Tissue Integrity - Day 1

Tissue Integrity Overview

• Definition: Tissue integrity refers to the intact state of skin and underlying tissues. When skin is compromised, it becomes vulnerable to infection and other complications.

• Functions of Skin: Protection, sensation, temperature regulation, absorption, excretion.

• Layers of the Skin:

  • Epidermis: Outermost waterproof layer.

  • Dermis: Contains connective tissue, blood vessels, nerves, and glands.

  • Subcutaneous Tissue: Fat storage, insulation, protection.
    
    

Factors Affecting Skin Integrity

• Risk Factors:

  • Age (older adults at higher risk)

  • Chronic illnesses (diabetes, vascular disease)

  • Malnutrition & dehydration

  • Reduced mobility

  • Sensory deficits (neuropathy, paralysis)

  • Incontinence (moisture-associated skin damage)

  • Prolonged hospitalization

  • Smoking
    
    

Wounds and Wound Healing

A. Types of Wounds

1. Open vs. Closed:

   • Open: Skin surface broken (e.g., laceration, surgical incision)

   • Closed: No break in skin, but soft tissue damage (e.g., bruises, internal injury)

2. Acute vs. Chronic:

   • Acute: Heal quickly in days to weeks (e.g., surgical wounds, abrasions)

   • Chronic: Delayed healing, stays in inflammatory phase (e.g., pressure ulcers)

3. Intentional vs. Unintentional:

   • Intentional: Planned (e.g., surgery, IV therapy)

   • Unintentional: Accidental (e.g., trauma, burns)

B. Phases of Wound Healing

1. Inflammatory Phase (3-6 days):

   • Vasoconstriction → Platelet aggregation → Fibrin clot forms.

   • Leukocytes & macrophages clean debris & release growth factors.

2. Proliferative Phase (3-24 days):

   • Fibroblasts form new tissue, granulation tissue develops.

3. Maturation Phase (Day 21+):

   • Collagen strengthens tissue, scar formation occurs.

C. Types of Wound Healing

1. Primary Intention:

   • Wounds with well-approximated edges (surgical incisions, clean cuts)

   • Heal quickly, minimal scarring, low infection risk.

2. Secondary Intention:

   • Wounds with edges that are not well-approximated (e.g., pressure ulcers, burns)

   • Longer healing time, increased scar tissue, high infection risk.

3. Tertiary Intention:

   • Left open initially to allow infection or swelling to resolve before closing.

   • Higher infection risk, longer healing time.
     
     

Pressure Injuries

• Definition: Localized damage to skin and underlying tissue due to prolonged pressure or friction.

• Common Sites: Bony prominences (sacrum, heels, elbows, hips).

• Risk Factors:

  • Immobility

  • Poor nutrition

  • Moisture (incontinence, excessive sweating)

  • Sensory impairments

  • Medical devices (oxygen tubing, catheters, splints)

A. Stages of Pressure Injuries

1. Stage 1: Non-blanchable erythema of intact skin.

2. Stage 2: Partial-thickness skin loss with exposed dermis (blister or shallow wound).

3. Stage 3: Full-thickness skin loss; visible adipose tissue, possible slough or tunneling.

4. Stage 4: Full-thickness skin and tissue loss; exposed muscle, bone, tendon.

5. Unstageable: Covered by slough or eschar, preventing depth assessment.

6. Deep Tissue Pressure Injury: Non-blanchable deep red, purple, or maroon discoloration due to damage beneath intact skin.
   
   

Prevention & Nursing Interventions

1. Repositioning:

   • Bed-bound patients: Turn every 2 hours.

   • Chair-bound patients: Shift weight every hour.

2. Skin Care:

   • Keep skin clean and dry.

   • Apply barrier creams for incontinence patients.

3. Nutrition & Hydration:

   • Encourage high-protein diet, vitamin C, zinc for wound healing.

   • Ensure adequate hydration.

4. Braden Scale for Risk Assessment:

   • ≤9: Very high risk.

   • 10-12: High risk.

   • 13-14: Moderate risk.

   • 15-18: Low risk.

5. 19-23: No risk.
   
