Alterations in Tissue

Anatomy

functions: against infection, UV, chem, injury, temp regulation, sensation, insensible fluid loss

produce vit d / excrete water, ammonia, urea

stratum

  1. corneum

  2. lucidum

  3. granulosum

  4. spinosum

  5. basale

epidermal contains normal flora

→ Staphyloccoccus

  • epidermitis

  • aureas

  • cutibacterum acnes

dermis → sweat glans, hair/follicles, muscle, sensory, blood/ lymph

hypodermis → fat, connective tissue, follicles, sensory, vessels

5ht decade → thin

stages of healing

  1. hemostasis/ inflammation

    1. clotting cascade, vasoconstriction, fibrin mesh

    2. vasodilation → hyperemia + edema

    3. chemotactic + growth factors → healing

    4. neutrophils → cytokines

  2. proliferation: 3-10days → weeks

    1. granulation

    2. repair of vascular

    3. →epithelialization + fibroblasts

  3. tissue remodeling: 21 days → 1y

    1. synthesis of new cells to degradation of tissue

    2. collagen

    3. wound edges are closer

    4. apoptosis of fibroblast

    5. no more angiogenesis → normal blood flow

risk factors for skin injury

inc age (<65y), physical limitations, poor nutrition, incontinence, poor circulation/ O2, decreased sensation, altered cognitions (aggresive) , polypharmacy(steroids), ADL dependent

inc physiological stress → surgery, trauma, illness, exarbation of chronic, emotional stress

healthcare system

skin irritations, pressure, friction, shearing of skin

Moisture:

  • inc susceptibility of shearing and friction → skin flora can enter

  • incontinence- associated dermatitis

  • skin folds are susceptible

    • intertrigo → inflammation of skin folds → maceration → infection w/ candida

  • Moisture-associated skin damage

Friction: superficial

  • mechanical force of dragging skin across surface

Shearing: deeper

  • interior body move in opposite directions = deep tissue injury

  • when body is pulled down or up

those with impacted mobilty →

skin tears: wounds due to mechanical forces

→ partial flop or total flop

conditions for wound healing

perfusion is necessary → if not = chronic wounds, non healing

proteins, COH, fats, Vit, growth factors

Proteins:

  • fuel for tissue repair

  • 10% of lean mass loss= low immunity

  • lost in wound exudate

  • amino acids:

    • arginine: inflammatory process + collagen synthesis → GH + T-cells

    • glutamate: inflammatory + guard against wound infection

COH:

  • fuel

  • increase hormone and growth factor

Fats:

  • normal cell functions

  • precursor to prostaglandins → inflammation and metabolism

Vitamin:

  • A: fibroplasia, epithelialization

  • B: enzymatic

  • C: Collagen, antitoxin, angiogenesis

  • D : structural integrity + epithelial movement

  • E: negative effect in collagen

Minerals:

  • Zinc: immune

  • curcumin (turmeric) : inflammatory, proliferation, remodeling phases

conditions that impact wound healing

Vasoconstriction

  • causes → cold, alpha androgenic 1, beta antagonists, pain, fear, hypovolemia, nicotine

Medications: immunosuppress

  • corticosteroids

  • anti-inflammatory in first few days of injury

  • chemo

Conditions that affect perfusion:

  • PAD, radiation, excessive pressure

  • CVD: venous HTN

  • DM: poor infusion, neuropathy, low collagen, angiogenesis

    • impaired immunity

    • wound hypoxia w/ low angiogenesis + neovascularization

  • Tobacco, nicotine, epinephrine

    • inc CO2 + low immune

obesity:

  • oxidative stress → low perfusion + epithelization + infection

stress: inc cortisol, glucocorticoids, catecholamines → impair immune

wound conditions:

