Exam 3: Tissue Integrity — Pressure injury

Tissue integrity

The state of structurally intact and physiologically functioning

epithelial tissues, such as the integument (including skin and

subcutaneous tissue) and mucous membranes

What does impaired tissue integrity reflect?

reflects varying levels of damage to one or more groups of epithelial cells

What do epithelial cells form?

form a continuous, tightly packed layer on surfaces in and out of the body

Skin function

• Critical barrier

  • 1st line of defense

• Regulates water loss and temperature

  • Secretion + excretion

• Provides sensory input

  • Nerves allow for sense of touch, temperature, and pain

• Vit D produced by body from sun

• Wound healing

What does the dermis consist of?

• Epidermis

• Dermis

• Subcutaneous tissue

Subjective assessment of skin

• Lifestyle and Personal Habits

• Allergies (skin, food, medications, chemicals)

• Previous skin conditions

• Personal and family history of skin cancer

• Specific symptoms to determine a specific disease: OLDCART

• Use and types of cosmetics, soaps, shampoos, laundry detergent, etc

Objective inspection of skin

• color

• Lesions

• Open areas/wounds

• Pigmentation changes

• Surgical incisions

• Scars (note scar formation)

Objective palpations of skin

• temperature (back of hand)

• Moisture

• Skin turgor

• Color return

Tented skin turgor

indicates dehydration (not a specific assessment)

Color return

assessing capillary refill

How do you assess for the patients risk for skin breakdown?

Braden scale

Diagnositic testing assessment

• skin biopsy

• Patch testing

• Skin scraping

• Tzanck smear

• Wood light

• Culture + sensitivity

Skin biopsy

sample of a nodule, plaque, blister or other lesion

Patch testing

applying suspected allergens x 48 hours to determine sensitivity

Skin scrapings

◦microscopic examination tissue samples from fungal lesion(s)

Tzanck smear

microscopic examination of blister secretions

wood light

lamp using long-wave UV rays to examine for tinea (Assess for infection)

Culture and sensitivity

suspected bacterial infection

Age related changes

• fragility and thinning

• ↓ elasticity and turgor

• ↓ thickness (tissue and fat)

• ↓ sebum (of sebaceous glands)

Considerations for examination/diagnosis

• meds can lead to photosensitivity

• Loss of subcutaneous tissue

• Vascular changes can impact fragility of skin and would healing

• Increased susceptibility to trauma (skin tears, bruising)

Pressure injury

Localized injury to skin and underlying soft tissue due to intense and/or prolonged pressure with or without shear or friction

• can also be caused by pressure that doesnt include shear and friction

Pressure injuries tend to occur over…

Bony prominences

• not much subcutaneous tissue

What can pressure injury can be precipitated by? Examples?

Any hard surface in contact with the patient

• Examples: bed, wheelchair, armrest

Never events

Serious and preventable patient safety incidents that should never occur in healthcare settings

How to ensure never events do not occur

• Reposition patients often

• Skin monitoring

• Redistribution of pressure

never events are _____-_____ problems

nursing sensitive

First sign of pressure injury

Erythema

Erythema

Redness of skin due to dilation of capillaries

• first sign of a pressure injury

High risk areas for pressure injuries in supine position

High risk areas for pressure injuries in lateral position

High risk areas for pressure injuries in Prone position

How to prevent pressure injury when lateral

make sure that the extremities are not rubbing on eachother and cause pressure

Friction and location

force of rubbing two surfaces against each other

• outside of skin

Shearing and location

exerting a parallel force on patient’s body

• deeper tissue (e.g., muscles)

Why do we need a lifting device to move patients?

we need to have a lifting device to move patients so there is no friction/shearing when the bed is moving against their body we need to have a lifting device to move patients so there is no friction/shearing

Risk assessment for pressure injuries

• Skin: inspect each pressure site

• Mobility: get patients moving in some way)

• Neurologic status: ↓ LOC, ↓ sensory perception bc decreases mobility

• Vascular status: poor circulation

• Nutrition: malnourishment

• Incontinence or increased moisture (pay attention to skin folds — especially in larger ppl)

• Shear and friction

Braden Risk scale assessment scale

• Sensory perception

• Moisture

• Activity

• Mobility

• Nutrition

• Friction and shear

Risk levels for pressure injury based on Braden assessment

• Low risk = 15-16

• Moderate risk = 13-14

• 12 or less = high risk

Stage 1 pressure injury and signs

intact skin

• Non-blanching erythema

• Skin may be warm to touch and painful

Stage 2 pressure injury and signs

Partial-thickness tissue loss involving dermis and epidermis

• Shallow open ulcer, blister, or abrasion with a red-pink and moist wound bed

• No slough or bruising

Stage 3 pressure injury and signs

Full-thickness tissue loss

• Subcutaneous tissue may be visible

• Slough may be present but able to visualize wound bed

• May include undermining and/or tunneling

Sloughing

the process where the outer layer of skin (epidermis) detaches and is shed

Stage 4 pressure injury and signs

Full-thickness tissue loss with exposed bone, tendon, and/or muscle

• Slough or eschar may be present

What is the MAJOR risk of stage 4?

