Tissue Integrity, Infection, & Inflammation

Terminology

Color: #ef42ae

• Alopecia: Hair loss

• Cyanosis: Bluish color of skin

• Dehiscence: Separation of wound edges

• Evisceration: Protrusion of organs through a wound

• Diaphoresis: Sweating

• Ecchymosis: Bruise or contusion

• Erythema: Redness of skin

• Hematoma: Localized blood leakage

• Jaundice: Yellowing of skin and eyes (Liver Failure)

• Pallor: Pale skin

• Pruritus: Itching

• Purulent: Containing pus

• Slough: Dead tissue, often cream or yellow in color

• Striae: Stretch marks

• Necrotic Tissue: Non-viable tissue

• Eschar: Dry, black necrotic tissue

• Exudate: Fluid that leaks out of blood vessels

• Serous Exudate: Clear, pale yellow fluid

• Serosanguineous Exudate: Pinkish watery drainage

• Sanguineous Exudate: Blood drainage

• Undermining: Pocket under the wound surface

• Tunneling: Wound tunnels beneath the skin surface (Tracks underskin)

A&P Review: Integumentary System

• Key Structures:

  • Nail, hair shaft, medulla, cortex, cuticle, sebaceous gland, arrector pili muscle

  • Skin layers: Epidermis, dermis, subcutaneous tissue

• Functions of the Skin:

  • Protection: Barrier against infection and injury

    • Protects organs, from pathogens, cools us down, etc.

  • Temperature Regulation: Through perspiration and muscle contraction

  • Psychosocial: Role in self-esteem and communication

    • Confidence, express yourself, etc.

  • Sensation: Touch, pain, pressure, temperature

  • Vitamins: Production of Vitamin D via sunlight

    • UV rays produce vitamin D

  • Immunologic: Inflammatory responses

  • Absorption & Elimination: Excretes small amounts of substances

    • Absorbs Substances (medication, lotion, topical cream)

    • Gets rid of water and nitrogen waste in sweat

Risk Factors for Skin Alteration

• Age: Thinning of tissues, reduced elasticity

  • Older and Younger people

  • Older adults have less elasticity and is more fragile.

• Lifestyle: Occupation, sun exposure, body piercings

  • Working outside (sun exposure/skin cancer)

  • Body piercings can cause infection

  • Chemical burns

• Health State: Dehydration, malnutrition, reduced sensation

  • Less elasticity, more flaky, easier to break

  • Protein and hydration is IMPORTANT

• Illness: Impaired immune system causes

  • Can cause cuts and sores to heal slower

  • More susceptible

• Diagnostic Measures: Tests that can cause skin breakdown

  • Prep can cause skin breakdown

• Therapeutic Measures: Medical staff interventions affecting skin integrity

  • Taking dressings off to fast

  • BP cuff pumped too high can cause bruising

  • Casts can cause skin breakdown from water or other methods of scratching. If too loose or tight can cause pressure injuries

  • Bed rest

Assessment

Subjective Data

• Gather health history focusing on risk factors, past skin issues, recent changes

• Key questions:

  1. Past skin diseases

  2. Change in pigmentation or moles

  3. Excessive dryness, moisture, pruritus (itching), bruises (Echomosis)

  4. Rashes or lesions

  5. Skin (chemicals, cosmetics, hygiene items), hair, or nail (Swelling, darkening, breakage, etc.) recent changes

  6. Medications and environmental hazards (Tetracyclines, Fluoroquinolones, and NSAIDs can cause photosensitivity)

  7. Environmental or occupational hazards

  8. PCC

Objective Assessment Equipment

• Strong direct lighting, ruler, gloves, magnifier/dermatoscopy

• Dermatoscope- is a magnifying device that allows you to look at lesions and moles etc.

• Measure Length, Width, and depth in mm or cm

• Natural lighting is the best

Skin Assessment Techniques

• Inspect and Palpate: Color, temperature (use dorsal aspect), moisture, texture, thickness

  • Check for edema (pitting or non), turgor (Hand or clavicle), and vascularity

  • Incorporate into assesment

  • Assess entire body including mucous membranes, scalp, and nails

Normal and Abnormal Findings

Skin Normal Findings

• No edema, normal mobility, and turgor, typical vascularity

• Skin color consistent with genetic background

• Warm temperature, normal moisture, smooth texture

Skin Abnormal Findings

• Temp: Hypothermia or hyperthermia

• Color:Pallor, erythema, cyanosis, jaundice

• Moisture: diaphoresis, dehydrated skin, mucous membranes

• Texture: Rough, dry, flaky skin

• Thickness: Very thin, shiny skin

• Edema: Present

• Mobility & Turgor: Decreased when edema presents signs of dehydration.

