Tissue Integrity Outline Spring 2023
Tissue Integrity Outline Spring 2023
Tissue Integrity Outline Spring 2023
Tissue Integrity:
➢ The state of structurally intact and physiologically functioning epithelial tissues.
1. Protection
1. The skin consist of strong and elastic protein fibers, collagen, keratin, and elastin that
protects the body from UV radiation and mechanical, thermal, and physical injury
2. The skin also protects the underlying tissues from invasion of harmful microorganisms
2. Sensation
1. Contains somatic sensory receptors that aid in sensation
2. The nerves in the skin enable the perception of touch, pain, pressure, heat, and cold
3. Thermal regulation and insulation
1. Dilation of blood vessels and secretion of sweat by the eccrine sweat gland which
functions under the control of the CNS and enables body to release excess heat
4. Excretion and secretion
1. Excrete water to the skin surface via diffusion
2. Secrets waste products such as urea, salt, sodium, water via sweating
5. Immunity
1. Langerhan cells of the epidermis can interact with T cells to help protect the body
from bacterial agents
2. Phagocytic cells in the hypodermis can engulf bacterial cells — how the skin helps to
detect infections
6. Endocrine/Vitamin D production
1. Cells in epidermis produce vitamin D3 by using the energy stored in UV radiation
7. Growth/absorption
1. Can expand into the elastin fibers meaning as the organism grows so does the skin
Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds
Internal Factors
➢ Genetics
➢ Skin color is a biologic variation (amount of melanin in skin)
➢ People with light skin tones produce less melanin than people with dark skin
tones
➢ Melanin helps protect skin from easy damage; other aspects of sensitivity to
light and any allergies a person may have
➢ Age
➢ Very young and very old skin are more fragile and susceptible to injury than
that of most adults
➢ Underlying health conditions
➢ Pts with peripheral artery disease — the skin on their legs may damage
easily
➢ Pt on steroids — can cause thinning of the skin
➢ Some meds can increase sensitivity to sunlight and predispose someone to
severe sunburns such as some antibiotics, chemotherapy drugs,
psychotherapeutic drugs
➢ Nutrition
➢ Appearance and function of skin are affected by poor diet; a well-balanced
diet is recommended
External Factors
➢ Activity
➢ Can affect integrity of the skin by pressure, friction, shearing (cutting), falls,
and surgical procedures
Pressure Injury risk factors
a.) Example: when sheets are rubbing against the skin this can cause abrasion to the skin
removing superficial layers
2.) Immobility
a.) Extreme weakness, pain, or paralysis can hinder the ability to change positions and
relieve discomfort due to pressure bc they cannot move on their own
a.) Can cause weight loss, muscle atrophy, and the loss of subcutaneous tissue
b.) Reduce the amount of padding between skin and bone — increasing the risk of
pressure ulcers development
a.) Moisture from incontinence promotes skin laceration which is tissue that is softened
by prolonged wetting or soaking and makes the epidermis more easily eroded and
susceptible to injury
b.) Digestive enzymes in feces, urea in urine, and gastric food draining contributes to skin
excoriation (area of the skin loses superficial layer)
c.) Long exposes to urine and stool can be hazardous to skin tissues
a.) Pts who are unconscious, heavily sedated, or have dementia are more at risk for
pressure ulcers due to the diminished ability to recognize or respond to pain from
prolonged pressure
a.) Pts who suffer from paralysis, stroke, or other neurologic diagnosis can cause loss of
sensation which reduces the ability to respond to trauma, severe heat and cold, and
healing that signals loss of circulation
a.) Elevated body temperature increases the metallic with the metabolic rate so the cells
need for oxygen is also increased — so when you have pressure areas where oxygen is
already insufficient and there is even less oxygen coming to that area this will inhibit the
ability to deal with severe infections
8.) Advanced age
a.) The loss of lean body mass, thinning of the epidermis layers, decrease elasticity, and
strength increase dryness, diminished pain perception, and demand venous and arterial
flow due to avian vascular walls — makes the older person more prone to impair skin
intelligence
a.) Pts who have diabetes and cardiovascular disease are risk factors for pressure injuries
bc they compromise oxygen delivered to tissues and result in poor perfusion causing risk
for poor healing and pressure sores
Assessment
WHO WHEN
Braden Scale
a.) Used so that we can have a structured, consistent approach to assessing pts for risks
b.) Made up of 6 sub scales and a total of 23 points is possible and an adult who scores below 18
points is considered at risk
c.) The sub scales are sensory perception, moisture, activity, mobility, neutron, friction or shear
d.) Risk factors are rated on a scale of 1-4 with 1 being completely limited and 4 being no
impairment
e.) The scores from the 6 categories are added and the total score indicates a pts risk for
developing a pressure injury based on these ranges
***Mild risk: 15-18. Moderate risk: 13-14. High risk: 10-12. Severe risk: less than 9***
Assessment Labs
1. WBC — looking to see if it is decreased; if low this can cause a delay in healing and
increase possibility of infection
2. RBC — can tell if a pt has a decreased hemoglobin count which indicates poor oxygen
delivery to tissues; hemoglobin is a protein in RBCs that carry oxygen throughout the body
3. Platelet — counts amount of platelets in blood; platelets are cells that help your blood clot; a
low platelet count might be a sign of a certain cancer or infection; a high platelet count can put
you at risk for harmful blood clots or strokes; coagulation studies are important bc prolonged
coagulation time can result in excessive blood loss and prolonged clotting; hyper coagulation
can lead to intravascular clotting which is clotting in the blood vessels and results in a deficient
blood supply through the wound area
4. Serum Protein/Albumin — provides an indication of the body’s nutritional reserves for
rebuilding cells; albumin is a protein made by your liver and it is an important indicator of the
pts nutritional status; a value below 3.5 grams per deciliter indicates poor nutrition and can
result in poor healing and infection
5. Serum Albumin
6. Wound Culture and Sensitivity — a wound culture can confirm or rule out the presence of an
infection (wound care nurse does this); a sensitivity study is helpful in the selection of
appropriate antibiotic therapy
Nursing Process for Impaired Tissue Integrity- What happens during this Nursing Process?
