Tissue Integ exemplar
Tissue Integrity Exemplar 1: Dermal Ulcers
Pathophysiology
Cause: Prolonged pressure on skin and underlying tissue leads to ischemia, which causes tissue damage and necrosis.
Mechanism: Pressure exceeds capillary perfusion pressure, thereby reducing blood flow and oxygen delivery to tissues.
Assessment
Risk Factors
Immobility or bedbound status.
Advanced age.
Malnutrition or dehydration.
Incontinence, particularly involving moisture.
Decreased sensation.
Chronic conditions, such as diabetes and vascular disease.
Friction and shear forces.
Cues (Signs & Symptoms)
Stage 1: Non-blanchable erythema on intact skin.
Stage 2: Partial-thickness skin loss with exposed dermis; shallow open ulcer.
Stage 3: Full-thickness skin loss; subcutaneous fat visible.
Stage 4: Full-thickness tissue loss; exposed muscle, tendon, or bone.
Unstageable: Degree of tissue loss is obscured by eschar or slough.
Diagnostics & Labs
Visual inspection and staging of the ulcer.
Wound culture if infection is suspected.
Nutritional assessment.
Analysis/Diagnosis
Impaired Skin Integrity.
Tissue Integrity Exemplar 2
Analysis/Diagnosis
Risk for infection.
Impaired tissue perfusion.
Pain.
Planning (Outcomes)
Promote wound healing.
Prevent infection.
Prevent new ulcer formation.
Manage pain effectively.
Implementation
Medications
Topical Antimicrobials: To be used if an infection is present.
Analgesics: Administer before dressing changes.
Enzymatic Debriding Agents: As ordered by the physician.
Management & Interventions
Follow wound care protocol:
Use a cleansing agent.
Possible debridement.
Rinse with solution.
Apply antibacterial/antiseptic as ordered.
Documentation: Note the following:
Drainage (color and amount)
Swelling
Temperature
Odor
Skin color
Pain
Document before-and-after treatment comparisons.
Application Guidelines
Follow manufacturer's instructions for each preparation.
Apply treatment to clean, non-irritated skin only.
Avoid doubling missed doses.
May require occlusive or wet dressings as per order.
Protect from air and sunlight exposure as indicated.
Properly dispose of contaminated materials.
Pressure Relief
Reposition patients every 2 hours.
Use pressure-redistributing surfaces.
Patient Education
Proper application technique is essential.
Report increased redness, swelling, pain, drainage, fever, or worsening symptoms.
Notify prescriber if no therapeutic response is seen within 48-72 hours.
Arrange home health care if needed post-discharge.
Evaluation
Monitor for improved skin condition.
Look for decreased lesion size.
Assess for reduced swelling, redness, itching, and healing progress.
Evaluate for adverse effects ranging from site irritation to systemic toxicity.
Tissue Integrity Exemplar 4: Impetigo
Pathophysiology
Cause: Bacterial invasion through minor skin breaks or secondary to existing dermatosis.
Common Organisms: Staphylococcus aureus (most common) and Streptococcus pyogenes, which produce exfoliative toxins disrupting the skin barrier and causing blister formation.
Types of Impetigo:
Nonbullous: Most common form with vesicular lesions.
Bullous: Caused solely by S. aureus; blisters enlarge and coalesce to form bullae.
Both forms of impetigo begin as vesicles that rupture, forming characteristic honey-colored crusts.
Assessment
Risk Factors
Age 2-5 years (most common population).
Crowded conditions and poor sanitation.
Attendance at daycare facilities, schools, or camps.
Hot, humid climates (especially mid-to-late summer).
Anemia and malnutrition.
Pre-existing skin conditions.
Cues (Signs & Symptoms)
Presence of vesicles that rupture.
Honey-colored crusts (hallmark sign).
Lesions commonly located on face (around nose/mouth), hands, and exposed areas.
Highly contagious nature of the condition.
Incubation period: 7-10 days.
Diagnostics & Labs
Clinical diagnosis based on appearance and symptoms.
