Foundations: Caring for Clients with Impaired Tissue Integrity

Module 3 content

Tissue Integrity

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

Skin Integrity

Unimpaired condition of the skin

Aging and tissue integrity

drying of skin d/t loss of elasticity and adipose tissue

Mobility/Immobility and tissue integrity

reduced circulation, atrophy, and impaired sensation

pressure

incontinence

Nutritional impact on skin integrity

obesity

malnutrition

Chronic Illness impact on tissue integrity

Hepatic, Renal, CV disorders

Altered Elimination pattern

Miscellaneous risks for tissue integrity

smoking

stress

genetics

previous injury

medications

Assessing the Skin for admission

Head-to-Toe with the primary and admitting nurse

Assessing the skin for a shift assessment

conducted by the primary nurse

skin is an essential

component of whole patient assessment

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Skin assessment components

Temperature

Turgor

Color

Moisture

Skin Integrity

Locations of bony prominences

Occiput, scapula, sacrum, heels

skin beneath and around devices

oxygen tubing (behind ears)

braces (arms, shin)

skin to skin areas

back of knees, inner thighs, buttocls

all areas where the patient _________ should be assessed

lacks sensation, has skin folds, or had previous breakdown

Braden Scale

assesses for risk based on six categories.

lower score = greater the risk

Six categories of the Braden Scale

Sensory Perception

Moisture

Mobility

Nutrition

Friction/Shear

How to avoid skin trauma while in bed

assess every 2 hours

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

pad bony prominences

use specialty equipment

How to avoid skin trauma while in chair

seat cushion

How to avoid skin trauma with Mobilization

ambulate early and often

encourage frequent weight shifting

do NOT slide (friction shearing)

maintaining skin hygiene

cleanse skin with wipes/warm water

cleanse immediately following incontinence

do NOT massage bony prominences

types of wounds to look for

pressure injuries

moisture associated skin damage

venous ulcers

arterial ulcers

diabetic foot ulcers

what are names of other wounds

abrasions

skin tears

lacerations

lesions

surgical wounds

burns

pressure injury

an injury to the skin and underlaying tissue resulting from prolonged pressure or pressure and shear

HAPI

Hospital acquired pressure injury

stage 1 pressure injury

intact skin with non-blanchable redness of a localized area (typ. bony prominence)

darkly pigmented skin may not have visible blanching and may differ in color from the surrounding area

Stage 2 pressure injury

partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed

may also present as an intact or open/ruptured serum-filled blister

Stage 3 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 tissue loss

Stage 4 pressure injury

full thickness tissue loss with exposed bone, tendon, or muscle

slough or eschar may be present on some parts of the wound bed

often include undermining and tunneling

deep tissue injury

purple or maroon localized area of discolored intact skin

blood-filled blister due to damage of underlaying soft tissue from pressure and/or shear

painful, firm, mushy, baggy, warmer, or cooler compared to adjacent tissue

unstageable pressure injury

full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green, or brown)

eschar (tan, brown, or black) in the wound bed

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)

MASD treatment can include

exudate management

absorbent dressings

barrier creams

venous ulcers are most commonly found

around the ankles d/t a problem with circulation (ex. PVD)

venous ulcer treatment can include

compression socks/wraps

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

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

arterial/ischemic ulcers treatment

surgery

smoking cessation

blood sugar control

weight loss

diabetic foot ulcers occur mostly on

the plantar aspect of the feet d/t

neuropathy

poor circulation

foot deformities

trauma etc

diabetic foot ulcers treatment can include

surgery

offloading

blood sugar management

primary intention wound healing

little to no tissue loss

edges well approximate

low infection risk

minimal scarring

secondary intention wound healing

loss of tissue

edges poorly approximated

heals from bottom up (granulation tissue)

increased risk of infection/scaring

tertiary intention wound healing

delayed primary closure

uses combination of primary and secondary

used for dirty wounds at time of injury

hemostasis phase of wound healing

stops bleeding

inflammation phase of wound healing

prevention of infection

remodeling phase of wound healing

wound closure

complications of wound healing

infection

osteomyelitis

necrosis/gangrene

peri-wound dermatitis

risk for impaired wound healing

tissue perfusion

immunocompromise

infection

medications

malnutrition

chronic disease (diabetes)

impaired oxygen delivery (decreased Hgb/smoking)

measuring the wound: length

head to toe

measuring the wound: width

side to side

measuring the wound: depth

straight down into wound bed

measuring the wound equation

L x W x D

assessing the wound edges for

tunneling

undermining

observe the wound bed for

granulation

slough

eschar

exudate

fluid produced by the healing process

assess wound amount

none, scant, small, moderate, large/copious

assess wound order and consistency

thin/watery vs thick/sticky

assess wound color

serous (clear, watery)

serosanguinous (pale, blood tinged)

sanguineous (bloody, bright or dark)

purulent (thick, various colors)

types of wound closure

sutures

staples

adhesives

negative pressure wound therapy

in order to do wound care

you need an order

a wet wound bed

increases risk for infection

it needs to dry

dressing can be wet when removed

(gauze, foams, alginates)

a dry wound bed

wont granulate

need to keep it moist

(wet-to-dry, hydrocolloids, hydrogels)

goal of wound care and choosing the right dressing

moist wound healing

uses or drains

decrease accumulation of fluid

reduce inflammation

collect fluid

classifications of drains

active or passive

open or closed

types of drains

Penrose

Jackson Pratt (JP)

Hemovac

drainage document

amount, color, consistency, oder, and date/time

drainage insertion site

monitor for s/sx of infection

drain care, cleaning

daily w/ NS unless orders state otherwise

drain care nursing considerations

monitor for kinking of tubing

regularly empty drain to maintain suction

secure drain