1. Assessment — always includes the integumentary system; the nurse should always be alert
to skin abnormalities when providing routine care to pts
2. Observation and patient interview — conduct general observation of patients skin during
interview checking for color, erythema (superficial reddening of the skin as result of injury/
irritation), dryness, rashes, lesions, hyperpigmentation, and hypopigmentation. Want to inquire
about skin diseases, skin lesions, and healing of sores
3. Physical examination — include inspection and palpation of skin; looking at skin color
distribution, turgor, edema, and characteristics of lesions. Pay close attention to skin folds
around the breast, the groin, the perineum, and bony prominences (bones at high risk for
pressure ulcers). Remove anti-embolic stockings, braces, or other medical artificial devices to
assess the skin underneath
4. Diagnostic tests — skin biopsies to differentiate a benign lesion from skin cancer. Cultures
can be performed to identify infections on tissue samples or on drainage and exudate
5. Independent interventions — set goals to control the severity of the diagnosis, prevent
infection, and promote healing. Teach pt about good hygiene: rinse thoroughly after using soap
to prevent dryness, use moisturizing lotion after bathing, cleaning and dressing wounds, and
how to properly dispose of soil dressings. Teach pt how to recognize signs of an infection or
necrotic tissue. Encourage expertise and proper nutrition
6. Collaborative therapies — may include the nurse, UAP, a wound care nurse, nurse case
managers, HCP, a dermatologist, an oncologist, and maybe a surgeon
7. Pharmacologic/ Non-pharmacologic Therapy — directed by HCP; pts with skin integrity
issues can benefit from a variety of non-pharcologic therapies such as a wound bag, diet high
in protein, and diet high in vitamins that promotes healing (vitamins A & C)
Diagnosing Planning Implementing
Risk for pressure ulcer Maintain skin integrity Support wound healing
Risk for impaired skin Avoid potential associated Prevent pressure ulcers
integrity risk
Dressing and cleaning wounds
Impaired skin integrity -
applies to pressure ulcers into Supporting and immobilizing
wounds pending through the wound
epidermis but not through the
dermis
Pressure Ulcers are - Injury to skin or underlying tissue, usually over a bony prominence, as a
result of force alone or in combination with movement.
Preventable — hospitals are not reimbursed when these injuries occur in a hospital setting
Ischemia — a deficiency in blood supplies to tissue; when blood cannot reach the tissue the cells
are deprived of oxygen and nutrients.
Deprivation - The waste products of metabolism accumulate in the
cells and the tissue consequently dies. Prolonged unrelieved
pressure also damages the small blood vessels. After the skin has
been compressed it appears pale as if the blood has been squeezed
out of it.
Reactive Hyperemia - When pressure is relieved it takes on a
bright red flush color
Vasodilation - The flush is vasodilation; a process in which extra
blood flows to the area to compensate for the previous period of
impended or blocked blood flow. Some common areas are sacral
areas which are trochanter and heal (**remember to raise heals to
prevent pressure ulcers and turn pt every 2 hrs to prevent injury in
other areas**)
What is Ischemia?
What is Vasodilation?
1. Pain
2. Anxiety
3. Fear
Non-blanchable
erythema signals (presents as a
potential Dressing change: deep crater, with Assess for
ulcerations hydrochloride or without osteomyelitis
undermining or
adjacent tissues) Fever, pain,
and fatigue are
Can stick a Q-tip Symptoms
under the surface
of the skin at the Dressing change:
edge of the Hydrochloride
wound
Nursing Nursing Nursing Nursing
Interventions Interventions Interventions Interventions
Hydrogels —
liquefy necrotic Assess for
tissue and fill in complications
dead space such as
(glycerin or Osteomyelitis
water-based non- (bone infection)
adhesive) and Sepsis
Alginates —
Absorb exudates Assess for
and eliminate undermining
dead space (used which is region
for pressure directly under
ulcers, skin tears, wound and under
venoustais edge of wound
ulcers, surgical
wounds,
chemical debris
Why do we use Wound Dressings?
