Understanding Tissue Integrity and Wound Care

Did you know our skin is the largest organ of our body? And it also serves as our number one defense against infection, which is why tissue integrity is so important. Today we're going to be talking about tissue integrity and when poor tissue integrity happens, how do we manage these wounds? You'll be needing both of your texts today as we'll be in Giddens 26 and Davis 35. And we're going to be completing concept study guide version B for this chapter, defining and describing the concept of tissue integrity, noticing the risk factors for impairment, recognizing when an individual has impaired tissue integrity, and then figuring out what do we do about interventions to promote optimal tissue integrity. So let's go ahead and start with the definition. So tissue integrity means our skin is unbroken, our skin is intact and is functioning, and both the epithelial tissues like the skin and the subcutaneous tissue, the tissue right under the skin, as well as the mucous membranes. These are all the most outer parts of our body and are the most protective parts for protecting against things like infection. Now the scope of this concept ranges from intact skin, which is what we hope for, to damaged skin, either with a partial thickness injury or a full thickness injury. In other words, how far down does that tissue damage go in the body? Now in terms of the anatomy and physiology, the epidermis is the uppermost layer of the skin, with the dermis being the layer just below that. And you also have accessory structures in the skin, such as sweat glands and the tiny little muscles that cause goosebumps to help us with thermoregulation, as well as all the capillaries and blood vessels that are involved, the hair shafts that are involved. There's all these little micro accessory structures in the skin, while the epidermis and the dermis are the main levels of the skin. Now the mucous membranes of the body are those areas that secrete a mucus to keep them slippery and have a mucus layer on them. Seeing things like the inside of the nostrils, the inside of the mouth, the genitals, and the inside of the eyelids, and the ears, the urethra, and the anus are all considered mucous membranes. And all of these parts together make up the integumentary system. Now the epithelial cells are what make up our integumentary system. And these epithelial cells cover all internal and external body surfaces. And they have multiple functions, including protection, keeping us protected kind of as a barrier, a physical barrier. Absorption, things can be actually absorbed through the skin. Secretion, the body can secrete things like oil. And then excretion, where the body can get rid of things like toxins. Now, in terms of wound healing, there's three types of wound healing processes that the body can use. Primary intention means there was a cut, but those edges are close together. And it's easy for that. The wound edges are approximated, meaning they're close together. And it's easy to just create a small amount of healing between those two edges. create a nice clean healing process. Secondary intentions are when the wound edges are not close together, there's a gap there. And so the body has to make extra granulation tissue just to fill in the gap, which is kind of what we would call scar tissue. And because the body has to make extra tissue to fill in the gap, it's going to need more time to heal and create that tissue. And then tertiary intention is when wound healing is delayed. when there's some kind of massive open gaping wound that was previously opened and is now closed. And it's usually the process associated with large infected wounds and contaminated wounds that are then later closed. So primary intention is ideal. You have a wound, but the edges come close together and the body is able to heal it quickly. Secondary, there's a gap between the edges and the body fills it in with granulation tissue. and tertiary intention where the body has a big gaping wound that later becomes closed, but is not closed by primary intention. So you see here an example of primary intention. It's a clean surgical incision and the edges are approximated, meaning close together right next to each other. And primary intention really has minimal scarring and so you can have sutures that really help approximate those wound edges to allow the wound healing to happen. That's primary intention. Secondary intention is when the wound edges are not approximated. There's this tissue loss. and it heals from the inner layer up to the surface, which is why it takes longer. And then tertiary intention is when really the secondary process happened, this granulating process happened, and then they close through like suturing, close the wound edges over that granulated tissue. Now, as the wound heals, there's... there's three types of wound healing and there's also three phases of wound healing. The first stage is that inflammatory stage. And that's what we talked about with inflammation. That's exactly what's happening. Increased swelling and increased warmth and bringing all the proteins and the WBCs in to try to fix and clean up this area and allowed additional blood flow to happen. After that first inflammatory phase, then you get into the granulation phase. And that lasts anywhere from the end of the week one to week three. when this is where new blood vessels and tissues are formed by the body. And then the final phase is that maturation phase, and this can go on for months, where collagen fiber is remodeled, scar formation and contraction can occur, and it really settles into what this scar is going to be in the long run. Now, our skin really keeps the bad things out of our body and also keeps the good things in. So anytime that there's impaired tissue integrity, you risk these complications. Impaired thermoregulation, because when the body is open, it cannot control its heat as well. Fluid and electrolyte imbalance, as additional fluids can be lost to the environment