  • excessive exudate, hemorrhage, biofil, infection, slough, eschar

impact in overall health

scarring:

excessive wound healing → continuous wound inflammation

hypertrophic: excess collagen → organized and smooth → aligned w/ wound → can shrink

keloid scarring: expand beyond borders

  • → associated w/ infection, tension, foreign body, trauma

  • hyperactive fibroblasts

chronic wounds: open for more than a month and do not go to normal wound healing

→ by metabolic disorders (DM/ obesity), vascular deficits, pressure in skin

diabetic foot ulcers → impacts blood flow → slow healing more infection → necrotic, amputation, sepsis

s/s: pain, diff sleeping, low function (low ADL)

→ tx = pain control (prior to any dressing changes)

  • also check psychological s/s since may impact wound healing

s/s

pain, warmth, red, bleeding, oozing

acute alterations from acute wounds

  • skin incisions

  • tears

  • abrasions

  • Moisture-associated skin damage

chronic wounds

arterial ulcer:

  • deep wound w/ punched out appearance

  • smooth, well- demarcated borders

  • may contain eschar

  • poor perfusion → pale, hairless, cool

venous:

  • shallow wound in medial area of LE + edema

  • no eschar

DM ulcer:

  • plantar of foot

  • callous

  • superficial → deep

wound classification: size, location, depth, and drainage

systematic cause: DM, malnutrition, connective tissue disease (RA)

Regional: neuropathy, arterial/ venous insufficiency, lympj

local: continued pressure, infection, and autoimmune

labs:

ABI

  • lower than 0.8 = PAD

Doppler

Acute infection s/s not present in chronic

→ biopsy = >100K = infection

→ use Levine tech

dx:

digital planimetry → epithelialization, necrotic tissue

ultrasonography, CT, MRI, SPECT, terahertz spectroscopy → wound tissue + bony structure

Lab:

CBC (anemia, WBC, platelet)

BMP, serum protein, pre/albumin, transferrin

bacterial protease activity (BPA) = detect pathogenic

excessive inflammatory protease activity (EPA) = identify unlikely healing wounds

→ further wound debridement is warranted

infection → CRP, procalcitonin, presepsin, microbial DNA

STONEES:

  • Size becoming larger

  • Temperature increasing

  • Os (bone exposed)

  • New breakdown

  • Erythema

  • Exudate

  • Smell

nursing role

Ensure proper equipment

pain meds before dressing change

affordability

assess tissue + cultural preferences

PPE + debriment equipment

wound, ostomy, continence nurses (WOCN)

education::

assess knowledge of condition, cultural, SDOH,

caregiver preference + barriers to learning

EBP, resources

implement and evaluate plan = teach back

assessment:

  • Clinical Judgment Measurement Model

  • look for wound not progressing

  • depth, width, length, describe bed and edges

  • undermining, tunneling

  • COCA

    • color, odor, consistency, amount

  • health hx + reasons (systematic, regional, local)

  • VS, incontinence

analyze:

  • PAD, DM, CV, edema, immobility

hypothesis

tx infections is priority → nutritional deficiency, (control BG, blood flow, Medications)

check protein lavels, pain management,,

take implementations:

abx, position change, control moisture, dietary education

types of dressing

  • if wound wet → remove wet

  • if dry → moisturize

tx:

diet:

  • protein, calorie count, accurate I&O

Rx:

  • analgesics, abx, wound dressing

  • common infections: staphylococcus aureus, coagulation-negative staphylococci, enterococci, Escherichia coli, and pseudomonas.

surgical management:

  • surgical debriment

  • large wounds w/ surgical closure or placement of skin graft

negative pressure wound therapy tx:

  • dressing, sealing w/ occlusive dressing and vacuum w/ -50 → -125mm Hg

electric stimulation: electrodes near wound → 150- 250 volts

hyperbaric O2: pressure chamber w/ ATM and 100% O2

→ improves circulation, O2, and lower edema

light adn phototherapy (PDT) : light doses → reduce bacteria, inc perfusion, inc ATP prduction

→ also works w. inflammatory conditions and cancerous lesions

lab/dx: Pressure injuries

Pressure, friction, shearing = bidirectional = bony prominence + hard surface place pressure on skin → blood flow is compromised

sacrum, hip, buttock, heel, back of head, shoulder, elbow

factors:

  • fragile skin

  • low blood flow, muscle

  • spinal cord injury

  • nutrient

  • moisture from incontinence

Braden Scale:

immobility and older age (low healing due to low perfusion/ protein/ tissue density)

stages:

  1. nonblanchable red

  2. partial thickness loss + ~ blisters, wound bed moist + pink

  3. adipose tissue

    1. check for undermining or tunneling

  4. full thickness loss; fascia muscle, or bone

  5. unstageable: full thickness extent to wound by slough or eschar

  6. deep tissue injury: non/intact persistent nonblanchable deep red/maroon/ purple

    1. ~ blood-filled blister

nurse role:

safety check for fall hazards

wound specialists → use EBP

education:

  • mobilization and postion change

  • proper hygiene in skin folds and perineal

Braden Scale, head-to-toe assessment

size, shape, location, depth, drainage, undermining, or tunnelin, color, temperature, drainage, or odor of the wound.

infection → debridement → wound perfusion

interventions:

heels, elevate then, position q2h

airbeds, turn pt 30 degrees, lateral side-lying

protect sacrum with soft silicone multi-layered

HOB less than 30 + glide sheets

moisture control: pH cleaners, barrier cream, breathable incontinence pad

healing:

  1. offload pressure from injury

  2. nutrition management, infection prevention

  3. photgraph wound

DIDN’T HEAL

  1. DM

  2. Infection

  3. Drugs

  4. Nutrition

  5. Tissue Necrosis

  6. Hypoxia

  7. Excessive wound tension

  8. Another wound

  9. Low temperature in area of wound

tx:

NSAID, acetaminophen → morphine, oxycodone

superficial → topical abx

deeper → PO or IV abx

surgical management:

  • debridement: necrotic tissue, biofilm, infected material

  • cleaned after debridement

Common skin inflammation / infection

inflammation → WBC + inflammatory mediators = bradykinin + histamine

vasodilation causing red + warmth

all wounds have flora → infection when contaminated by skin normal flora or other

if multiplying but does not overwhelm immune system = colonization

local infection = colonization → challenge immune

→ surrounding tissues → systematic

inflammation:

  • Omega 3/6 protective against inflammatory infections

  • negative effect → smoking, alcohol, poor sleep, obesity

infections:

  • impacted by immune system, # of microbes, species, and combination, and location

  • Staphy. aureus + MRSA

  • Streptococcus, Group A = necrotizing fasciitis

risk factors:

  • gluten, low fiber, omega

  • smoke, drink, obesity

  • atopic dermatitis in children → if adults = its eyes

  • older adults →

    • pruritis, eczema, seborrheic dermatitis, and fungal

  • immunocompromised, steroids, malnutrition

Comorbidities:

  • gluten, DM, CV, infection, inflammatory skin, immune, SUD, connective tissue disorders

Inflammation disorders:

  • acne: when oil block hair follicle

  • allergic reactions: bright red macules / papules ~ blisters

    • SJS + toxic epidermal necrolysis → skin will slough off

  • atopic dermatitis: eczma

    • ~genetic, immune, or environment

    • inflammation, redness, irritation

    • rash bubble up → fluid

    • scratching → bleed

  • contact dermatitis:

    • itchy, red, inflamed d,ue to contact

  • Herpes: cold sore/ shingle

    • painful sores → tingling, itching, burning

    • HSV 1/2

  • Infections: Athlete’s foot, cellulitis, warts

  • Psoriasis / Rosacea← overactive immune

    • dry, thick raised

    • scale/ plaque

    • scalp, elbow, knees

  • Urticaria (Hives) ← allergic response, stress, cold, unknown

    • patches of red bums

Bacteria infections:

  • cellulitis: redness, swell, pain, warmth ~ in LE

  • impetigo: red itchy sores → fluid = yellow crusty ~ in nose/mouth

  • Skin Staphy → red pimples, boils, painful, swollen, leak fluid

Fungi:

  • Athlete’s foot: dry skin, itching, burning, peeling, swelling, blistering

  • Yeast: mouth, throat, skin folds, vagina

    • cracks on corner of lips, white patch in tongue, itching in skin folds, vaginal itching, sore, drainage

Parasite:

  • Lice → itching, tiny bites

  • Scabies: itching, pimple like rash

Virus:

  • shingles: painful blistering rash → scab ~ 7-10 days

  • Wart appearance: raised bumps or flat

  • ~ Herpes Simplex

Infection Continuum:

  1. contamination

  2. colonization

—- biofilm/ abx needed —-

  1. local infection: topical

  2. spreading infection: IV/ PO/ Topical

    1. swelling of lymph nodes → malaise, anorexia

  3. systematic

lab/dx:

by s/s

patch tests, blood, or bipsy

patch for contact dermatitis → 2-4 days → specific cause

CRP, presepsin, procalcitonin

Microbial DNA

role of nurse:

  • check if is contageous → standar abd PPE, and Contact precaustions (scabies, lice, impetigo)

  • education about contact in schools, daycare, communal living,

assess:

hx inflammation, experience with a similar skin condition; medications taken; or exposure to any chemical or irritant.

infections

check if anaphylaxis:

  • hives, GI upset, dizzy, tight throat, low BP, wheeze, high HR< impending doom, CV arrest

  • allergens:

    • nuts, fish, shell, milk, egg

    • latex

    • penicillin, ASA, NSAID, anesthesia

    • insect: bee, wasps, hornets, yellow jackets, fire ants

tx:

topical steroids for inflammatory

cool compress, not scratching, emollients/ lotion

anaphylaxis:

  • epinephrine, steroids, antihistamines

  • SAFE: Seek tx (911), Allergen idntify, Follow up wl specialist, Carry epinephrine

abx + s/s of infection

prioritize:

acute infection, anaphylaxis → severe rash, fever, mucous membreanes, skin breakdown

Rx:

inflammatory:

Steroids: hydrocortisone, prednisone, topical

antihistamines: diphenhydramine, cetirizine, loratadine, fexofenadine

  • reduces itching

Calcineurin inhibitor: pimecrolimus

pain: acetomenaphen + NSAID

Abx:

  • abx topical: bacitracin, neomycin, centamicin

  • abx oral: vancomycin, linezolid, doxycycline, clindamycin

  • abx IV: dalbavancin, oritavacin, tedizolid, delafloxacin

  • antifungal: fluconazole, ketoconizole

  • antiviral: acyclovir

  • Lece/ scabies: Rib/ Nix, Permethrin

Burns:

release cytokines → local and systemic reactions + histamine, prostaglandins → vasodilation

→ improves blood flow + O2

→ vascular permeability → exudate leak → edema

3 dimensional zones:

  1. coagulation zone: protein coag + low blood flow = tissue loss

  2. potential for skin loss but can be reversed w/ burn resuscitation

  3. outermost → hyperemia from histamis → less damage

causes: flames, scald, electrical, chemical

increase metabolic + fluid demands (4days - 3yrs) → can loss lean mass → become malnurish

low fluid → organ failure + CV + AKI

K released, myoglobin → rhabdomyolysis + AKI

cause psychological stress

s/s:

  1. epidermis → sunburn

  2. epidermis + dermis

  3. ^^ → skin grafting

  4. ^^ + fat layer

  5. muscle layers

  6. bone

suoerficial → epidermis

superficial partial thickness → pink + blistering + wet

deep partial thickness: deep in dermis and white/ yellow, dry, nonblanchable

full thickness: damage to epi/ dermis, subq → white/ brown and leathery, nonblanchable

chemical acid: coag

alkali: deep penetration into skin → necrosis

electrical: small entry and exit wound but significant damage under skin

radiation: itching, red, edema → severe burn

thermal: depends

lab:

CBC: bleeding, anemia, WBC daily

BMP, albumin (fluid/ protein), BUN, Cr, GFR, ABG + carboxyhemoglobin

Coagulation: PT, INR, PTTM Thrombo, time, Xa, V, fibronogen

LFT

ionized calcium, albumin, Cr kinase

CXR, CT, PFT, bronchoscopy when resp is suspected

nutrition: Protein, carbohydrate, and fat needs should be met, glutamate, vitamin C, zinc, and selenium.

limited mobility: ROM exercises

  • sedation, edema, bulky, edema

perfusion ~ shock

aseptic and private room

if electrical → remove from scene

decontamination procedures

nursing:

assess:

body substance isolation (BSI): gloves, gowns, eye protection, and respiratory protection

hx of burn: type, location, length of exposure, other trauma

primary: AB (in chest, neck) CD(assess neuro) E (remove clothing, jew, lenses, assess temp to avoid making pt low T)

second:

  • hx of events/ health

  • Head-to-toe

  • depth, size, severity

check for inhalation injury, compartment syndorm, hypothermia

Rx may require ventilation, check fluid volume

burn center referral criteria:

  • >10%

  • face, hands, feet, genitalia perineum, or major joints

  • 3rd

  • electrical, chemical

  • inhalation injury

  • preexisting conditions that could complicate + other traumatic injuries

severity of burn is reassess 48hr to 72hrs since may not reveal true extent

total body surface area:

or Lund and Browder chart

for transfer:

→ safety, stabilize VS, ABC, fluid resuscitation, pain, large bore PIV

minor burn → cool burn w/ cool water for 3-5 minutes (no ice)

→ chem need more time

4C

  • Cool w/ tap water/ saline

  • clean w/ mild soap

  • cover w/ antimicrobial ointment + absorbent dress

  • comfort w/ OTC

older than 14y 500ml of LR/ hr

fluid formula: 2-4mL x kg xTBSA

urinary catheter when fluid resuscitation (0.5 mL/ kg/ hr) , NG tube, check edema/ compartment syndrome, HOB elevated at all times

schedule dressing changes, check for ROM

check for potential infection

tx:

diet:

daily weight/ lab: serum protein, albumin, pre-albumin, and glucose

PO/ enteral/ or IV

Rx:

opioid: morphine, fentanyl, hydrocodone, oxycodone

BZ:

topical abx: bacitracin, silvadene

silver sulfadiazine can be used but not in eye or pregnat

silver nitrate: abx but → tissue blackening and low Na

nanosilver, slowly release silver → less changes

Mafenide acetate → penetrate eschar (ADR metabolic acidosis)

debridement: necrotic tissue removed 48hrs after burn → antimicrobial dress, autograft, allograft, skin substitute

skin graft nonadherence → poor wound be preparation, shearing/ trauma, or infection

antimicrobial dress: Bacitracin, xeroform, and Silvadene (1-2 changes/day)

biologic dressing: apiary honey

autograft: unburned skin to burn

→ if large, no so cultured epithelial → grow

allograft: from donor to temporarily cover wound

skin substitutes → adhere to wound until epithelization occurs and allows exudate to leave

xenograft → porcine skin (animal)

escharotomy: remove eschar

fluid requirements: main choice crystalloid, nd somtimes colloids (albumin/plasma)

ABA: (TBSA x kg )/ 8 = mL/hr ( 40-80kg)

Rule of 10: al least 40kg, for every 10kg, increase over 80kg + 100mL/hr

  • TBSA x 10

  • TBSA (if client weighs less than 80 kg) x 10 (round to nearest 10) and multiply by 10 for the amount of fluid

Parkland: 2-4mL x kg xTBSA

  • 1st half 8hr, next 16hrs

Goals:

  • 0.5 mL/kg/hr;

  • base deficit less than 2 to normalize pH;

  • systolic blood pressure greater than 90;

  • no AMS

those w/ rhabdomyolysis or AKI = 1mL/kg/ hr

check HR + lactate

CO, SV, Systematic vascular resistance

Urine output, BP, HR