Lecture Notes: Tissue Integrity and Wound Management

Introduction

• Skin: The largest organ, primary defense against infection.
• Tissue Integrity: Important for maintaining skin's protective role against infections.
• Texts: Giddens 26 and Davis 35.
• Focus: Concept of tissue integrity, risk factors, recognizing impairments, interventions.

Definition of Tissue Integrity

• Meaning: Skin is unbroken and intact, includes epithelial, subcutaneous tissues, and mucous membranes.
• Scope:
  • Ranges from intact skin to damaged skin.
  • Damage assessed by depth (partial/full-thickness injury).
• Anatomy:
  • Epidermis: Uppermost skin layer.
  • Dermis: Below epidermis with accessory structures (sweat glands, muscles, capillaries, etc.).
  • Mucous Membranes: Cover areas like nostrils, mouth, genitals, eyelids, etc.

Functions of Epithelial Cells

• Protection: Physical barrier.
• Absorption: Substances can be absorbed through skin.
• Secretion: Substances like oil.
• Excretion: Removal of toxins.

Wound Healing Processes

1. Primary Intention: Edges are close, minimal scarring.
2. Secondary Intention: Edges not close, needs granulation tissue.
3. Tertiary Intention: Delayed healing, often for large/infected wounds.

Phases of Wound Healing

1. Inflammatory Phase: Swelling, warmth, protein and WBC influx.
2. Granulation Phase: New blood vessels and tissue formation.
3. Maturation Phase: Long-term scar formation, collagen remodeling.

Complications of Impaired Tissue Integrity

• Thermoregulation Issues.
• Fluid/Electrolyte Imbalance.
• Pain and Risk for Infection.
• Body Image Concerns.

Risk Factors for Impaired Tissue Integrity

• Populations at Risk: Infants, children, elderly.
• Aging Effects: Less elastic, drier skin, reduced collagen.
• Contributing Factors: Nutrition, hydration, circulation, mobility, sensation.
• Lifestyle and Environmental Exposures: Tanning, extreme temperatures, trauma.

Recognizing Impaired Skin Integrity

• Assessment Tools: Health history, inspection, palpation.
• Wound Assessment: Acute vs. chronic, location, size, color, cleanliness, odor.
• Staging Pressure Ulcers:
  • Stage 1: Non-blanchable redness.
  • Stage 2: Partial thickness loss.
  • Stage 3: Full thickness, adipose exposure.
  • Stage 4: Bone/muscle exposure.
  • Unstageable: Covered by slough/eschar.

Classifying Wounds

• Types: Open vs. closed, acute vs. chronic, clean vs. contaminated.
• Penetrating Wounds: Stabs, gunshots, punctures.

Types of Wound Drainage

• Serous: Clear fluid.
• Serosanguinous: Pink-tinged.
• Sanguinous: Bloody.
• Purulent: Infected appearance.

Complications of Wound Healing

• Dehiscence: Wound reopening.
• Evisceration: Muscle layer splitting open.

Pressure Injuries

• Nursing Role: Prevention and treatment.
• Causes: Unrelieved pressure causing ischemia.
• Assessment Tools: Braden scale for risk assessment.

Interventions to Promote Tissue Integrity

• Prevention Strategies: Hygiene, nutrition, sun exposure, ulcer prevention.
• Nursing Interventions: Turning schedules, keeping patients dry, assessing nutrition.
• Collaborative Interventions: Antibiotics, steroids, chemotherapy, phototherapy.
• Nutritional Support: Focus on protein, vitamins A and C.

Wound Care

• Assessment: Initial and ongoing.
• Cleaning and Dressing: Saline irrigation, specific dressings.
• Advanced Techniques: Vacuum-assisted closure (wound vac).

Conclusion

• Focus on pressure injuries as key exemplar.
• Emphasize prevention, risk assessment, and appropriate interventions for maintaining tissue integrity.