from open large wounds. Pain certainly can be a problem. Safety and the risk for infection. Impaired body image, which is something that's really important to our patients. And again, like I said, the risk of infection is a huge consequence of impaired tissue integrity. So what kind of risk factors are we talking about for impaired tissue integrity? Now certainly populations who are at risk include infants and children, especially in talking about kids, they're more likely to have falls and kinds of injuries that can cause tissue integrity. And then of course the very young and the very old, because they don't have a lot of ability to self-regulate and if there becomes a compromise in their tissue integrity, it can really lead to more risk with things like infection thermoregulation than someone who is maybe middle-aged. So let's think for a minute, why is it that the older population is at more risk for compromise in tissue integrity? Well, as you age, the skin becomes less elastic and more dry. It's got reduced collagen. And it's more prone to injury. And because of their mobility status often decreasing, there can be an increased risk for pressure in certain areas leading to pressure injuries. Shearing, which is when it's a friction idea, is when one item stays immobile and the other one kind of rubs against it. So think about every time that we boost our patients up in bed, there can be that risk for shearing as where the bed is the bottom. the patient gets moved up in bed and is rubbing their whole backside against the bed. That's a shearing friction and can cause injury. And so pressure and shearing and friction can lead to breakdown in the elderly population who's already at more risk for it because of the changes in the integumentary skin. Other contributing factors include things like nutritional and hydration status, poor hydration and poor protein. in the body is going to cause a decrease in repair of the skin. And decreased sensation means the patient might not feel the pressure, might not feel the discomfort. And so they might not recognize the risk for a pressure injury soon until it's too late or until it has gotten too out of hand. Now certainly impaired circulation has negative effects on tissue metabolism. Because remember, we need oxygen and glucose and white blood cells to all go to the party whenever there's an infection. And if you have poor circulation, then you're not bringing all those people to the party to help fix this area where there's impaired skin integrity. And it can cause decrease in wound healing. This is why our diabetic patients will oftentimes have diabetic ulcers in their feet. Because they don't have good circulation to their feet. So they don't feel their feet as much. They don't. feel if there's an injury there. And then when they do get an injury, they don't have good circulation. And so they're not bringing all the WBCs and the protein and the glucose and the oxygen to the party to get that cleaned up. Now, certainly different medications can have side effects like itching and rashes that can cause problems with skin integrity, especially if it becomes so itchy that the patient actually breaks the skin integrity because of the itching. And finally, moisture leads to maceration. If you've ever, do you ever, are you a cook? Do you like to bake? Have you ever macerated strawberries? You know, you just put some strawberries in some sugar and over time they break out their juice and they become nice and like wet and like juicy and delicious on strawberry shortcake. Not so great if you have macerated skin, however. It also becomes kind of wet and juicy and then it can lead to easy breakdown. A fever can also cause problems with your metabolic rate and moisture and lead to problems with skin repair. An infection is going to impede healing because the body's already working on trying to heal the body and its reserves and its ability to fight all this off becomes overwhelmed. And then things like lifestyle choices, tanning, bathing, piercings, and tattoos can have factors on skin integrity. Now, in terms of individual risk factors, patients with specific health conditions are going to have problems with skin integrity. People with poor peripheral perfusion, peripheral meaning not central, not in the middle of their body, but at the ends of their body, like their feet and their hands. Because again, we need good circulation to have good tissue repair. Patients with malnutrition because they need the nutrients that they need for good tissue repair. Or patients with obesity just because of pressure causes increased tissue damage or increased risk for tissue damage. We need good plump, skin. And so if you're dehydrated, that can cause tissue damage. But we also need our skin to be not too much, have too much moisture, too much swelling in it, which is called edema. And so if you have either ended the skin in terms of tissue, really dehydrated, or really overly saturated with fluid, you can have risks for impaired skin integrity. And then certainly people with impaired mobility, because that puts them at risk for pressure injuries. And then people who are immunosuppressed. Immunosuppression means they're unable to fight off infections. They're going to have a harder time with tissue repair because their body doesn't have the right building blocks to really repair and restore their body. And then of course patients who are exposed to specific irritants, like extreme temperatures, frostbite. or burns, either thermal burns or electric burns, chemical or mechanical trauma, medical treatments are all irritants that can cause changes in skin integrity. And then of course, tissue trauma itself. You know, we see a lot of avocado cuts in the ER where patients come in and they wanna get the avocado pit out and they pop the knife in so they can twist it to get the seed out. and they miss and they get their hand instead and that's a common one we see in the er and it's a tissue trauma related to an injury so all of these concepts