Tissue Integrity

Concept Learning Outcomes for Tissue Integrity

• Summarize the physiology of the integumentary system as it relates to tissue integrity.

• Examine the complex relationship between tissue integrity and other physiological concepts or body systems.

• Identify commonly occurring alterations in tissue integrity and describe their related therapeutic interventions.

• Differentiate between common assessment procedures used to examine tissue integrity across the various stages of the human life span.

• Describe various diagnostic and laboratory tests utilized to determine an individual’s tissue integrity status.

• Explain the management of tissue integrity and the various methods for the prevention of impaired tissue integrity.

• Demonstrate the application of the nursing process in providing culturally competent and caring interventions for individuals across the life span with common tissue integrity alterations.

• Compare and contrast common independent nursing interventions and collaborative interventions for clients experiencing alterations in tissue integrity.

Anatomy and Physiology of the Integumentary System

• The integumentary system is comprised of several key components:

  • Skin

  • Hair

  • Nails

  • Sebaceous glands

  • Sweat glands

  • Mammary glands

• Important nursing functions related to this system include:

  • Maintaining the client's skin integrity.

  • Promoting the process of wound healing.

• Normal Presentation and Functions of the Skin:

  • Protection: Acts as a barrier for underlying tissues.

  • Perception: Nerves and specialized skin structures enable sensory perception.

  • Regulation: Responsible for body temperature regulation.

  • Synthesis: Synthesizes Vitamin D.

• Layers of the Skin:

  • Epidermis: The outermost layer of the skin.

  • Dermis: The second, deeper layer of the skin.

  • Subcutaneous tissue: The layer located beneath the dermis.

Genetic and Lifespan Considerations in Tissue Integrity

• Newborns: Infant skin is significantly thinner than adult skin and contains very little subcutaneous fat.

• Aging Process: Skin changes are considered normal during the aging process, affecting all layers:

  • Epidermis: The thinning of the outermost layer.

  • Dermis: Changes in structural integrity and elasticity.

  • Subcutaneous tissue: Decrease in fat and padding.

• Older Adults:

  • Characterized by diminished epidermis and diminished collagen.

  • Displays less elasticity.

  • Skin is often dry and flaky.

  • Sensory perception is frequently diminished.

Alterations to Skin Integrity and Manifestations

• Skin Disorders:

  • Infectious: Caused by pathogens.

  • Inflammatory: Reaction to irritants or allergens.

  • Neoplastic: Pertaining to skin cancers or growths.

• Skin Lesions: These vary significantly in shape and are categorized into two types:

  • Primary Lesions.

  • Secondary Lesions.

• Wound Classification:

  • Intentional: Created during therapy (e.g., surgical incision).

  • Unintentional: Accidental injuries.

  • Degree of Contamination: Range from clean to infected.

  • Wound Depth: Used for technical classification.

  • Status: Wounds are differentiated between being treated or untreated.

• Related Concepts:

  • Immunity.

  • Infection.

  • Mobility.

Prevalence and Risk Factors of Skin Disorders

• Prevalence Statistics:

  • It is estimated that 1 in 3 individuals in the U.S. has a skin disorder at any given time.

  • Skin cancer is the most common form of cancer in the United States.

• Most Common Disorders:

  • Acne.

  • Dermatitis.

  • Inflammatory reactions to topical drugs.

  • Infectious diseases of the skin.

• Nonmodifiable Risk Factors (Genetics/Inherited Disorders):

  • Epidermolysis bullosa.

  • Ichthyosis.

  • Albinism.

  • Ethnicity and Skin color.

  • Gender and Age.

• Modifiable Risk Factors:

  • Preventive screenings.

  • Lifestyle choices.

Diagnostic Tests and Nursing Assessment

• Common Diagnostic Procedures:

  • Skin biopsy.

  • Cultures (for identifying causative organisms).

  • Immunofluorescent studies.

  • Wood lamp examination.

  • Tzanck test.

  • Patch tests (for identifying allergens).

  • Laboratory data Analysis.

• Nursing Care Components:

  • Assessment: Evaluation of current skin status.

  • Interventions: Action steps taken to improve or maintain integrity.

  • Therapies: Home-based therapies and collaborative medical efforts.

  • Goals of Treatment: Control severity of the condition, prevent infection, and promote healing.

Physiology of Wound Healing

• Overview of Healing:

  • Focused on the quality of living tissue and the regeneration of tissues.

  • Considerations include various types and specific phases.

• Types of Wound Healing:

  • Primary intention healing: Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss.

  • Secondary intention healing: Extensive and involves considerable tissue loss; edges cannot be approximated.

  • Tertiary intention healing: Delayed primary closure; wound is left open for several days then closed.

Phases of Wound Healing

• Inflammatory Phase:

  • Duration: Lasts the first $3$ to $6$ days after injury.

  • Mechanisms: Hemostasis (cessation of bleeding), deposition of fibrin, cell migration of macrophages, and phagocytosis.

• Proliferative Phase:

  • Duration: Starts from day $3$ or $4$ and lasts until about day $21$.

  • Mechanisms: Development of collagen and granulation tissue.

• Maturation Phase:

  • Duration: Starts around day $21$ and can continue for $1$ to $2$ years.

  • Outcome: Final remodeling of the scar; may result in a Keloid.

Complications and Prevention in Wound Care

• Potential Complications:

  • Hemorrhage: Massive bleeding.

  • Hematoma: Internal collection of blood.

  • Infection: Contamination with microorganisms is often inevitable in open wounds.

  • Dehiscence: Partial or total rupture of a sutured wound.

