Week 13- Tissue Integrity

tissue integrity

state of structurally intact and physiologically functioning epithelial tissues, including the integument and mucous membranes

impaired tissue integrity

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

partial thickness injury

loss of epidermis and dermis

full thickness injury

loss of epidermis, dermis, and SQ tissue

what are the functions of the skin?

defense, regulates temperature, controls fluid loss, senses

infants lifespan consideration

skin is thinner and more permeable, they have less SQ fat, melanin is not fully developed until around 6 months

adolescents lifespan considerations

increased apocrine sweat and sebaceous gland activity

older adults lifespan considerations

decrease is skin strength, moisture, pain perception, blood flow, decrease in growth of hair and nails, decrease is sebaceous gland activity

6 major types of impaired tissue integrity

trauma/injury, loss of perfusion, immunologic reaction, infection/infestations, thermal/radiation injury, lesions

types of trauma/injury

unintentional (open or closed injury) and intentional (surgical)

examples of loss of perfusion impaired tissue integrity

venous ulcer, arterial ulcer, pressure ulcer

venous ulcer

chronic, wet, weepy

arterial ulcer

dry

pressure ulcer

short term, bony prominences

examples of immunologic reaction impaired tissue integrity

urticaria, contact dermatitis, SJS

examples of infections

fungal (tinea corporis), viral (herpes zoster), bacterial (cellulitis)

tinea corporis

ringworm, too much moisture in skin folds

examples of infestations

scabies, lice

scabies

contagious skin disease transmitted by the itch mite, contact precautions

thermal or radiation injury examples

scald burn, sunburn, radiation burn

benign skin lesions examples

acne, skin tags, seborrheic keratosis, cherry angioma, freckle, mole

malignant skin lesions

basal cell carcinoma, squamous cell carcinoma, keratoacanthoma, melanoma

lesion

area of skin different from the area around it

phases of healing

hemostasis, inflammation, proliferation, remodeling/maturation

types of healing

primary and secondary intention

hemostasis

clot formation

inflammation

exudate and erythema (3 days)

proliferation

granulation and epithelialization (new connective tissue, 3-14 days)

remodeling and maturation

scar tissue

primary intention

wound margins are well approximation, healing is more rapid and less scarring

secondary intention

wounds have distant edges and granulation tissues gradually fill the gap

secondary intention examples

ulcers, surgical wounds with dehiscence

when tissue integrity is impaired, disruptions are seen in...

thermoregulation, fluid and electrolyte balance, infection protection, comfort/pain, body image

populations at risk- infants/toddlers

diaper rash, injuries from mobilization, inability to protect themselves

populations at risk- school aged children

active play injuries

what is the most common type of injuries in children?

burns

populations at risk- older adults

risk for skin tears, burns, and poor wound healing

why are older adults at risk for poor wound healing?

muted inflammatory response and decrease circulation

individual risk factors

poor peripheral perfusion, impaired immune system, DM, malnutrition, obesity, smoking, impaired mobility, exposure to moisutre

what should you inspect for skin lesions?

location, size, shape, color, distribution, pattern, elevation, border

wound assessment examination

type, location, size, degree of tissue injury, wound base, wound edges, exudate

petechiae

small, pinpoint hemorrhages, non-blanchable

papular

raised bumps, often associated with rash, blanchable

lab tests- impaired sin integrity

skin biopsy, patch testing, CBC w/ diff, albumin, blood glucose

interpretation- decreased Hgb

less oxygen is being transported to the wound site, decreasing the wounds healing ability

interpretation- increased WBCs, neutrophils, and or bands

sign of systemic infection either caused by the wound or contributing to delayed healing

interpretation- decreased platelets

impaired granulation tissue formation

interpretation- decreased albumin

impaired tissue repair and regeneration, indicates low protein

interpretation- increased BG or Hgb A1C

short term- significantly harms the immune system response, long term- leads to structural changes that increase risk of chronic wound development

