Tissue Integrity Study Notes

Tissue Integrity

Concept Overview

  • Concept: Tissue Integrity

  • Relevant Chapters: Iggy Chapter 22 & 23

Definition

  • Tissue Integrity: The state of structurally intact and physiologically functioning epithelial tissues, which include the integument (skin, subcutaneous tissue, and mucous membranes).

  • Impaired Tissue Integrity: Refers to damage to any layers of the integumentary system.

Categories of Impaired Tissue Integrity

  1. Trauma or Injury: Wounds

  2. Loss of Perfusion: Can lead to tissue necrosis

  3. Immunological Reaction: Symptoms can include redness, rash, hives

  4. Infections and Infestations

  5. Thermal or Radiation Injuries: Burns

  6. Lesions: Includes benign vs malignant types

Anatomy & Physiology Review

Structure of the Skin

  • Three Layers:

    1. Subcutaneous Tissue (Fat):

      • Inner most layer covering muscle and bone

    2. Dermis:

      • Middle layer with collagen and elastic fibers

      • Contains protective mast cells and macrophages as well as capillaries and lymph vessels

    3. Epidermis:

      • Outermost layer, less than 1 mm thick

      • First line of defense for the body, does not possess its own blood supply

Functions of the Skin

  • Protection

  • Homeostasis: Maintenance of a stable internal environment

  • Temperature Regulation

  • Sensory Organ

  • Vitamin Synthesis

  • Psychosocial Functions:

    • Body language

    • Social isolation

    • Hygiene considerations

Age-related Skin Differences

Infants, Children, Adolescents

  • Skin is thin and more permeable

  • Less subcutaneous fat leads to smooth and dry skin

  • Puberty: Increased sweat and sebaceous gland activity, can lead to acne

  • Implications:

    • Greater potential for fluid loss

    • Less effective temperature regulation

Older Adults

  • Characteristics:

    • Skin is thin, decreased strength, moisture & elasticity

    • Diminished supportive tissues: lean muscle mass & subcutaneous fat leading to wrinkling and loose hanging skin

    • Diminished perception of pain

    • Reduced blood flow leading to slowed wound healing and increased injury susceptibility

    • Slowed hair and nail growth

    • Rough, dry, and itchy skin due to decreased sebaceous gland activity

Assessment

Patient History

  • Key elements to assess include:

    • Nutritional Status

    • Family History and Genetic Risk: Conditions like melanoma, eczema, psoriasis

    • Current Health Problems

    • Psychosocial Assessment:

    • Body language

    • Social isolation

    • Hygiene practices

Inspection

  • Assessment for darker skin:

    • Skin Color Indicators:

    • Pallor: Check mucous membranes

    • Cyanosis: Evaluate lips, tongue, palms, soles

    • Jaundice: Examine hard palate, conjunctivae, sclera

    • Skin Bleeding: Note darker than normal presentation

    • Inflammation: Warmth, change in texture

Skin Assessment for Lesions

  • Use the ABCDE method:

    • A: Asymmetry of shape

    • B: Border irregularity

    • C: Color variation within one lesion

    • D: Diameter greater than ¼” (6mm)

    • E: Evolving or changing in any feature

  • Identify breaks in tissue integrity: Palpation for turgor, and check for macular or popular rashes

Pressue Ulcer / Dermal Ulcer

Definition

  • Pressure Ulcer: A compression of skin and underlying soft tissue due to mechanical forces such as pressure, friction, and shear.

Mechanical Forces Leading to Pressure Ulcers

  1. Pressure: Constant pressure on any part of the body can diminish blood flow, which is essential for delivering oxygen and nutrients to tissues. Without them, skin and tissues can be damaged or die over time.

  2. Friction: Occurs when skin rubs against clothing or bedding, example: pulling a patient up in bed.

  3. Shear: Occurs when two surfaces move in opposite directions. For instance, raising the head of a bed while a patient slides down can create shear force on tissues.

Contributing Factors to Pressure Ulcers

  • Prolonged bed rest

  • Immobility

  • Incontinence

  • Diabetes Mellitus

  • Inadequate nutrition or hydration

  • Altered mental status

  • Peripheral vascular disease

  • Age

  • Lack of sensory perception

Prevention of Pressure Ulcers

  • Early identification of high-risk patients

  • Implement aggressive interventions with pressure relief devices, such as cushions and air beds

  • Frequent repositioning of the patient

  • Use of protective devices like pillows and towels to reduce pressure

  • Avoid shearing by using lift sheets

  • Ensure that the head of the bed is elevated no more than 30 degrees

  • Nutrition: Increase protein for wound healing

  • Protect skin with moisture barriers and perform daily inspections

Wound Management Strategies

Non-surgical Management

  • Dressings:

    • Alginate: Absorbent, forms gel with contact

    • Antimicrobial: Products like medical-grade honey, chlorhexidine

    • Collagens: Used with secondary dressings

    • Foam: Holds fluids/exudate

    • Gauze: Maintains a moist environment

    • Hydrocolloid: Requires secondary dressing, contours to area

    • Hydrogel: Maintains moist environment

    • Superabsorbent: Prevents adherence to the wound

    • Transparent film: Impermeable to fluid, bacteria

  • Other Non-surgical Strategies:

    • Pressure relief, nutrition therapies, education, ambulation, electrical stimulation, negative pressure wound therapy (VAC), hyperbaric oxygen therapy (HBOT), topical growth factors, skin substitutes, ultrasound

Surgical Management

  • Interventions:

    • Excisions

    • Debridement

    • Skin grafts

Assessing Risk for Pressure Ulcers and Management

Risk Assessment

  • Assess patients using the Braden Scale which measures:

    • Sensory perception

    • Moisture

    • Activity

    • Mobility

    • Nutrition

    • Friction and shear

  • Scoring System:

    • 15-16: Mild Risk

    • 12-14: Moderate Risk

    • <11: Severe Risk

Types of Pressure Ulcers and Management

  1. Stage 1: Intact skin, non-blanchable redness

    • Treatment: Pressure relief and skin care

  2. Stage 2: Open sore, pink or red and moist

    • Treatment: Pressure relief, wound cleaning, and dressing

  3. Stage 3: Full-thickness skin loss with visible fat

    • Treatment: Pressure relief, debridement, specialized dressings

  4. Stage 4: Full-thickness tissue loss, exposed muscle or bone

    • Treatment: Extensive debridement and possible skin grafts

  5. Unstageable: Full-thickness loss but obscured

    • Treatment: Pressure relief and ongoing assessment

  6. Suspected Deep Tissue Injury: Damage under the surface

    • Treatment: Pressure relief and comprehensive wound care

Special Skin Conditions

Psoriasis

  • Description: An autoimmune disorder characterized by silver, patchy scales, commonly on knees, elbows, trunk, and sacrum.

  • Treatment: Includes corticosteroids, topical treatments, UV therapy, and systemic therapy in severe cases.

  • Implications: Emotional support is important due to decreased self-esteem and body image since there is no cure.

Dermatitis

  • Causes: Can stem from external/internal allergens, stress, or unknown factors

  • Types: Non-specific dermatitis, contact dermatitis, atopic dermatitis

  • Treatment: Involves the use of steroids, antihistamines, and non-fragrant products for skin care.

  • Prevention: Keeping the skin clean and avoiding known irritants.

Bacterial Infections

  • Diagnosis: Involves microscopic examination, culture & sensitivity tests, and possibly biopsy.

  • Examples:

    • Furuncle (Boil): Caused by Staph, needs I&D and antibiotics if systemic infection occurs.

    • Folliculitis: Inflammation at hair follicles needing hygiene improvements and topical treatments.

    • Cellulitis: Requires warm compress, I&D, and antibiotics.

    • MRSA: Potentially severe, requiring appropriate antibiotics and infection control measures.

Viral Infections

  • Diagnosis: Microscopic examination and culture tests along with pain management.

  • Examples:

    • Herpes Zoster (Shingles): Treated symptomatically with antiviral medications.

    • Herpes Simplex: Characterized by grouped vesicles and treated with topical and systemic antivirals.

Fungal Infections

  • Diagnosis: Similar to other infections with culture and sensitivity.

  • Examples:

    • Tinea (e.g., athlete's foot): Treat with antifungals and proper hygiene.

    • Candidiasis: Treated with antifungals, particularly in moist areas.

Parasitic Infections

  • Common types: Bed bugs, scabies, lice requiring topical treatments.

Environmental Hygiene and Prevention

  • Importance of good hygiene in preventing infections

  • Avoid sharing personal items

Skin Cancer Overview

Types of Skin Cancer

  1. Squamous Cell Carcinoma: Firm, nodular lesions with crust, rapid invasion.

  2. Basal Cell Carcinoma: Pearly papules, metastasis rare.

  3. Melanoma: Irregularly shaped, pigmented with a high mortality rate.

Preventive Measures

  • Avoid sun exposure and tanning beds

  • Use sunscreen, hats, and conduct regular self-exams for lesions.

Conclusion

  • Highlights the interrelated concepts: Mobility, Sensory Perception, Pain, Nutrition, Infection, and their relationships with Tissue Integrity and Health.