Culture if Methicillin-resistant Staphylococcus aureus (MRSA) is suspected.
Analysis/Diagnosis
Impaired Skin Integrity.
Risk for infection spread.
Risk for secondary complications, such as glomerulonephritis with streptococcal impetigo.
Planning (Outcomes)
Promote healing (typically 12-14 days with appropriate treatment).
Prevent transmission of infection.
Prevent complications related to the infection.
Implementation
Medications
Topical Antibiotics (7-10 days):
Mupirocin (Bactroban).
Bacitracin (Baciguent).
Oral Antibiotics: (in severe cases or for perioral lesions).
Cephalexin (first-line therapy).
Alternative agents if MRSA suspected: Clindamycin, doxycycline, trimethoprim-sulfamethoxazole.
IV Antibiotics: Administered in cases of extensive impetigo.
Management & Interventions
Gently wash lesions 3 times daily with a warm, soapy washcloth.
Soak and carefully remove crusts before applying topical ointment.
Ensure good handwashing technique; demonstrate and have return demonstration from patient.
Properly dispose of contaminated materials to prevent spread.
Emphasize that sharing of towels, glasses, or personal items should be avoided.
Patient Education
Children cannot attend school/daycare for 24 hours after starting treatment;
Notify the school of the diagnosis to ensure proper procedures.
Evaluation
Assess for lesion healing and absence of new lesions.
Monitor for no transmission to others and adherence to treatment regimen.
Tissue Integrity Exemplar 7: Psoriasis
Pathophysiology
Nature: Chronic, relapsing, immune-mediated inflammatory disorder.
Cellular Interactions: Involves interactions between immune cells, including macrophages, dendritic cells, and T-helper cells.
Specific Activation Pathway: The interleukin-23 (IL-23) mediated activation of T-helper 17 pathway leads to:
Secretion of inflammatory mediators such as TNF-α, IL-12, IL-17, and IL-23.
Keratinocyte proliferation and angiogenesis, which contributes to immune cell infiltration.
Genetic Factors: Resulting disordered immune system exhibits polygenic inheritance.
Assessment
Risk Factors
Genetic predisposition, with onset typically occurring before age 40.
Environmental triggers such as skin trauma, infection, smoking, and pre-existing comorbidities like obesity, hypertension, and diabetes.
Additional triggers include climate changes, stress, excessive alcohol consumption, and dry skin.
Cues (Signs & Symptoms)
Plaque Psoriasis (Most Common Type):
Characteristics: Large, dry, erythematous scaling patches with silvery-white scales on top.
Commonly affects: nails, scalp, genitals, lower back, elbows, and knees.
Possible pruritus in moderate to severe cases.
Koebner Phenomenon: Lesions appear at trauma sites.
Other Forms:
Inverse, guttate, pustular, and erythrodermic psoriasis may also occur.
Complications: Psoriatic arthritis and nail disease (e.g., pitting, onycholysis).
Diagnostics & Labs
Clinical diagnosis based on symptomatology and lesions observed.
Monitor white blood cell (WBC) counts, particularly when systemic therapies are applied.
Analysis/Diagnosis
Impaired Skin Integrity.
Risk for infection, especially for patients receiving systemic biologics.
Chronic pain or pruritus.
Potential for body image disturbance.
Planning (Outcomes)
Aims include achieving remission, reducing flare-ups, managing symptoms, and preventing complications.
Minimize the risk of secondary infections with systemic therapy.
Implementation
Medications
Topical Treatments (for mild to moderate cases):
Corticosteroids (first-line therapy).
Systemic/Biologic Treatments (for moderate to severe cases):
IL-17A inhibitors: Ixekizumab (Taltz), Secukinumab (Cosentyx).
IL-12 inhibitor: Ustekinumab (Stelara).
TNF inhibitors: Adalimumab (Humira), Etanercept (Enbrel).
Other biologics: Brodalumab (Siliq), Guselkumab (Tremfya), Risankizumab (Skyrizi).
Phosphodiesterase-4 inhibitor: Apremilast (Otezla).