of friction and shearing moisture and pressure are things you really want to think about especially with your bed bound hospitalized patients because all of those things really put them at risk for poor skin integrity so you don't want your patients to be sitting there wet in soiled briefs you want to watch how much your moving them around in bed, you can use pressure reducing mattresses so that they don't get these pressure points on their bodies. So what are the things we can do to really reduce those pressure and reduce the risk of tissue trauma? But we're getting ahead of ourselves. That part is for the intervention part, which is coming a little bit later here. So how do we recognize when an individual has impaired skin integrity? Well, first we're going to want to do a health history, talk about past and current conditions, and kind of be alerted in your mind on which ones might put your patient at risk for impaired skin integrity. Ask about allergies and what kind of skin reactions they've had. Talk about current and recent medications and any history of skin disorders they might have. When you're inspecting the body, inspecting means looking. We're looking at the general color and skin condition of the skin. And if there are any lesions, meaning any wounds or any areas that are abnormal, we're going to be noting the location, the size, the shape, the color, any patterning, and any characteristics like is it raised or is it flat? Is it dry or does it have exudate? And then we can palpate. Palpate means feel. So we look, we inspect, and then we palpate with our hands. We feel. We can feel the skin for surface characteristics, temperature, and texture. And we can also pinch the skin to do a skin turgor test to see if it has tenting. Remember, if the skin stays up pinched after you let go, it means that the skin is very dehydrated. And when we're assessing wounds and ulcers themselves, we're going to Think about, is this acute? Is it a new, fresh wound? Or is it chronic? Something that the patient has dealt with for a long time is having a hard time getting healed. We're going to talk about the location, the size, both in the length, the width, and the depth of the wound. What's the color? Is it red, yellow, or black? What's the cleanliness? Is the wound clean or contaminated? I've had patients come in. No joke with maggots in their wounds. Sometimes that can be put in as a therapeutic measure by a surgeon, or sometimes patients just get maggots in their wounds at home, which is super disgusting, but also sort of helpful because the maggots actually eat the dead tissue. I'm sorry. I hope you're not eating while we're talking about this. It's not the best conversation to have while you're trying to eat lunch. We'll just keep going. You're going to think about odor. Are there any drains in place for that wound? And then is there any drainage or exudate? And then if there is drainage, you're going to want to kind of assess that and determine what kind. So is it serous drainage? Serous meaning very clear. Serosanguinous, sanguine means blood. So serosanguinous would be like pink tinged where it's serous fluid mixed with a little bit of blood. Is it just sanguinous where it's very red exudate? Or is it purulent and it looks infected? And then finally, you can stage wound ulcers by stage one, two, three, or four, or non-stageable if based on the type of assessment you're unable to tell. And so here's a quick example of what each of those stages of pressure injuries are. And so you can see a description here, along with an infographic, and then an actual picture. And so you'll see stage one means the skin is intact. but the redness is non-blanchable meaning when you push on that area of redness when you let go it stays red it doesn't turn white for a second um and so it intakes with a non-blanchable redness to a localized area usually over a bony provenance over kind of an area that there's a very you know harder bone underneath with not as much cushion stage two is the next one there's a partial thickness loss of the dermis creating a very shallow open ulcer. So now the skin is not intact. Uh, and then the stage three is a full thickness. And so you're going to start seeing that, uh, adipose tissue layer. So you're going to start seeing little bits of the subcutaneous fat, but also, um, remember that bone tendon and muscle are not exposed in this layer. And then finally, the fourth stage is when you're actually seeing exposed bone tendon or muscle. That's how deep that wound has gotten. Now sometimes the ulcer can be covered with sloth and or eschar. Sloth meaning like exudate, just stuff that's coming out of the wound. And eschar meaning like a black scab that has formed over the wound. And either way, when it's covered with the sloth or covered with the eschar, you can't see what's going on underneath that. So you don't know what stage that one is, which is why it's called unstageable. And then finally, you can see a deep tissue injury where the skin is intact, and it might be even like a blood blister, but you don't know what's going on underneath. You know that there's some kind of deeper injury, but the skin on top is intact. And it may look like a blood blister, or it may look kind of purplish, but you just won't know what kind of deep tissue injury you're dealing with because that first layer is still intact. And as we're talking about wounds, we can classify them by different things. They can be open wounds where the skin is no longer intact, or they can be closed. They can be acute, meaning happening just now, or chronic, that's happened over the long term. They can be clean, they can be contaminated or infected. You can see superficial or partial thickness or full thickness wounds. And then you can have penetrating wounds. Penetrating wounds are things that went into the body. like a stab wound, a gunshot wound, or even a kitchen knife can cause this, or a puncture wound. Anything that goes through the body would be considered a penetrating