Tissue Integrity - Summary / Podcast

• The human body has a unique ability to regenerate and maintain the integrity of the skin and its underlying tissues. The skin’s integrity is influenced greatly by age and other conditions, including immobility and cancer.

• The main functions of the skin are to provide a barrier against injury, infection, ultraviolet radiation, and fluctuations in temperature changes.

• Skin frailty refers to at-risk, vulnerable skin. Many factors, such as age, decreased mobility, and malnutrition, may exacerbate the vulnerability of the skin. An important aspect of nursing care is maintaining clients’ skin integrity.

• Wound care includes irrigation, various types of debridement (surgical, enzymatic, and biologic), and dressing changes.

• Wound dressings are classified as either dry or wet. Various types of dressings are available for use, depending on the wound base, healing rate, and amount of exudate.

• Wound drains are used when there is a large amount of drainage present that hinders wound healing. Drains can be open or closed, with their usage depending on the type of surgery and the surgeon’s preference.

• The most often identified risk factors for pressure injury development are immobility, malnutrition, impaired perfusion, and sensory impairment.

• Tight hair braids next to the scalp can increase the risk of pressure injury development.

• The Braden Scale rates a client’s risk for alterations in tissue integrity using six categories: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

• Pressure injuries are classified into stages according to the amount of skin and tissue damage observed.

• Nurses, through regular skin assessments, observations of environmental factors, and diligent implementation of prevention measures, can decrease clients’ risk of tissue breakdown and delay the progression of existing wounds.

• Wounds are classified as acute or chronic based on their origin and healing progression.

• Holistic skin care addresses not just tissue injury prevention, but also a comprehensive plan covering clients’ hygiene, nutrition, hydration, and circulation needs.

• Prevention of pressure injuries focuses on two main components: identification of clients at risk, and implementation of interventions that are designated to reduce their risk.

• Surgical site infections may be superficial and localized, or they may extend deep into tissues.

• Major complications of wounds include infections, dehiscence, evisceration, and bleeding/hemorrhage.

Overview of Tissue Integrity

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Transcript

Speaker: Tissue integrity is a vital component to the care we give our clients. The skin is the largest organ system of the body and is affected by age, illness, immobility, and nutrition. I want to spend some time talking with you today about different touch points related to tissue integrity-- topics like identifying risk, assessment findings, and wound care.

As you begin your journey in the nursing world, I look back to my own journey and one of the clients I had the honor of caring for with skin integrity issues. This was a complicated case, an elderly client who was diagnosed with abdominal cancer and had a serious open wound that measured 16 centimeters long and 10.1 centimeters wide. It was a huge wound and required packing several times a day. The drainage was copious and foul smelling.

The client and his family were wrought by the devastating diagnosis of cancer. And that wound dramatically affected the client's quality of life. Caring for the client encompass body, mind, and emotional components that would address the trauma of the situation, as well as the need for physical assessment and effective treatment that would lead to recovery.

As we dive into tissue integrity, we look at specific factors that contribute to tissue integrity. We need our skin to provide a barrier against injury, infection, UV rays, and fluctuations in temperature changes. The skin, as you know, has three layers-- the epidermis, the dermis, and a fatty subcutaneous layer of adipose tissue. The outermost layer is the epidermis. The second layer is the dermis, which contains capillaries, blood vessels, and lymph vessels.

Another important point to remember for the dermis is that this is where collagen and elastin fibers are found. This is a big deal because it protects our clients from alterations in tissue integrity. If you care for the elderly, remember this information because when collagen and elastin fibers decrease due to the aging process, this places the client at greater risk for developing alterations in tissue integrity.

Last but not least is the third layer, which is that subcutaneous tissue. Since the subcutaneous tissue layer is mainly composed of adipose tissue, it helps insulate the body, absorb shock, and also patch the internal organs and structures. So now let's talk about risk factors for impaired tissue integrity. What usually pops to mind for risk factors is immobility. And that was certainly the case in the elderly client that I was caring for.

The weakness of his condition and the massive size of his wound made mobility a challenge. The age of this client was also a risk factor as we remember that those early in life and later in life have a risk for impaired tissue integrity. During infancy, this skin is immature which increases the risk for maceration and dermatitis. And for those later in life, they are at greater risk for tissue trauma, skin tears, and infection. It is important to consider these risk factors as we step into the topic of assessment where tissue integrity is concerned.

Let's begin by discussing the major elements of a skin assessment. This includes gathering the client's medical history, their risk factors, and assessing the skin for any alteration. Careful and frequent assessment of the skin and soft tissue is important.

Assessing environmental factors and ensuring preventative measures are understood and in place will decrease the risk of breakdown and decrease progression of current wounds and skin situations. The findings of our assessment lead us to types of wounds that we may encounter. Wounds can be classified as acute or chronic based on their origin and their stage of healing.