interpretation- positive wound C&S

sign that infection is present and determines most effective antibiotic

two types of wound C&S

aerobic and anaerobic

steps to obtaining a wound C&S

maintain aseptic technique, irrigate the wound first, wipe the surface of the wound with a sterile saline moistened gauze, identify viable wound tissue, rotate the tip of the swap over the area for 5 seconds, apply enough pressure that would fluid is collection, transport

skin hygiene across the lifespan- infants/toddlers

remove food residue, frequent perineal care and diaper changing

skin hygiene across the lifespan- adolescents

frequent bathing to reduce body odors and oils

skin hygiene across the lifespan- older adults

moisturize, blot skin dry to avoid irriation

protein

build, maintained, and repair body tissues

calories

provide energy

vitamins and minerals

repair and rebuild damaged tissues (vit c, vit a, zinc, iron)

when can infants not use sunscreen unitl?

6 months

burn prevention

avoid carrying infants and hot food at the same time, oven safety, test bath water

goals of tissue healing

prevent or treat infection, control co-morbid conditions, protect tissue

pharmacotherapy interventions

antimicrobial therapy, steroids, emollients

surgical treatment

excisions, debridement, skin grafts

expected response from interventions

no tissue breakdown, wound progresses through healing stages

unexpected response from interventions

tissue breakdown, adapt plan of care

HAPI

localized skin injury and/or underlying tissue during an inpatient hospital stay

HAPIs are considered...

never events

stage 1 ulcer

non-blanchable erythema

stage 2 ulcer

partial thickness skin loss with exposed dermis

stage 3 ulcer

full thickness tissue loss with visible fat

stage 4 ulcer

full thickness loss; can see organs/ bones; very painful

unstageable ulcer

Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.

deep tissue injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

STAND acronym

score on risk scale, turn and offload, apply barrier cream, nutritional intervention, discuss with sepcialist

score on the risk scale

< 18 implement the STAND bundle in full, documented minimally every 24 hours

how often should patients be turned?

2 hours

how often should you check for tubes or devices?

2-4 hours

how many pressure injuries are caused by medical devices?

1/3

what to apply if a patient is incontinent?

barrier cream

what to apply if a patient is continent

bordered foam dressing (allevyn maximum 5 days)

hard to heal wounds

stuck in the inflammatory phase, caused by intrinsic and extrinsic factors

intrinsic factors of delayed wound healing

elderly, stress, depression, over/under weight, DM, PVD, smoking, drug use, malnutrition, steroids, immunosuppressnats

extrinsic factors of delayed wound healing

pressure, shear, friction, not following aseptic technique, leaving dressing in place for too long, overuse of cleansing agents, necrotic tissue, drying out of wound bed, excessive moissture

signs of hard to heal wounds- wound bed

desiccation, slough, eschar

signs of hard to heal wounds- size and depth

no change or increases

signs of hard to heal wounds- wound edges

rolling, tunneling, undermining, or dehiscence

signs of hard to heal wounds- exudate

increased amount or odor, change to purulent

signs of hard to heal wounds- periwound

increased temperature or erythema, induration, maceration, nonblanchable

goals of chronic wound management

create a viable and healthy wound bed, maintain optimal moisture, advancement of wound edges

chronic wound treatments

cleansing and debridement, antimicrobials, appropriate moisture, optimize nutrition

wound cleansing

prepares and maintains the wound bed by removing debris, reducing bacteria, and preventing biofilm

normal saline

preferred, physiologic

providone iodine

broad spectrum antimicrobial, drying effects, discolors skin, can be cytotoxic

dakins solution

dilute solution of bleach, kills pathogenic microorganisms, can be mildly cytotoxic

wound debridement

the removal of nonviable tissue in a wound

mechanical debridement

wet to dry dressing, not usually recommended as it is painful and removes viable tissue

autolytic debridement

use of the body's enzymatic system for removal of dead tissue through dressings that promote moist wound healing

Enzymatic debridement

topical applications of enzymes to dissolve necrotic tissue

signs a wound is too wet

dressing is saturated, maceration of periwound (notify WOC)

dressings for heavily exudating wounds

specialty absorptive dressings, alginate (seaweed), foam