Risk for osteomyelitis

• Bone infection

• Serious complication

Unstageable pressure injury and signs

Stage is unclear because we can’t tell the deepness/base of the wound d/t slough and eschar

• Full-thickness tissue loss

How can we determine the level of damage of unstageable pressure injury?

Remove slough to determine depth/stage

Deep tissue pressure injury

Damage to underlying soft tissue

Characteristics of deep tissue injury

• Purple or maroon localized area

• Skin intact or blood-filled blister

• Painful

• Boggy or mushy but can be firm

Assessment of pressure injury

• • Inspect

  • Color, blanchable

  • Document size: measure in centimeters, always length x width x depth

  • Determine presence of undermining or tunnelling

  • Describe any drainage including amount and odor

  • Describe wound bed tissue

  • Describe wound edges

  • Observe condition of surrounding tissue

  • Palpate

  • Surface temperature over injury area

  • Bony prominences & dependent areas for edema and/or bogginess

Types of drainage

Sanguinous

Serous

Serosanguineous

Purulent

Salguinous drainage

• Appearance: Bright red, fresh blood

• Indicates: Active bleeding or trauma to blood vessels

Serous drainage

• Appearance: Clear or pale yellow, watery fluid

• Indicates: Normal healing or mild inflammation

Serosanguinous drainage

• Appearance: Pink or light red, mix of clear fluid and blood

• Indicates: Mild bleeding with serous fluid, often seen in healing wounds

Purulent drainage

• Appearance: Thick, cloudy, yellow, green, or tan pus

• Indicates: Infection with bacteria and white blood cells present

To heal a wound, you must _____ the wound

clean

Wound bed tissue types (4)

• Granulation

• Epithelialization

• Necrotic slough

• Necrotic eschar

Wound edges types (4)

• Epibole

• Macerated

• Fibrotic

• Callused

Epibole wound edge

Rolled-under wound edges where epithelial cells have curled down instead of migrating across; stalls healing because the wound “thinks” it’s closed

Macerated wound edge

Soft, mushy, white or pale edges caused by excess moisture breaking down skin (often from prolonged drainage or over-moist dressings)

Fibrotic wound edge

Thick, dense, and tough edges made mostly of scar-like connective tissue; usually from chronic inflammation or long-standing wounds

Callused wound edge

Hard, thickened skin around the edges from repeated friction or pressure; common in diabetic foot ulcers and can block epithelial migration

Lab tests for wounds

• CBC

• Wound culture and sensitivity

• Serum protein

• Albumin

• Prealbumin

CBC

Measures WBC (infection concern) and hemoglobin (anemia concern)

Wound culture + sensitivity

Done when there is an infection to determine what the bacteria is and what antibiotics work on it

Serum protein, albumin, and prealbumin

All 3 are used to determine nutrition status

• Protein: measures overall protein in blood

• Albumin: measures long-term nutritional status

• Prealbumin: measures short-term nutritional status

Purpose of nutrition for wound healing

provides the body with the necessary building blocks to repair damaged tissue, fight infection, and maintain overall health

Prevention of pressure injuries (7)

• Reduce pressure over bony prominences

• Smooth surfaces

• Frequent weight shifts (repositioning)

• Exercise and ambulation

• Lifting devices (particularly helpful to prevent injury from shearing or friction)

• HOB < 30 degrees

• Early nutritional consultation

Prevention devices

• Mattresses that are air filled and can blow up in ways that are best for the patient’s body

• Pillow

• Heal boots (for ppl that are immobile to prevent friction from the bed)

Treating pressure injuries

• Remove direct pressure

  • Do not massage reddened areas

  • Provide devices to reduce/diffuse pressure

  • Increased repositioning

• Provide ROM exercises

• Consult Certified Wound and Ostomy Nurse (CWON)

  • Clean and dress the wound as prescribed

  • Obtain culture & sensitivity (C&S) if indicated

• Collaborate with wound care/skin service providers

• Teaching for patient and family

Autolytic wound debridement

uses body’s own enzymes to break down tissue

Enzymatic wound debridement

enzyme containing ointment, speeds rate of necrosis removal

Mechanical wound debridement

wet-to-damp dressings, wound irrigations

Biologic wound debridement

enhance wound healing through contact

Surgical wound debridement

removal of tissue to promote wound healing

Considerations when selecting a dressing

• Keep wound bed continuously moist

• Keep surrounding skin healthy & dry

• Control exudate (wound drainage) without drying out wound bed

• Consider time & costs

Types of dressings

• Passive

• Interactive

• Active

Passive dressings

protective only

• transparent film

• Gauze

Interactive dressings

Protect wound and absorb wound damage

• Create a moist environment

• hydrocolloid dressings

• Manage exudate to aid in healing

Active Dressing

skin grafts and substitutes that actively participate in the healing process

• create a moist wound environment

• promote autolytic debridement (gently remove dead skin cells)

• incorporate bioactive agents or mechanically stimulate wound contraction

Wound vac wound healing

Negative pressure develops to help pull exudate out of the wound

Hyperbaric oxygen therapy

Patient put in chamber that’s has increased pressure and 100% has O2, which increases the O2 levels in the blood and tissues to promote healing and fight infections