Tissue Integrity Exemplar

Serous Drainage

Primarily clear, serous portion of blood, watery

Sanguineous Drainage

Large number of red blood cells (bright is fresh, dark is old)

Serosanguineous Drainage

MIxture of serum and RBCs, light pink to blood tinged

Purulent Drainage

WBC, liquified dead tissue debris. Thick musty or foul smelling, yellow/green

Drains

Can be used to promote would healing of dismissal of fluids by preventing fluid accumulation (stagnant fluid causes infection), negative pressure systems promote tissue approximation, reduces swelling and pain

Cellulitis

Bacterial skin infection that affects the deep dermis and subcutaneous and inflames it. Cytokines and neutrophils go to affected area and cause erythema (redness), warmth, edema, and tenderness. This can lead to bacteremia, endocarditis, and osteomyelitis

Cellulitis Risk Factors

Anything that can cause breakdown in skin like injuries, iv site punctures, surgical incision, insects, fissures, or comorbidities

Clinical Manifestations of Cellulitis

Spreading of erythematous inflammation of the deep dermis and subcutaneous. Worsening erthema, edema, warmth and tenderness, unilateral.

Cellulitis Diagnostics

Blood work via CBC, ESR, CRP, would culture, Imaging

Cellulitis Medical Management

Antibiotics via PO for mild or IV for severe

Cellulitis Nursing Assessment

Look for warmth, erythema, edema, tenderness, look for the source of it, assess between toes and swollen lymph nodes (lymphadenopathy)

Diabetic foot ulcer

Common complication of patients who do not control their diabetes well. Cause of osteomyelitis and amputation

Pathophysiology of Diabetic Foot Ulcer

Development of callus resulting for neuropathy (sensation loss and pins and needles). Can also develop severe atherosclerosis of the small blood vessels in the legs and feet. Because of vascular compromise delayed wound care

Clinical Manifestations of Diabetic Foot Ulcers

Most common in weight bearing areas. Indicates for neuropathy (parasthesia, hypo or hyperesthesia (sensation), or anhidrosis (sweating)). Vascular insufficiency like loss of hair, shiny skin, atrophy from poor perfusion. Signs of infection

Diabetic Foot Ulcer DIagnostics

Blood work like CMP, CBC, A1c, etc.

Cultures

X ray to show osteomyelitis, air, or signs of fractures

Arterial dopplers can rule out PAD

Diabetic Foot Ulcer Management

Wound care, off loading, debridement, infection treatment, revascularization, amputation, hyperbaric oxygen therapy

Diabetic Foot Ulcer Assessment

Assess feet and lower extremities for sensation, parasthesia, anhidrosis, loss of hair, shiny skin, atrophy, purulence, erythema. Also history like fever, chills, pain, smoking, vitals, diet and exercise

Healthcare Associated Pressure Ulcer (HAPI)

Localized damage to the skin and underlying tissue that usually occurs over a bony prominence or related to the use of device and develops under care.

HAPI Basics

Sustained compression obliterates arterial and capillary perfusion to the ski, ischemic damage to underlying tissue. Reperfusion can cause injury as oxidizing agents can spark inflammatory response. Can result to necrosis

Friction

When two surfaces rub against each other and is like abrasion. Example is wrinkled sheets, pulled over sheets

Shear

When one layer of tissue slides over another layer. This will separate skin from underlying tissue

HAPI Risk Factors

Incontinence, aging skin, immobility, malnutrition, lower LOC

Stage 1 Pressure Injury

Erythema of the skin that does not blanch

Stage 2 Pressure Injury

Erythema with the loss of partial thickness of the skin that will blister

Stage 3 Pressure Injury

Full thickness ulcer that might involve the subcutaneous fat

Stage 4 Pressure Injury

Full thickness ulcer with the involvement of the muscle or bone

Braden Scale

HAPI Screening Tool that allows to identify high risk patients. Risk factors are sensory perception, moisture, activity, mobility, nutrition, and friction and shear

HAPI Diagnostics

CBC used to see if infection is setting in. Wound culture, BMP to see albumin (indicator of nutrition)

Purosanguineous

Mixed drainage of pus and blood (newly infected wound)

Hydrocolloid

Occlusive dressing that swells in the presence of exudate composed of gelatin and pectin, it forms a seal at the wound’s surface to prevent evaporation of moisture from the skin. Used to treat HAPIs

Hydrogel

Composition is mostly water. Gels after contact with exudate, promoting autolytic debridement and cooling. Rehydrates and fills dead space, used to treat HAPIs

Alginates

Nonadherent dressings that conform to the wound’s shape and absorb exudate, treats HAPIs

Collagen

Powders, pastes, granules, sheets, gels, and pastes, treats HAPIs

Vacuum Assisted Closure System

Use of foam strips laid into the wound bed with an occlusive sealed drape applied and suction tubing placed for negative pressure (suction) to occur once the tubing is connected to the systems therapy unit, used to treat HAPIs

Fistula Formation

Can occur from incision complications, abnormal passage from internal organ or vessel to outside of body or from one internal organ or vessel to another. Usually the result of infection that has developed into an abscess

Dehiscence

Partial or total separation of wound layers or as a result of excessive stress on wounds that are not healed, complication of incision

Evisceration

Most serious complication of dehiscence. Abdominal would completely separates and there is a protrusion of viscera through incision area