• Vascularity: Multiple bruising at different signs of healing. Needle marks or tracks may be present from IV drugs.

• Primary lesion- check over time

• Secondary lesion- crusts over

Cyanosis & Jaundice

Build-up of bilirubin

Normal Findings - Hair

• Color: May vary. Graying begins early 30s due to genetics

• Texture: Fine or Thick, straight, curly or kinky, should look shiny

• Lesions: Clean

Abnormal Findings - Hair

• Dull, brittle texture; presence of nits or ringworm

Normal Findings - Nails

• Smooth, rounded edges, normal pink color, and capillary refill

Abnormal Findings - Nails

• Shape: Spoon nails, inflammation at base

• Consistency: Pits, grooves, lines, thickened, spongy nail base

• Color: Cyanosis, brown linear streaks, hemorrhages, abnormal capillary refill time

• Clubbing common 5,8, 15- KNOW.

Special Considerations for Skin Assessment

• Recognize color changes in darker skin types (e.g., pallor and cyanosis)

  • Darker skin is going to look ashen, gray, or dull

  • Cyanosis appears in conjunctiva, palms, lips, tongue will look gray/white

  • erythema looks purplish

  • Jaundice: check sclera for yellow/orange tinge on palms and soles

Labs & Diagnosis

• Labs: CBC (look at leukocytes for infection), ESR, CRP, serum protein, albumin, prealbumin.

• Tissue culture: Taken from wound or lesion to see if there is bacteria and what kind

• Biopsy: Seeing what kind of lesion it is

• Vascular study: checks blood flow especially in lower extremities

• Radiology/imaging: shows how far infection has traveled

Wound Classification and Assessment

Types of Wounds

• Intentional: Surgical (planned)

• Unintentional: Accidental (unexpected trauma)more likely for infection

• Open: Breaks skin

• Closed: No break (bruise)

• Acute: surgical or traumatic. Takes 4-6 weeks or less to heal.

• Chronic: Develops over time, takes longer than 6 weeks (diabetic ulcer)(scab keeps falling off)

Assessment Techniques

• Inspection: Look for sight/smell, appearance, drainage, and odor

• Palpation for tenderness and warmth; measure dimensions, pain, and change in appearance (drainage?)

• Appearance: location describe in relation to the nearest anatomical landmark

• Measurements in mm or cm

  • Length, width, and depth

• Assess for approximation, color, presence of drains or tubes, the surrounding skin, odor, drainage, sutures or staples, wound healing

Phases of Wound Healing

Systematically lead to the repair of the injury.

1. Hemostasis: Immediate response

2. Inflammatory Phase: 2-3 days post-injury. Chronic if stuck in phase 2 & 3

3. Proliferation: The repair phase, can last several weeks

4. Maturation: The remodeling phase continuing for months or years

Intentions

• Primary intention:

• Secondary intention:

• Tertiary intention:

Types of Inflammation

Acute inflammation: characterized by pain, heat, redness, and swelling

Occurs during the inflammatory phase of wound healing

Chronic Inflammation: wounds remain in the inflammatory phase

Cardinal Signs

• Local Response:

  • Heat/Warmth

  • Redness

  • Swelling

  • Pain

  • Loss of function

• Systemic Response:

  • Fever

  • Leukocytosis

  • Malaise

  • Full body aches and pains

  • Dry eyes

  • SOB

  • Can progress to sepsis

Factors Affecting Wound Healing

Local:

• Pressure

• Desiccation

• Maceration: Over moisturization of the cells that causes skin break down.

• Trauma

• Edema: Interferes with blood flow to the area, and compresses blood vessels so oxygen cannot get to the wound.

• Infection: The body is trying to focus on infection instead of healing.

• Excessive bleeding

• Necrosis: Eschar (black) & slough (yellow/green stringy) delays wound healing until removed.

• Biofilm: A shiny film on top of the wound from sugars in bacteria the tissues cannot form to fix wounds.

Systemic:

• Age: older people are more prone

• Circulation & Oxygenation

• Nutritional Status: need hydrated patient

• Wound Etiology or Cause

• Medications or other therapies: Steriod use can decrease the inflammatory process, which delays wound healing.

• Immunosuppression

• Adherence to treatment plan

Types of Wounds

• Incision

  • Made by cutting

  • Surrounding tissue undamaged

  • Least likely to be infected

  • Intentional, Open, Acute

• Contusion

  • Ecchymosis/bruise

  • Done with a blunt instrument

  • Injury to underlying soft tissue due to capillaries bursting

  • Many bruises in different stages of healing can indicate fall risk, abuse, etc.