   

Wound Complications & Nursing Management

• Infection: Purulent drainage, fever, redness, swelling, increased WBC count.

  • Nursing Action: Culture wound, start antibiotics, monitor for sepsis.

• Hemorrhage: Greatest risk 24-48 hours post-op.

  • Nursing Action: Check dressings frequently, apply pressure if needed.

• Dehiscence (Wound Separation): Skin layers separate, common in abdominal wounds.

  • Nursing Action: Apply sterile dressing, notify provider.

• Evisceration (Organs Protruding): Medical emergency!

  • Nursing Action: Cover with sterile saline-soaked gauze, place in low Fowler’s position, call provider immediately.
    
    

Delegation & Prioritization

• Registered Nurse (RN) Responsibilities:

  • Initial wound assessment & staging.

  • Developing nursing care plans.

  • Performing wound debridement.

  • Educating patients.

• Licensed Practical Nurse (LPN) Responsibilities:

  • Reinforcing wound care education.

  • Administering wound treatments per protocol.

  • Monitoring for wound healing progress.

• Unlicensed Assistive Personnel (UAP) Responsibilities:

  • Repositioning patients.

  • Assisting with hygiene.

  • Reporting changes in skin condition to the RN.

Prioritization Strategies:

• ABC (Airway, Breathing, Circulation) First!

• Prioritize acute over chronic conditions.

• Signs of infection or dehiscence/evisceration take priority.

SAFETY

• Pressure Injury Prevention:

  • Reposition patients every 2 hours in bed and every 1 hour in a chair.

  • Use pressure-relieving devices (e.g., specialty mattresses, heel protectors).

  • Keep skin dry and clean to prevent moisture-related injuries.

  • Ensure adequate nutrition and hydration to support skin integrity.

• Wound Care & Healing:

  • Primary intention (surgical wounds, clean & well-approximated edges) heals faster.

  • Secondary intention (large, open wounds, burns, pressure ulcers) takes longer.

  • Tertiary intention (left open initially, then closed) used for infected wounds.

  • Signs of infection: Purulent drainage, redness, fever, increased WBC count.

• Postoperative Safety - Dehiscence & Evisceration:

  • Dehiscence: Partial or total separation of a wound.

  • Evisceration: Internal organs protrude.

  • Nursing Action: Cover with sterile, saline-soaked gauze, notify provider immediately, keep patient in low Fowler’s position.

• Braden Scale (Pressure Injury Risk Assessment):

  • Score ≤9: Very high risk

  • Score 10-12: High risk

  • Score 13-14: Moderate risk

  • Score 15-18: Low risk

  • Score 19-23: No risk
    

DELEGATION

• RN Responsibilities (Cannot Delegate):

  • Initial assessment & wound staging

  • Developing nursing care plans

  • Performing wound debridement

  • Educating patients on wound care

  • Administering medications & dressing changes requiring sterile technique

• LPN Responsibilities:

  • Reinforce wound care education (after RN has taught).

  • Administer prescribed wound care treatments (excluding complex wound debridement).

  • Monitor wound healing progress and report changes to the RN.

• UAP (CNA) Responsibilities:

  • Reposition patients to prevent pressure ulcers.

  • Assist with hygiene and skin care.

  • Report changes in skin condition to the nurse.

  • Apply non-medicated barrier creams per protocol.
    

PRIORITIZATION

• ABCs (Airway, Breathing, Circulation) always come first!

  • Example: A patient with a deep pressure ulcer (Stage 4) with signs of sepsis (fever, tachycardia) is a higher priority than a patient with a Stage 2 ulcer and no systemic symptoms.

• Acute vs. Chronic Conditions:

  • Acute changes (e.g., sudden worsening of a wound, new onset of drainage, fever) take priority over chronic conditions.

• Infection vs. Non-infection:

  • A wound showing infection signs (redness, swelling, purulent drainage, fever) takes priority over a clean, healing wound.

• Stage 3 & 4 Pressure Injuries (Full Thickness) Require Immediate Attention:

  • Risk of osteomyelitis, sepsis, and necrotizing infections.