Tissue Integrity
Page 1: Skin Integrity & Wound Care
Page 2: Objectives
Discuss the risk factors that contribute to impairment in skin integrity.
Explain the normal process of wound healing.
Describe the components of performing a wound assessment and interpret the findings.
Contrast differences in wound healing by primary and secondary intention.
Outline complications of wound healing and their management.
Identify factors that impede or promote wound healing.
Compare nursing care for acute vs. chronic wounds.
Discuss different types of wound care management and relevant nursing considerations.
Describe pressure injury staging system.
Identify risk factors for the development of pressure injuries.
Explain methods for assessing risk for skin integrity impairment.
Identify interventions to minimize skin trauma.
Discuss appropriate interventions for clients with pressure injuries.
Describe assessment techniques for clients with skin alterations.
Page 3: Assessment of Tissue Integrity
Page 4: Definition of Tissue Integrity
Tissue integrity refers to the human body's ability to regenerate and maintain normal physiological functioning.
Protective barriers include skin, cornea, subcutaneous tissue, and mucous membranes.
Page 5: Skin and Subcutaneous Tissue
Three Main Layers of the Skin
Epidermis: The outermost layer of the skin.
Dermis: The layer beneath the epidermis, containing connective tissue and blood vessels.
Subcutaneous Layer: The deepest layer, composed of fatty tissue.
Page 6: Skin Assessment Guidelines
Assessment Protocols
Acute Care
Assess at admission, every shift, and upon change in condition.
Long-term Care
Assess at admission and weekly based on facility policy.
Home Health Care
Conduct assessments upon admission and every visit.
Early detection and treatment of skin issues are crucial.
Page 7: Historical Context of Skin Assessment
Focus Areas
Assess risk factors contributing to skin integrity impairment.
Conduct a physical assessment of the skin.
Page 8: Factors Contributing to Tissue Integrity
Risk Factors for Impaired Integrity
Very thin or obese individuals
Excessive perspiration
Skin diseases
Dehydration
Developmental stage and overall health
Skin Concerns
Maceration: prolonged moisture exposure
Dermatitis
Skin tears and frailty
Pressure injuries
Cellulitis
Page 9: Understanding Wounds
Definition of Wound
A wound is a break or disruption in the skin and tissue's normal integrity.
Wound Classification
Acute vs. Chronic: Understanding the differences in their healing processes.
Page 10: Types of Wounds
Examples of Acute Wounds
Surgical wounds
Moisture-associated skin damage (MASD)
Page 11: Assessment of Wounds
Key Aspects of Wound Assessment
History: Gather recent skin changes, skin care routines, activity level, nutritional and elimination patterns, cognitive state, and signs of infection.
Page 12: Detailed Wound Assessment
Important Factors to Assess
Inspection: Observe tissue type, size, and odor.
Palpation: Feel for appearance and pain.
Drainage: Evaluate the amount, color, odor, and consistency.
Note any sutures, drains, tubes, or complications present.
Staging: Only applicable for pressure injuries.
Page 13: Risk Factors for Wound Development
Common Medical Conditions
Vascular diseases
Diabetes
Malnutrition
Use of certain medications
Excess moisture, external forces, and aging process.
Page 14: Understanding Tissue Types in Wounds
Describing Wound Bed
State the percentage of each tissue type (e.g., 50% slough, 50% granulation).
Types of Tissue
Eschar: Dead tissue.
Slough: Yellow, dead tissue.
Granulation: New connective tissue and blood vessels formed during healing.
Page 15: Wound Measurement Techniques
Key Measurements
Size: Measure length and width in centimeters, drawing or describing the shape.
Depth: Assess tunneling as per protocol.
Page 16: Understanding Tunneling and Drainage Types
Tunneling and Sinus Tract
Definitions and techniques to measure both.
Drainage Types
Serous: Clear fluid.
Serosanguinous: Mixed fluid.
Sanguinous: Blood-tinged.
Purulent: Pus-filled.
Page 17: Measurement of Wounds
Measurement Guidelines
Length designated as ‘A,’ width as ‘B,’ and depth as ‘C’.
Ensure measurements are in centimeters and note any undermining.
Page 18: Classification of Wounds by Thickness
Thickness Categories
Superficial Wound: Only involves epidermis.
Partial-Thickness Wound: Involves epidermis and dermis but does not reach subcutaneous layer.
Full-Thickness Wound: Extends through dermis to underlying tissues.
Page 19: Pressure Injuries
Definition
Localized injury to skin and underlying tissues, typically over bony prominence.
Can also be called pressure sore, decubitus ulcer, or bed sore.
Page 20: Key Factors in Pressure Injury Formation
Pressure Injury Risk Factors
Pressure intensity, tissue ischemia, blanching, duration of pressure, and tissue tolerance.
Page 21: Common Sites for Pressure Injuries
Anatomical Vulnerabilities
Shoulder blades, elbows, sacrum, ischial tuberosity, heels, occiput.
Page 22: Shearing Forces
Effects of Shearing
Tissue damage due to sliding movements, examples include patients sliding down beds or transferring.
Page 23: Understanding Friction
Impact on Skin
Friction causes injuries to the epidermis, often presenting as redness and discomfort.
Page 24: Main Factors Contributing to Pressure Injuries
Pressure, shear, and friction.
Consideration of body weight pressure.
Page 25: Identifying Risks
Risk Assessment Techniques
Employ history, physical exams, and tools like the Braden Scale.
Page 26: Braden Scale Overview
Key Assessment Factors
Sensory Perception: Ability to respond to pain.
Moisture: Skin exposure to moisture.
Activity: Degree of physical activity.
Mobility: Ability to change body position.