wound. As I mentioned previously, here's the types of wound drainage. You can pause right here and read this for yourself. You might want to make flashcards on these. These are types of wound drainage that you should be able to understand. Now, not all wounds heal the way we hope they will or the way that we want them to, and so you can have some complications of wound healing, and your Davis text talks specifically about these, but the first type is dehiscence, where that top layer of skin... actually opens up after it's already been closed. And so the muscle's intact, but you can see the adipose tissue, that fatty layer, and that wound has split open, which had previously been closed. And then you can see the evisceration where not only does that first layer of skin split open, but the muscle itself splits open and the bowel can actually come through the wound causing evisceration. Now, pressure injuries are one of our main conversations this week, main exemplars, and it's because nurses play such a huge role in prevention and treatment of these pressure injuries. Unfortunately, pressure injuries are going to affect 15% of hospitalized patients, and it's really due to just nursing not doing what we, we own pressure injuries, we really do, and so getting patients on a good turning schedule, keeping them dry, assessing their nutritional status. getting them out of bed if they're able to get out of bed are all areas things that we can do to prevent pressure injuries from happening and they're really pressure injuries are caused by unrelieved pressure to an area which results in ischemia meaning a lack of blood flow to that area get lack of blood flow you're not going to get good tissue repair and you're going to end up with a wound so not only do we need to be really good at preventing any pressure ulcers or pressure injuries from happening, but we need to be aware of who is at risk for these types of injuries. And one of the ways we do that is doing a skin and wound assessment, a focused assessment to identify patients'risk factors for impaired tissue integrity. And one of the things that we look for is this thing called the Braden scale. Now, we're going to be using this in class and practicing using a Braden scale tool, but anyone who scores less than an 18 on this scale is going to be at increased risk for skin breakdown. And it's going to assess for things like the patient's ability to perceive pain, their nutritional status, the risk for friction and shear and moisture. Are they able to be mobile? What's their activity level? Because all of these things are the types of areas that create increased risk for skin breakdown. I got so excited that we started talking about interventions before we even got here, so you might already recognize a few of these. Just get into it, I guess, today. But let's talk about what those interventions are, both for nursing and collaborative, to promote optimal tissue integrity. So the first thing is prevention. Prevention is worth a lot more than treatment, so we really want to focus our efforts on prevention of skin breakdown. And that includes things like making sure our patients have good skin hygiene. have adequate nutrition, that we advise avoiding excessive sun exposure or using good sunscreens when possible. We're going to talk about preventing burns in the home and then talk about dermal ulcer prevention. How do we prevent people from getting these kind of ulcers to begin with? And in terms of pressure injuries specifically, again, it's about preventing, it's about turning our patients, keeping them dry. making sure they have adequate nutrition and skincare, giving them a therapeutic mattress, which is going to reduce pressure, and teach the patient and family what they can do to be involved in the care as well. Now, in terms of collaborative interventions, antibiotics to treat infections, steroids to treat inflammation, different creams, chemotherapy if it is a skin cancer. Phototherapy can be used for things like jaundice to break up the bilirubin in the skin that's used for babies with jaundice. Surgical interventions, they can do things on wounds surgically to remove the area that is infected, or even do skin grafts to replace skin on areas that don't have skin on them. Excellent wound care is important. And then nutritional support. So there's specific macro and micronutrients that are critical to wound care and to tissue integrity. And specifically, we're talking about protein, vitamin A and vitamin C. Make sure you write those down because you'll really wanna know if your patients are getting adequate protein and vitamin A and C in terms of wound healing. Now there are some things we need to talk about in terms of wound care. So you'll need to do initial and ongoing assessments of all wounds to track how they started and how they're progressing. In terms of cleaning, irrigating is when we are really flushing out an area of a wound and that's typically used with just a normal saline solution. We really avoid harsh solutions because they're very harsh and can damage the wound bed itself. So typically just a normal saline to flush things away is appropriate. There's a bunch of different dressings out there and you know each wound is going to have very specific instructions either by the wound care nurse or by the doctor on which type of dressing is appropriate. And then sometimes they use vacuum assisted systems, a wound vac, to help increase circulation in the area because remember we got to get all the players in the body to the party. to try to help clean up that wound and so a wound vac actually helps to encourage better circulation to that area. Here are all your interrelated concepts, both the causes of impaired tissue integrity and the effects of having poor tissue integrity are all listed here on this map. A number of featured exemplars in your Giddens text but for the sake of this week's lesson, we're going to be focusing especially on pressure injuries or pressure ulcers as the featured exemplar.