• Abrasion

  • Caused by friction, rubbing, scraping of the epidermal layers of the skin

  • High infection rate because of contamination

  • Unintentional

• Laceration

  • Tearing of the tissues with a blunt or sharp instrument

  • Frequently contaminated with dirt or other materials

• Puncture

  • Blunt or sharp instrument

  • Intentional or unintentional

  • Think stepping on a nail

• Penetrating

  • Foreign objects has penetrated through the skin into the tissues

  • Can damage organs

  • Ex. Stabbing

• Avulsion

  • Tearing of a structure from the anatomical structure

  • Can damage tissues, blood vessels or organs

  • Ex. Degloving

• Chemical

  • Toxic agents that cause cellular necorosis

  • Ex. Acid burn

• Thermal

  • From high or low temperatures

  • Ex. Burn

• Irradiation

  • From UV exposure or radiation

  • Ex. Radiation for cancer

• Venous Ulcers

  • Poor venous return

  • Result of issues with veins returning blood back to your heart

  • Usually from obstruction

  • Above ankle bones

  • Ex. Blood clot

  • Shallow, uneven edges, and oddly shaped

• Arterial Ulcers

  • Deep punched-out wound

  • Well defined borders

  • From lack of blood flow down to extremities- Arteries cannot bring oxygen-rich blood to the tissues(atherosclerosis)

  • Has necrotic tissue

  • Deeper than VU

  • Effect shin or toes

• Diabetic Ulcers

  • Ex. Diabetic neuropathy

  • Occur over soles of feet or pressure points

  • Caused by increased glucose level that damages the nerves, which causes no feeling.

Performing a Skin Integrity Risk Assessment

Braden Scale

• Assess mental status, continence, mobility, activity, and nutrition

• Used to predict pressure ulcer risk

• Numerical score assigned to each assessment area

• Scores:

  • 19-23: No risk

  • 15-18: mild risk

  • 13-14: moderate risk

  • 10-12: high risk

  • 9 or below: Very high risk

Sensory Perception

Ability to respond meaningfully to pressure-related discomfort

Completely Limited

Very Limited

Slightly Limited

No Impairement

Moisture

Degree to which skin is exposed

Constantly Moist

Very Moist

Occasionally Moist

Rarely Moist

Activity

Degree of Physical Activity

Bedfast

Chairfast

Walks Occasionally

Walks Frequently

Mobility

Ability to change and control body position

Completely Immobile

Very Limited

Slightly Limited

No Limitation

Pressure Injuries

• Localized damage often over bony prominence due to pressure

• Can be acute or chronic

• External pressure applied results in occluded blood capillaries and poor circulation to tissues

• Looking for drainage, depth,

Stage 1

Intact & localized

Reddened area, non-blanched

Light-pigmented skin, darker skin appears darker or purple/blueish but not blanched

Stage 2

Partial Thickness skin erosion

Sometimes fluid-filled blister

Stage 3

Full thickness ulcer extending into Subq tissue, resembles a crater

Stage 4

Full thickness ulcer extends into support tissue

Exposed muscle, tendon, or bone

Unstageable

Full-thickness skin and tissue loss

Has slough or eschar

Deep Tissue Injury

Persistent non-blanchable deep red, maroon, or purple discoloration

Results from intense or prolonged pressure and shear forces

Skin Lesions

Primary

Developed on previously unalterated skin

Secondary

Lesion changes over time or is because of scratching or infection

Shapes & Configuration

• Annular:

• Confluent:

• Discrete:

• Grouped:

• Gyrate:

• Iris or Target:

• Linear:

• Zosteriform:

Infection Process

Inflammatory Responses and Risk Factors for Infection

• Intergrity of skin and mucous membranes

• pH levels of GI or GU tracts

• number of WBCs

• Invasive devices

• Age, Race, Sex

Subjective Data

• Past and Present infections

• Dates and types of treatments

• Fevers

• History

• Response to treatment

Local Infection Assessment Findings

• Tenderness

• Redness

• Presence of foul smelling drainage

• Swelling

• Warmth

• Loss of function

Surgical Wound Infections

May not be evident until post-op day 5

Local signs may be absent if infection is deep

Preventative Measures

• Use of PPE

• Handwashing

• Cleaning- Your equiptment

• Linen care

• Follow Guidelines

Primary

Skin care, diet, activity, hand hygiene, reduce risk for injury and infection

Secondary

Skin care, Treatment, Wound care

Tertiary