Wounds are either intentional or unintentional. An example of an intentional wound is a surgical wound. An unintentional wound is the result of a traumatic injury such as a gunshot. The wound of my elderly client was an intentional wound resulting from a surgical incision.

Let's dive deeper into a surgical wound. These wounds are classified as clean, clean-contaminated, contaminated, or dirty. Clean and clean-contaminated wounds have a minimal bacterial load, while the contaminated and dirty wounds will have a higher bacterial load. Higher bacterial loads are not good because they can interfere with healing.

My client had a wound with a high bacterial load, and the drainage so massive that the wound could not be closed. And this resulted in a longer healing time and more extensive treatment. We expect for a closed surgical wound to be intact with well approximated edges. That wound is going to change in color as it heals.

For example, at first, the wound may look red. But it will appear pale pink after about 15 days. Most wounds will have exudate, which is a normal part of the inflammatory phase of healing. However, we should expect for the exudate to decrease and subside after about five post-op dates in normal circumstances.

Another type of wound that we want to discuss is moisture-associated skin damage wounds. This is caused when the skin is exposed to feces, urine, and wound exudate. This can cause pain for the client, itching, and can even predispose the client to pressure injury formation. It is important to assess for this type of wound in the client that has mobility issues.

Lastly, we will discuss chronic wounds. These types of wounds can evolve from venous insufficiency, peripheral artery disease, and diabetes. People that are at risk for these types of chronic wounds are smokers, our clients that are undernourished, and, again, those who are immobilized. When a nurse assesses a wound, it is important to note wound exudate. We know that wound exudate can be serous, serosanguinous, sanginous, or purulent.

Serous exudate is clear, thin, and watery. Serosanguinous exudate is thin, pink, watery in its presentation as well. Sanguinous is that fresh, bloody exudate that appears when skin is breached, whether from surgery, injury, or other [audio out]. And sanguinous drainage is bright red and somewhat thicker in its consistency.

Lastly, we want to talk about purulent drainage, which is distinctively thick, yellowish, grayish, or greenish in color and consisting largely of inflammatory cells and of dead or dying microorganisms. We definitely do not want to see purulent drainage because this means that infection is present in the wound. This is the type of exudate that my elderly client exhibited. Because it was so copious, dressing changes were necessary every two hours.

During wound assessment, the wound should also be measured. The nurse can either trace the wound circumference and calculate the wound surface area using a see-through film, or can measure the length and width with a ruler. A huge responsibility of the nurse is to decrease the risk of pressure injury by completing a thorough risk assessment on the client and not just maintaining a focus on the current wound being treated. Remember that immobility causes our clients to be at greater risk for pressure injury.

One reliable tool that is used in hospitalized clients is the Braden Scale. The Braden Scale is a scale made up of six subscales which measure elements of risk that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. These subscales are sensory perception, moisture, activity, mobility, friction, and shear.

The assessment conducted by the nurse will help to determine the type of wound care necessary. For serious wounds, surgical debridement may be necessary to clean the wound and remove the dead areas that can prevent healing. As a nurse, you will likely change a lot of wound dressings with wet to dry gauze dressing changes that are widely utilized to create and maintain moist environment. These are able to provide the optimal conditions to be more beneficial for wound healing.

Now let's switch gears and discuss complications of wound healing. The first complication is infection. An infection where a wound is present will present with redness around the wound, skin that is warm to touch, exudate, as we have talked about, and foul odor. If the infection persists, then the client is at risk for the infection becoming systemic. The symptoms for this include fever, chills, nausea, vomiting, increased white blood cells, and possibly changes in mental status.

This was a concern for my elderly client that presented with symptoms of infection and needed to be treated with systemic antibiotics. Other issues the nurse may encounter may be dehiscence and evisceration. When a wound is healing, the edges should meet neatly. And the edges are held closely together by sutures or staples.

With dehiscence, the edges are no longer approximate, meaning that they do not meet. Evisceration is rare but severe surgical complication where that surgical incision is no longer approximated, and the abdominal organs then protrude or come out of the incision. Remember that evisceration is an emergency and should quickly be treated as such.

So how does the nurse promote holistic wound healing? First, we need to identify clients at risk. The nurse should recognize that the client who is malnourished, immobile, incontinent, or has decreased sensory perception, those are the clients that will be at increased risk for wounds or issues with wounds.

The nurse will further work to assess the environment to prevent further injury and provide a plan that considers the importance of hygiene, nutrition, hydration, and circulation. Developing a plan of care to minimize risk is going to be very important. For example, upon completion of the Braden Scale, the nurse identifies that the client is at risk for pressure ulcers, then that nurse should ensure that the client is kept clean and dry and that their position is frequently changed.

So as you can see, prevention is key. And as you begin your nursing career, I hope that you will consider each of these concepts to keep your client's skin integrity intact and free of complications. My elderly client was so appreciative of the extra measure of care where skin integrity was concerned that it made a beneficial difference in his ultimate recovery.