Module 4A - tissue integrity

functions of skin

• protection from microorganisms

• maintain body temperature

• elimination/absorption

• psychosocial impact

• sensation

• vitamin D absorption

integumentary system

• skin

• blood vessels

• sensory organs/nerves

• glands

• hair and nails

epidermis

• waterproof protective layer

• stratified epithelial cells

• contains no blood vessels

• regenerates quickly

dermis

• nourishment/waste elimination

• contains nerves, blood vessels, glands, immune cells, and hair follicles

subcutaneous tissue

• anchors skins to the tissues underneath

• functions: stores fat, heat insulator, cushioning

• consists of adipose and connective tissue

skin assessment

• skin turgor

• visualize/inspect before palpating

• look at nail beds

• note cleanliness and odors

• skin color

• documentation

• skin on soles of feet and palms should be thicker

• skin temperature (room temperature will effect this)

wound documentation

• location

• color

• size

• margins

• skin around wound

• s/s of infection/pain

• approximation

• stage

• depth

edema

• fluid accumulation from trauma, impaired venous return, etc

• skin appears shiny and tight

• pitting scored as 1+ - 4+

• not always pitting

• compare bilaterally

primary lesion

a skin lesion that appears on healthy skin

• examples: macule, papule, tumor, vesicle, etc

secondary lesion

a skin lesion that arises from a primary lesion

• examples: scales, crust, fissure, ulcer, scar, etc

lesions

• measure height, width, and depth

• assess for undermining or tunnels

• observe for exudate or odor

• note color

• when measuring and documenting 12 o’clock position is always towards the head

skin cancer ABCDE

a - asymmetry

b - border

c - color

d - diameter

e - evolving

melanoma

• can appear anywhere on the skin including palms, soles of feet, under the fingernails, or inside the body

• african-decent are at an increased risk

age related concerns

children - ringworm, eczema

adults - herpes simplex, sorosis

older adults - longer healing time, more prone to injury, harder to regulate temperature

types of wounds

• surgical

• traumatic

• vascular

• neuropathic

• pressure-injury

vascular wounds

• venous ulcers: shallow, caused by impaired venous flow

• arterial ulcers: deep, caused by inadequate blood supply, heal very slowly

pink

epithelial, final stage of healing, wound closed, healthy/normal

red

• cover

• healthy granulation, regeneration/remodeling of tissue, vascular, bleed easily

yellow

• clean

• presence of purulent drainage and slough

black

• debride

• presence of eschar that hinders healing and requires removal, necrotic

assessment for healing/infection

• inflammation - needed to begin healing

• odor - none, slight, moderate, strong - indicates infection

• pain - indicator of infection

• exudate - none to copious → purulent = infection

friction

2 surfaces rubbing together

• prevent: use devices/assistance when transferring

shearing force

friction + pressure

• moist skin stuck to sheets → sliding down in bed or chair

pressure injury

mostly over boney prominences or medical devices, can form in 1-2 hours

• ex: nasal cannula, pressure points

risk factors for wounds

• immobility/decreased mobility

• inadequate nutrition, malnourished

• decreased LOC, confusion

• diminished sensations

• obesity

• ischemia

• incontinence

primary intention

• surgical incision, edges are approximated

• reduced risk of infection

• closed by sutures, staples, glue, steri strips

secondary intention

• pressure ulcers, granulation

• tissue loss, wound edges are separated

• takes longer to heal

tertiary intention

• open, infected wound, closed later

• widely separated and deep

• longer healing time

• higher risk of infection

deshiscence

wound separation of a previously approximated area

evisceration

• organs in abdominal cavity become exposed

• do not reinsert organs

• put pt on back w/ knees bended

• keep moist with sterile dressing if available

wound cleaning

• least to most contaminated

• clean gently

• isotonic is preferred cleaning solutions

• no cotton balls or products that shed fibers

• only use one pass to prevent spreading of microorganisms

stage 1

• nonblanchable erythema, closed skin

• treat by relieving pressure → turning, pressure relieving device, keep pt clean and dry, hydrated and well nourished

stage 2

• partial thickness skin loss

• treat w/ occlusive dressing, nutritional supplements, assess pain, administer analgesics

stage 3

• full thickness skin loss → to subq tissue

• clean with prescribed topical/dressing

• wound care consult → request referral

• analgesics

stage 4

• full thickness skin loss with extensive destruction → down to bone

• treated with skin graphs, hyperbaric oxygen, wound vac, surgical interventions, antimicrobials

unstageable

• wound bed is necrotic, slough, or eschar present

• dead tissue impeded healing → must be removed by a trained professional

• can’t see what is going on under the dead tissue

deep tissue injury

• wound bed is purple or maroon - localized area of discolored intact skin

• indicated damage of underlying soft tissue

• caused by pressure injury or shear

• tissue might be painful, firm, mushy, boggy, warmer or cooler than surround area

debridement

• removal of damaged tissues

• surgical, enzymatic, biological, autolytic

• larval therapy

larval therapy

• wounds with MRSA, non-healing, diabetic/foot ulcers infected wounds, at risk of amputation

• uses sterile or disinfected maggots

autolytic debridement

• natural, highly selective process

• endogenous phagocytic enzyme break down necrotic tissue

• good for those with low pain tolerance and small amount of necrotic tissue

• for non-infected wounds only