Antineoplastic: Methotrexate.
Management & Interventions
Assess overall health status as well as immunosuppression history.
Monitor WBC counts with systemic therapy.
Increased infection risk associated with biologics, noted as the most serious adverse effect.
Provide FDA-approved medication guide for ixekizumab.
Assess skin condition in patients with darker skin tones by palpating for warmth and other signs.
Patient Education
Educate on avoiding triggers (stress, alcohol, skin trauma).
Encourage immediate reporting of signs of infection.
Stress the critical importance of adherence to medications for remission.
Educate that fluctuating patterns of recurrence and remission are expected.
Evaluation
Monitor for reduced lesion size, decreased inflammation, and absence of infection.
Assess improved quality of life indicators.
Tissue Integrity Exemplar 10: Wounds (Traumatic and Surgical)
Pathophysiology
Types of Wounds
Traumatic Wounds: Result from direct or indirect tissue injury (including lacerations, abrasions, punctures).
Surgical Wounds: Intentional incisions through tissue layers. Healing is dependent on surgical technique, tissue perfusion, and patient-related factors.
Both types heal through three phases: inflammatory, proliferative, and maturation.
Assessment
Risk Factors
Contamination during injury or surgical procedure.
Presence of preoperative infection.
Patient debilitation or immunosuppression.
Poor nutrition, particularly low protein and vitamin C intake.
Impaired tissue perfusion, diabetes, and obesity.
Cues (Signs & Symptoms)
Normal Healing Indicators:
Edges of the wound approximated, minimal drainage, and decreasing redness.
Infection Indicators:
Redness of surrounding tissue.
Foul odor emitted from the wound.
Presence of purulent drainage.
Increased pain and warmth.
Delayed healing progress.
Diagnostics & Labs
Conduct a wound culture if infection is suspected.
Assess the wound for location, size, shape, and color.
Document details regarding drainage—including color, odor, consistency, and amount.
Analysis/Diagnosis
Impaired Tissue Integrity.
Risk for infection.
Risk for delayed healing.
Planning (Outcomes)
Promote wound healing and closure of the wound.
Prevent or treat infection effectively.
Maintain adequate nutrition to support healing.
Implementation
Medications
Prophylactic antibiotics: Given before and/or during surgery; reevaluated 24 hours post-operative.
Treatment antibiotics: Reserved for when signs and symptoms of infection are present; systemic therapy may be warranted for infected wounds.
Management & Interventions
Perform wound assessment during dressing changes:
Document location, size, and character of drainage.
Check for signs of infection.
Note tissue types present (e.g., granulation, necrotic).
Follow wound care protocols:
Adhere strictly to surgeon's orders regarding irrigation, packing, and covering of the wound.
Conduct chemical or surgical debridement as necessary, especially for necrotic tissue (removal of eschar is essential for healing).
Consider vacuum-assisted closure (VAC) for large or open wounds.
Use cast windows for necessary wound observation; retain the removed piece to avoid localized edema.
Nutritional Support
Ensure adequate protein and vitamin C intake to facilitate healing.
Utilize protein shakes or supplements as needed.
Patient Education
Teach proper wound care techniques.
Instruct on signs and symptoms of infection that require reporting.
Highlight the importance of nutrition in supporting healing.
Encourage follow-up appointments for routine wound evaluations.
Evaluation
Monitor for wound closure and absence of infection.
Ensure adequate granulation tissue formation and verify patient adherence to the care plan.
Tissue Integrity Exemplar 13: Tinea Pedis (Athlete's Foot)
Pathophysiology
Nature: Fungal infection caused by dermatophytes that invade the stratum corneum, the dead layer of skin.
Transmission: Occurs through direct contact with the infectious organism, which may occur through person-to-person contact or fomites (e.g., walking barefoot on locker room floors).
Environment: Fungi flourish in warm and moist environments.
Response: Inflammation arises when fungi invade the dead skin layer, while sensitivity and itching occur when they penetrate deeper into the epidermis and dermis.
Assessment
Risk Factors
Wearing nonventilated athletic shoes.