Nutrition: Food intake patterns.
Page 27: Classification of Pressure Injuries
Stages
Stage I: Non-blanchable erythema.
Stage II: Partial-thickness skin loss.
Stage III: Full-thickness skin loss.
Stage IV: Extensive loss, possible exposure of muscle or bone.
Unstageable: Full-thickness loss obscured by slough or eschar.
Page 28: Deep Tissue Pressure Injury
Characteristics
Persistent non-blanchable discoloration, potential for rapid progression and deeper tissue damage.
Page 29: Device-Related Pressure Injuries
Causes
Resulting from pressure from medical devices like masks, catheters, and other equipment.
Page 30: Documentation of Pressure Injuries
Essential Elements to Record
Location, stage, size, tissue description, color, surrounding tissue condition, any drainage details, and pain.
Page 31: Nursing Interventions for Pressure Injury Prevention
Targeted Risk Factors
Decreased Sensory Perception
Provide pressure redistribution surfaces and protective measures.
Moisture
Use no-rinse cleaners and moisture-barrier ointments, maintain dry skin.
Friction and Shear
Educate positioning techniques, support surfaces, etc.
Page 32: Nursing Interventions for Activity & Nutrition
Reduced Mobility
Establish individualized turning schedules and use of positioning devices.
Nutrition
Ensure adequate nutrition and consult dietitians as needed.
Page 33: Nursing Care Strategies for Relieving Pressure
Frequent position changes, positioning aids, and monitoring.
Page 34: Types of Wound Care
Wound Care Methods
Dressings, debridement, and irrigation.
Page 35: Purpose of Wound Dressings
Provide comfort, control infection, absorb drainage, maintain moisture, protect the wound, and promote healing.
Page 36: Types of Dressings
Compare clean vs. sterile, dry vs. wet dressings, and semi-open vs. semi-occlusive.
Page 37: Dressing Changes
Procedure Guidelines
Explain to the patient, assess the wound, and maintain aseptic technique.
Page 38: Dressing Application Techniques
Steps Involved
Cleanse the wound, apply barriers, and place the dressing securely over the evaluated area.
Page 39: Wound Cleaning
Techniques for Cleanup
Clean from least to most contaminated areas, generally using saline for irrigation.
Page 40: Dressing Removal & Monitoring
Key Considerations
Carefully remove dressings observing for drainage, signs of infection, and changes over time.
Page 41: Wound Closures
Types of Methods
Utilizing sutures, staples, or skin adhesives to maintain tissue together.
Page 42: Negative Pressure Wound Therapy
Purpose:
To promote wound healing whilst maintaining a moist environment, and assist with granulation tissue production.
Page 43: Drain Usage
Overview
Used to decrease fluid accumulation and promote healing; can classify drains as active or passive.
Page 44: Drain Care and Management
Essential Monitoring Techniques
Regular check on drainage progress, skin care at the site, and assessment for infection.
Page 45: Phases of Wound Healing
Processes
Inflammatory Phase: Injury onset to 4-6 days.
Proliferative Phase: 4-24 days with formation of granulation tissue.
Maturation Phase: Starts at 3 weeks, potentially lasting for months or years.
Page 46: Factors Affecting Wound Healing
Nutritional Quality, Tissue Perfusion, Infection Risk, Age, and Disease Processes
Page 47: Wound Healing Management
Key Strategies
Education for patients and caregivers, ensuring necessary protection and nutritional interventions.
Page 48: Hygiene Measures for Prevention and Treatment
Importance of Hydration and Circulation
Page 49: Complications of Wound Healing
Types of Complications
Infections, hemorrhages, fistula formation.
Page 50: Infection Management in Wounds
Signs and Symptoms
Local manifestations: erythema, drainage changes, warmth, pain, swelling.
Page 51: Wound Culture Procedures
Purpose
To confirm the existence of infection, inform treatment options, and evaluate treatment effectiveness.
Page 52: Complications of Dehiscence and Evisceration
Key Definitions
Dehiscence: Partial or complete separation of tissue layers during healing.
Evisceration: Total separation with visible organs; deemed an emergency situation.
Page 53: Managing Wound Hemorrhage
Complications and Sign Monitoring
Signs include hematomas, bleeding from slipped sutures and other complications.
Page 54: Understanding Fistula Formation
Overview
Abnormal passageway development due to infection or other causes; associated risks include delayed healing and potential infections.
Page 55: Psychological Effects of Wounds
Emotional Impact
Consider pain, anxiety, fear, and how wounds affect daily living activities.
Page 56: Nursing Care for Heat Therapy
Benefits
Improves blood flow, decreases stiffness, assists in debridement, and promotes comfort.
Page 57: Devices for Heat Therapy Applications
Different methods available including hot water bags, electric heating pads, and aquathermia pads.
Page 58: Nursing Care for Cold Therapy
Effects of Cold Application
Causes vasoconstriction, reducing tissue oxygen consumption and swelling, providing localized anesthesia.
Page 59: Devices for Cold Therapy Applications
Ice bags, cold packs, and hypothermia blankets are among the common tools.
Page 60: Factors Affecting Hot and Cold Treatment Efficacy
Considerations
Duration, method, patient's age and physical condition impact effectiveness.
Page 61: Guidelines for Documenting Treatments
Documentation Practices
Include equipment used, patient assessments, and signs of infection alongside patient education documentation.
Page 62: Quick Quiz on Wound Healing Intention
Concepts to Know
Difference between primary and secondary healing, with primary being well approximated.
Page 63: Healing by Intention
Definitions
Primary Intention: Neatly approximated surgical incisions.
Secondary Intention: Wounds that do not close easily and require granulation.