  • Evisceration: Protrusion of internal viscera through an incision (often follows dehiscence).

• Preventive Measures:

  • Nutrition: Addressing issues in malnourished or obese clients.

  • Lifestyle: Encouraging exercise and non-smoking status.

  • Medications: Monitoring use of anti-inflammatory or antineoplastic drugs which interfere with healing.

  • Antibiotic Stewardship: Avoiding prolonged use of antibiotics.

Clinical Manifestations and Wound Exudate

• Exudate Types (Material such as fluid and cells that has escaped from blood vessels during the inflammatory process):

  • Serous: Clear, watery fluid; common in clean wounds.

  • Purulent: Thick, yellow, green, tan, or brown; indicates infection.

  • Sanguineous: Dark or bright red; common in deep or highly vascular wounds.

  • Serosanguineous: Mixed drainage consisting of clear and blood-tinged fluid; common in new wounds.

Pressure Ulcers: Pathophysiology and Etiology

• Definition: Ischemic lesions of the skin and underlying tissue caused by external pressure.

• Process:

  • Pressure is exerted on tissue between a bony prominence and an external surface.

  • Platelets aggregate in endothelial cells and form microthrombi.

  • This leads to ischemia and hypoxia of tissues.

  • Result: Cells and tissue die and become necrotic, leading to ulceration.

• Common Locations: Tend to develop over bony prominences.

• Prevalence: High incidence in hospitals, long-term care facilities, and home settings.

• Risk Factors:

  • Advanced Age.

  • Comorbidities.

  • Fecal and urinary incontinence.

  • Excessive dry skin.

  • Immobility and diminished sensation.

  • Malnutrition.

Prevention and Management of Pressure Ulcers

• Preventive Nursing Interventions:

  • Providing adequate nutrition.

  • Maintaining skin hygiene.

  • Avoiding skin trauma.

  • Frequent positioning (turning schedules).

  • Providing supportive devices.

• Staging of Pressure Ulcers:

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

  • Stage 2: Partial-thickness skin loss involving epidermis, dermis, or both.

  • Stage 3: Full-thickness skin loss; subcutaneous fat may be visible.

  • Stage 4: Full-thickness skin loss with exposed bone, tendon, or muscle.

  • Unstageable: Base of ulcer covered by slough and/or eschar.

  • Suspected Deep Tissue Injury (SDTI): Purple or maroon localized area of discolored intact skin or blood-filled blister.

• Supplemental Systems: Wound VAC (Vacuum-Assisted Closure) System.

• Diagnostic Testing for Ulcers:

  • Cultures of drainage or biopsied tissue to determine causative organisms and presence of secondary infection.

Pharmacologic and Nonpharmacologic Therapy for Ulcers

• Pharmacologic Therapy:

  • Enzymatic ointments.

  • Antibiotics and topical antimicrobials.

  • Muscle relaxers.

  • Topical lidocaine.

  • Nonopioid or opioid analgesics.

• Nonpharmacologic Therapy:

  • Prompt treatment.

  • Collaboration with Physical Therapists (PTs).

  • Education for the client, family, and caregivers.

Braden Scale for Predicting Pressure Sore Risk

• The Braden Scale measures six categories to determine risk. Each category is scored $1$ to $4$ (except Friction/Shear which is $1$ to $3$):

  • Sensory Perception: Ability to respond meaningfully to pressure-related discomfort ($1$: Completely limited to $4$: No impairment).

  • Moisture: Degree to which skin is exposed to moisture ($1$: Constantly moist to $4$: Rarely moist).

  • Activity: Degree of physical activity ($1$: Bedfast to $4$: Walks frequently).

  • Mobility: Ability to change and control body position ($1$: Completely immobile to $4$: No limitations).

  • Nutrition: Usual food intake pattern ($1$: Very poor to $4$: Excellent).

  • Friction and Shear: ($1$: Problem, $2$: Potential Problem, $3$: No Apparent Problem).

Dermatitis Overview and Etiology

• Contact Dermatitis (Eczema): Inflammation of the skin characterized by damage to the dermis and epidermis.

• Manifestations:

  • Red, itchy rash.

  • Vesicles or wheals may form, often in the shape of the irritating object.

• Etiology:

  • Allergic Contact Dermatitis: Cell-mediated or delayed hypersensitivity to allergens.

  • Irritant Contact Dermatitis: Inflammation of the skin resulting from contact with irritants.

• Risk Factors:

  • Allergies or family history of eczema.

  • Regular exposure to moist environments or burns.

  • Exposure to plants, chemicals, or metals.

• Lifespan Considerations:

  • Older adults are at increased risk due to impaired skin barrier function and slower healing.

  • They are more likely to develop allergic contact dermatitis but less likely to develop irritant contact dermatitis.

Management and Therapy for Dermatitis

• Diagnostic Tests:

  • Patch testing.

  • Skin prick testing.

  • Skin injection testing (intradermal testing).

• Pharmacologic Therapy:

  • Calamine lotion.

  • Cool compresses with aluminum acetate.

  • Wet dressings or colloidal oatmeal soaks.

  • Antihistamines.

  • Topical or oral corticosteroids.

  • Antibiotics (if secondary infection is present).

• Nonpharmacologic/Collaborative Care:

  • Identify and avoid causative agents.

  • Contact OSHA if exposure occurs at work.

  • Referral to an allergist.

  • Patient teaching on medications and OTC strategies.

Questions & Discussion

• The transcript lists categories for assessing wounds and pressure ulcers, including the Braden Scale. The use of culturally competent care is emphasized across the lifespan for all alterations in tissue integrity.