Having moist feet or excessive sweating.
Using shared shower facilities (gyms and schools).
Not allowing shoes to dry between wearings.
Cues (Signs & Symptoms)
Presence of fine vesiculopustular or scaly lesions on soles of the feet.
Lesions commonly found between the toes, especially in the web spaces of the 4th and 5th toes.
Lesions may also appear under nails, with peeling, fissures, and maceration seen in severe cases.
Symptoms include pruritus (itching) and burning.
Diagnostics & Labs
Culture taken from affected skin areas.
KOH wet mount of skin scrapings may be performed.
Use of Wood lamp (ultraviolet light) to check for spores that fluoresce blue-green.
Dermoscopy for detailed examination of skin lesions.
Analysis/Diagnosis
Impaired Skin Integrity.
Risk for secondary infections due to skin breakdown.
Acute Pain and Pruritus from the fungal infection.
Planning (Outcomes)
Goals to eradicate the fungal infection.
Prevent any recurrence of infection.
Promote adequate skin healing throughout the treatment process.
Implementation
Medications
Topical Antifungals: Considered first-line treatment for tinea pedis.
Systemic Antifungals: In cases that are difficult to treat which may include:
Griseofulvin (note that photosensitivity risks exist).
Itraconazole, with monitoring required for liver function.
Treatment duration is typically 6-8 weeks; may extend for nail infections.
Management & Interventions
Daily washing of feet, ensuring they remain dry.
Changing socks at least twice daily to manage moisture.
Advising patients to go barefoot or wear sandals whenever possible.
Selecting heavy cotton socks to absorb moisture and sweat.
Allow nonventilated shoes to thoroughly dry between wearings.
Applying talcum or antifungal powder twice daily for added preventative measure.
Using shower shoes in communal facilities to avoid footwear-related infections.
Avoid sharing towels, washcloths, or personal items.
Patient Education
Complete the entire course of medications, as stopping early increases the risk of recurrence.
Contact a physician if no improvement is noted after 4 weeks or if there is continued spread of infection after 1 week of treatment.
Reinforce that the presence of a fungal infection is not necessarily indicative of poor hygiene.
Evaluation
Monitor for the resolution of lesions, decreased pruritus, burning sensations, and absence of recurrence of infection.
Tissue Integrity Exemplar 16: Candida
Pathophysiology
Causative Organism: Candida albicans, a yeast-like opportunistic fungus found in the skin, mouth, gastrointestinal tract, and vagina.
Normal Defense: Commensal bacteria and local defense mechanisms usually control C. albicans.
When these defenses are compromised, Candida can transition from being a commensal organism to a pathogen, causing infection.
Assessment
Risk Factors
Preceding antibiotic therapy disrupting the normal microbiome.
Immunosuppression or neutropenia.
Pregnancy, diabetes mellitus, and oral contraceptive use.
Infants under 6 months due to decreased immune reactivity.
Warmth, moisture, maceration, or occlusion in certain areas.
Presence of indwelling catheters or IV lines, particularly in ICU patients.
Cancer (especially hematologic types), transplantation, and HIV/AIDS.
Cues (Signs & Symptoms)
Oral Candidiasis (Thrush):
White plaques or spots in the mouth.
Shallow ulcers upon removal of plaques.
Dense white coating observed on the tongue.
Red, tender underlying mucosa that may bleed.
Possible fever or GI irritation in infants.
Vaginal Candidiasis:
Symptoms include itchy, inflamed vulvar/vaginal tissues.
Presence of white "cottage cheese" discharge.
Cutaneous Candidiasis:
Affects skin folds, nail folds, interdigital regions, and diaper areas.
Invasive/Disseminated Candidiasis:
Symptoms include persistent or recurrent fever, hypotension, tachycardia, and deep organ abscesses (kidney, brain, liver, heart), with a 30% mortality rate.
Diagnostics & Labs
Identifying C. albicans spores through vaginal or oral samples.
Cultures and serologic tests are necessary for systemic infections.
Analysis/Diagnosis
Impaired Skin/Mucous Membrane Integrity.