4. Thermal insulation
2. Amount of exudate
Two popular dressing changes are transparent film and hydrocolloid dressing
Transparent film — often applied to wounds that are ulcerated or burned; act as temporary skin
and are nonporous, nonabsorbent, self-adhesive dressings that do not require changing. Usually
the nurse will leave them alone until the wound has healed
Hydrocolloid dressing — frequently used over pressure ulcers; advantages include lasting 3 to 7
days, not needing a cover dressing, and being water resistant so the pt can shower with this
dressing on. Act as temporary skin and provide an effective bacterial barrier. Decreases pain
which then reduces the need for analgesics (painkillers). Hydrocolloids can NOT be used for
infected wounds or those with deep tracks or fistulas bc they can facilitate anaerobic bacterial
growth
Dressings Review:
2. You can use hydrocolloid dressings on fragile skin but not on infected wounds
Types of Wounds
2. Closed — when the tissues are 2. Partial thickness — involve dermis and
traumatized without a break in the skin the epidermis
wound is considered closed
Ex. crushing injury or a bruise Healed by regeneration
3. Full thickness/penetrating — involve
dermis, epidermis, subcutaneous tissue,
and possibly muscle and bone
Red wounds are protected by gently cleansing the wound protecting the peri-wound skin
which is the skin that extends about 4 centimeters beyond the wound edge. Use alcohol
free barrier form. Fill in dead space with hydrogel or alginate covering the appropriate
dressing such as transparent film, hydrochloride dresses, or a clear absorbent acrylic
dressing and changing the dressing as frequently as possible
Yellow wounds are characterized primarily by liquid to semi-liquid sought that is often
accompanied by purulent drainage or a previous infection. The nurse will cleanse yellow
wounds to remove nonviable tissues by applying a damp to damp normal saline dressing,
irrigating the wound, using absorbent dressing materials such as impregnated hydrogel or
alginate dressing and consult with primary care provider about the need for a topical
antimicrobial to minimize bacterial growth
Black wounds are covered with thick necrotic tissue or eschar and require debridement
which is when you remove the necrotic tissue before you can save the wound and the
wound can heal. Once the scar is removed the wound is treated as yellow and then red.
When more than one color is present the nurse treats the most serious color first so that is
black then yellow then red
1. Sharp — scalpel or scissors; used to separate and remove dead tissue. Specialty trained
wound care nurses can perform this procedure
Types of Drains – important for nurse to frequently assess the color and amount of
drainage coming from the wound
1. Regeneration — refers to the quality of the living tissue; also known as renewal of
tissue
2. Types of healing — primary care physician can decide on different types of healing;
allowing wound to heal itself or to purposely close the wound
3. Phases of healing — refers to the steps in the body’s natural processes of tissue repair.
The phases are the same for all wounds but the rate and extent of healing depends on
factors such as the location, size, and the health of the pt
Types of Wound Healing – depends on the amount of tissue that is lost
1. Hemorrhage — severe bleeding that can be caused by dislodged clots, slip stitch, or
erosion of a blood vessel. Internal hemorrhaging may be detected by swelling or
dissension in the area of the wound and possibly by sanguineous drainage from a
surgical drain. Some pts have a hematoma which is a localized collection of blood
underneath the skin that may appear as a reddish blue swelling color or bruise. The risk
of hemorrhage is greatest during the first 48 hours after surgery.
2. Infection — the
contamination of
microorganism is
inevitable for wound
surfaces but the
presence of
contamination can
also impair wound
healing and lead to an
infection. When a
microorganism is
colonizing the wound
multiplying,
excessively, simply,
or vain tissue
infection occurs.
There will be a
change in color, an
odor, more pain, and
drainage in the wound. An infection can be confirmed by performing a wound culture
3. Dehiscence is the partial or total rupture of a wound (usually abdominal). The layers
below the skin also separate
1. Developmental considerations — age: healthy children and adults often heal more
quickly than older adults bc older adults are more than likely to have chronic diseases
that hinder healing such as reduced liver function which can impair the synthesis of
blood clotting factors.
2. Nutrition — Wound healing places additional demands on the body so nutrition plays
an important factor in healing. Pts will require a diet high in protein, carbohydrates,
lipids, vitamins A & C, minerals such as iron and copper. If a pt is malnourished the
HCP may have to improve their nutritional status before surgery. Obese pts are at risk
for wound infection and slower healing bc adipose tissue has a minimal blood supply
3. Lifestyle — excreting regularly helps bc leads to good circulation. Since blood brings
oxygen and nourishment to the wound people who expertise are more likely to heal
quickly. People who smoke heal slower bc smoking reduces the amount of functional
hemoglobin in the blood which limits the oxygen carrying capacity of the blood and
contract arterial
Practice questions —
Answer: D
Answer: B
Answer: C
Answer: B
Answer: B