Tissue Integrity

Tissue Integrity

the state of structurally intact and physiologically functioning epithelial tissue

Tissue

organized groups of cells with common functions

Epithelial Tissue

skin, mucous membranes, glands

Skin

protects, absorbs, repairs, senses; made up of epidermis, dermis and subcutaneous tissue

Epidermis

most superficial, thin layer of skin with no blood vessels

Dermis

sits deep to the epidermis and is well supplied with blood

Subcutaneous

adipose tissue deep to the dermis which is used as energy stores for the body

Mucous Membranes

line the eyes, nose, mouth, ears, genitals, and anus; secrete mucus to protect the body from infection

Glands

tissues which create and secrete chemicals responsible for bodily functions

Eccrine Glands

sweat glands which help to control body temperature

Apocrine Glands

sweat glands in the pubic and underarm areas

Describe the tissue types

epithelial, muscular, neural, connective

Superficial Impairment

surface level tissue impairment

Partial Thickness Loss

loss of the epidermis which appears smooth and red

Full Thickness Loss

loss of epidermis and dermis which appears with adipose, muscle, tendon, and bone

Granulation Tissue

pink, shiny, moist new tissue

Slough

yellow or white tissue that adheres with strings or clumps

Eschar

black or brown tissue which indicates necrosis

How is tissue integrity different in infants?

they have thinner, more permeable skin which leads to greater fluid loss and less effective temperature regulation

How is tissue integrity different in older adults?

they have thinner skin with decreased strength, moisture and elasticity

What are some categories of tissue impairement?

injury, loss of perfusion, immunologic reactions, infection, infestation

Tissue Trauma or Injury

damage to the tissue due to accidental injury, burns or surgical incisions

Poor perfusion can lead to _______ and ________.

ulceration and necrosis

How does an immunologic reaction appear on tissues?

redness, rash, urticaria, hypersensitivity reactions

Steven's Johnson Syndrome

severe, possibly fatal hypersensitivity reaction that mimics a burn

What are some subsequent effects of tissue impairment?

poor thermoregulation, infection susceptibility, sensation and pain, psychological distress and body image changes

Incision

margins of the wound are approximated

Contusion

blunt force injury

Abrasion

scrape due to friction or rubbing

Laceration

tearing of the skin

Puncture

small hole made by an object that does not come out the other side

Penetrating

small hole made by an object that does come out the other side

Avulsion

pulling a structure away from its anatomical position

What are different types of ulcers?

venous, arterial, diabetic, kennedy's terminal (occurs before death)

What are the phases of wound healing?

hemostasis, inflammation, proliferation, maturation

Desicration

dehydration of tissue

Maceration

overhydration of tissue which leads to further breakdown

What might cause maceration of tissue?

exposure to stool and urine, perspiration, tissue surrounding a wound or ostomy site

What are some complications of wound healing?

infection, hemorrhage, dehiscence, evisceration, fistula formation

Dehiscence

partial or total separation of wound layers

Evisceration

most serious complication of dehiscence in which internal organs protrude from the site

What factors are important to consider for a skin assessment?

appearance of the area, pt mobility, nutrition, pain, exposures

What are some examples of primary prevention for tissue integrity?

skin hygiene, nutrition, sun and burn protection, injury prevention

What are some examples of secondary prevention for tissue integrity?

early detection and treatment

What are some signs of skin cancer?

asymmetry, borders are irregular, color is uneven, diameter is changing, evolving (ABCDE)

Integumentary System

skin, hair, nails, glands

What are functions of the integumentary system?

protection, temp regulation, sensation, absorption, excretion

What are you looking for on inspection of the integument?

color, integrity, lesions, markings, infection, infestation

What are you looking for on palpation of the integument?

temperature, turgor, moisture, texture, edema

RYB Wound Assessment

red (protect), yellow (cleanse), black (debride)