Risk for disseminated infection (particularly in immunocompromised patients).
Acute pain and pruritus are also noted.
Planning (Outcomes)
Aim to eradicate the infection, prevent recurrence or dissemination, and restore normal flora balance.
Implementation
Medications
Oral Treatment for Thrush:
Use of Nystatin oral suspension.
Vaginal Candidiasis Treatment:
Nonprescription options (3-7 days): Miconazole, clotrimazole, butoconazole, terconazole, tioconazole.
Prescription options: Nystatin and higher-dose butoconazole or terconazole.
Systemic Candidiasis Treatments:
Administration of systemic antifungal agents, taking into account toxicity and resistance concerns.
Prophylaxis recommended for high-risk patients (e.g., those with hematologic disease or undergoing stem cell transplants).
Management & Interventions
Treat any concurrent maternal nipple or vaginal infections, particularly in infants.
Ensure sterilization of feeding bottles or nipples.
Maintain cleanliness and dryness in affected areas.
Consider simultaneous treatment of partners if there are recurrent infections.
Patient Education
Importance of completing the full treatment course.
Seek medical assistance for initial infections, persistence, or frequent recurrence of symptoms.
Breast-fed infants show lower prevalence of candidiasis compared to bottle-fed infants.
Evaluation
Verify resolution of symptoms, negative cultures, and absence of recurrence.
Tissue Integrity Exemplar 19: Pediculosis (Lice)
Pathophysiology
Infestation: Results from the presence of either Pediculus humanus (head/body lice) or Phthirus pubis (pubic lice).
Nature of Lice: Parasitic insects that feed on human blood.
Transmission: Occurs through direct head-to-head contact or the sharing of personal items like combs, hats, or bedding.
Assessment
Risk Factors
More common in school-age children.
Found in close contact settings such as schools, daycare, and camps.
Sharing personal items increases risk.
Infestation is not correlated with poor hygiene or low socioeconomic status.
Cues (Signs & Symptoms)
Intense pruritus affecting the scalp, neck, and ears.
Visible nits (lice eggs) attached to hair shafts.
Live lice may be present on the scalp; however, they can be difficult to see as they move quickly.
Excoriation resulting from scratching may occur.
Secondary infection may develop due to skin ulceration from scratching.
Diagnostics & Labs
Visual Inspection: Perform with a fine-tooth comb to identify live lice or nits.
Analysis/Diagnosis
Impaired Skin Integrity.
Risk for transmission to others.
Risk for secondary infections due to excoriation.
Planning (Outcomes)
Goals include eradicating the lice infestation, preventing transmission, and avoiding reinfestation.
Implementation
Medications
Over-the-Counter Pediculicides:
Follow instructions closely as indicated on the packaging.
Note: Do NOT apply more frequently than recommended.
Prescription Products: Used as per physician's instructions.
Contraindications exist for certain populations such as those with a history of seizures, pregnant women, and young children (due to potential central nervous system side effects like headache, dizziness, seizures).
Management & Interventions
Employ personal protective equipment (PPE) while providing care.
Pre-comb hair with a fine-tooth comb before and after applying shampoo.
Nit Removal Procedures:
Loosen nits with a vinegar and water mixture (half and half) or a commercial product (like Clear, Step 2) 1 hour before combing.
Comb hair when damp, neither wet nor dry, for the most effective removal.
Employ back-combing techniques with a fine-tooth comb for thorough removal.
Eyelash Treatment: Apply petrolatum 3-5 times daily for 8-10 days.
Patient Education
Notify the school nurse of the infestation for appropriate interventions.
Many schools have stringent “no nit” policies, requiring complete nit removal before allowing reentry, which has been challenged by recommendations from organizations such as the CDC and AAP due to missed school time and low transmission risk.
A child should not attend school for 24 hours post-treatment initiation.
Reassuring statements for parents include clarifying that a lice infestation does NOT indicate poor hygiene.
Evaluation
Evaluate for the absence of live lice, successful nit removal, and prevention of transmission to others.