of wastes
* Improves deliver of leukocytes and antibiotics to wound sote
* Promotes muscle relaxation
* Reduces pain from spasm or stiffness
* Provides local warmth

Cold Therapy

* Local anesthesia
* Reduced cell metabolism
* Increased blood viscosity
* Decreased muscle tension
* Reduces blood flow to injured site, preventing edema formation.
* Reduces inflammation
* Reduces localized pain
* Reduces oxygen needs of tissues
* Promotes blood coagulation at injury site
* Relieves pain

True

True or False: Hot and cold therapy should be applied for no more than 20 minutes.

Risk Factors for Pressure Injury Development

* Impaired sensory perception
* Impaired mobility
* Altered level of consciousness
* Moisture
* Friction and shear

Braden Scale

* Measures the risk for the development of pressure injuries
* The higher the score, the less likely a patient is to develop a pressure injury.
*

Medical Device Pressure Injuries

Occurs when the skin or underlying tissues are subjected to sustained pressure or shear from medical devices or equipment. Ex. Nasal cannula.

Considerations for Older Adults

* More comorbidities
* Decreased subcutaneous tissue which reduces padding protection over bony prominences
* Aging skin has decreased epidermal turnover and healing requires more time
* Diminished inflammatory response
* Decreased collagen
* Reduces elasticity
* Thinning of underlying muscles

True

True or False: Shear + Friction = Superficial damage

True

True or False: Pressure Intensity + Pressure Duration + Tissue Tolerance = Deep Damage

Serous

Clear, watery plasma

Purulent

* Thick, yellow, green, tan, or brown.
* Indicates infection

Serosangiuneous

* Pale, red, watery.
* Mixture of serous and sanguineous
* Common and normal early in healing

Sanguineous

* Bright red
* Indicates active bleeding