TB

Tissue Integrity Lecture Review

Tissue Integrity

Older Adults: Age-Related Changes

  • Reduced skin elasticity: Skin loses its ability to stretch and return to its original state.
  • Thinning of underlying tissues and muscles: Subcutaneous fat and muscle mass decrease.
  • Decreased collagen: The structural protein that provides skin strength and resilience diminishes.

Pressure Injuries

Damage caused by several factors, including:

  • Pressure Intensity: The amount of pressure exerted on a tissue.
  • Pressure Duration: The length of time pressure is applied.
  • Tissue Tolerance: The ability of tissue to withstand external pressure without succumbing to damage.

Risk Factors

  • Impaired Sensory Perception: Inability to feel pain or discomfort, preventing repositioning.
  • Impaired Mobility: Inability to change or control body position.
  • Alteration in Level of Consciousness: Confusion, disorientation, or coma affecting awareness of pressure.
  • Shear: The force exerted parallel to skin, resulting from gravity pushing down on the body and friction between the patient and a surface (e.g., sliding down in bed).
  • Friction: The force of two surfaces moving across one another (e.g., skin dragging across sheets).
  • Moisture: Prolonged contact with moisture (sweat, urine, feces) softens skin and increases susceptibility to damage.

Patients at Risk

Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure injury development. Specific examples include:

  • Older adults
  • Those who have experienced trauma
  • Individuals with spinal-cord injuries (SCI)
  • Those who have sustained a fractured hip
  • Patients in long-term homes or community care
  • The acutely ill
  • Patients in a hospice setting
  • Individuals with diabetes
  • Patients in critical care settings

Pressure, Shear, and Friction

  • Shear and Friction are significant mechanisms contributing to pressure injury, especially over areas like the back of the head, shoulders, base of spine, buttocks, heels, and toes from contact with the surface of the bed.

Sites of Bony Prominences

Pressure injuries commonly develop over bony prominences. These sites include:

  • Head: Skull, Ear
  • Upper Extremities: Shoulder/Scapula, Elbow, Wrist, Breast (in some positions)
  • Torso: Back, Sacrum, Coccyx, Buttock
  • Lower Extremities: Hip, Knee, Ankle, Heel, Toe

Stages of Pressure Injuries

Stage 1 Pressure Injury

  • Intact skin with a localized area of nonblanchable erythema (redness that does not turn white when pressed).
  • May appear differently in darkly pigmented skin.
  • Blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
  • Color changes do not include purple or maroon discoloration, as these may indicate deep tissue pressure injury.

Stage 2 Pressure Injury

  • Partial-thickness loss of skin with exposed dermis.
  • The wound bed is viable, pink or red, and moist.
  • May present as an intact or ruptured serum-filled blister.
  • Adipose (fat) is not visible, and deeper tissues are not visible.
  • Granulation tissue, slough, and eschar are not present.
  • Commonly results from adverse microclimate and shear in the skin over the pelvis and shear in the heel.

Stage 3 Pressure Injury

  • Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer.
  • Granulation tissue and epibole (rolled wound edges) are often present.
  • Slough and/or eschar may be visible.
  • The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop in deep wounds.
  • Undermining and tunneling may occur.
  • Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed.

Stage 4 Pressure Injury

  • Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.
  • Slough and/or eschar may be visible.
  • Epibole (rolled edges), undermining, and/or tunneling often occur.
  • Depth varies by anatomical location.

Unstageable Pressure Injury

  • If slough or eschar obscures the extent of tissue loss, it is considered an Unstageable Pressure Injury. The true depth cannot be determined.

Suspected Deep Tissue Injury (SDTI)

  • Intact or nonintact skin with a localized area of persistent nonblanchable deep red, maroon, or purple discoloration.
  • Can also present as epidermal separation revealing a dark wound bed or a blood-filled blister.

Wound Classification and Assessment

Measurement and Depth

  • Measure the longest length of the wound and the widest area of the wound.
  • To measure depth, insert a sterile applicator swab and measure against a measurement guide.

Undermining and Tracts

  • Wound undermining occurs when the tissue under the wound edges becomes eroded, forming a pocket beneath the skin at the wound's edge.
  • Document undermining using a **