You'll be needing both of your texts today as we'll be in Giddens 26 and Davis 35. And we're going to be completing concept study guide version B for this chapter, defining and describing the concept of tissue integrity, noticing the risk factors for impairment, recognizing when an individual has impaired tissue integrity, and then figuring out what do we do about interventions to promote optimal tissue integrity. So let's go ahead and start with the definition. So tissue integrity means our skin is unbroken, our skin is intact and is functioning, and both the epithelial tissues like the skin and the subcutaneous tissue, the tissue right under the skin, as well as the mucous membranes. These are all the most outer parts of our body and are the most protective parts for protecting against things like infection.

Now the scope of this concept ranges from intact skin, which is what we hope for, to damaged skin, either with a partial thickness injury or a full thickness injury. In other words, how far down does that tissue damage go in the body? Now in terms of the anatomy and physiology, the epidermis is the uppermost layer of the skin, with the dermis being the layer just below that.

And you also have accessory structures in the skin, such as sweat glands and the tiny little muscles that cause goosebumps to help us with thermoregulation, as well as all the capillaries and blood vessels that are involved, the hair shafts that are involved. There's all these little micro accessory structures in the skin, while the epidermis and the dermis are the main levels of the skin. Now the mucous membranes of the body are those areas that secrete a mucus to keep them slippery and have a mucus layer on them.

Seeing things like the inside of the nostrils, the inside of the mouth, the genitals, and the inside of the eyelids, and the ears, the urethra, and the anus are all considered mucous membranes. And all of these parts together make up the integumentary system. Now the epithelial cells are what make up our integumentary system. And these epithelial cells cover all internal and external body surfaces.

And they have multiple functions, including protection, keeping us protected kind of as a barrier, a physical barrier. Absorption, things can be actually absorbed through the skin. Secretion, the body can secrete things like oil.

And then excretion, where the body can get rid of things like toxins. Now, in terms of wound healing, there's three types of wound healing processes that the body can use. Primary intention means there was a cut, but those edges are close together.

And it's easy for that. The wound edges are approximated, meaning they're close together. And it's easy to just create a small amount of healing between those two edges.

create a nice clean healing process. Secondary intentions are when the wound edges are not close together, there's a gap there. And so the body has to make extra granulation tissue just to fill in the gap, which is kind of what we would call scar tissue. And because the body has to make extra tissue to fill in the gap, it's going to need more time to heal and create that tissue.

And then tertiary intention is when wound healing is delayed. when there's some kind of massive open gaping wound that was previously opened and is now closed. And it's usually the process associated with large infected wounds and contaminated wounds that are then later closed. So primary intention is ideal. You have a wound, but the edges come close together and the body is able to heal it quickly.

Secondary, there's a gap between the edges and the body fills it in with granulation tissue. and tertiary intention where the body has a big gaping wound that later becomes closed, but is not closed by primary intention. So you see here an example of primary intention.

It's a clean surgical incision and the edges are approximated, meaning close together right next to each other. And primary intention really has minimal scarring and so you can have sutures that really help approximate those wound edges to allow the wound healing to happen. That's primary intention. Secondary intention is when the wound edges are not approximated. There's this tissue loss.

and it heals from the inner layer up to the surface, which is why it takes longer. And then tertiary intention is when really the secondary process happened, this granulating process happened, and then they close through like suturing, close the wound edges over that granulated tissue. Now, as the wound heals, there's...

there's three types of wound healing and there's also three phases of wound healing. The first stage is that inflammatory stage. And that's what we talked about with inflammation.

That's exactly what's happening. Increased swelling and increased warmth and bringing all the proteins and the WBCs in to try to fix and clean up this area and allowed additional blood flow to happen. After that first inflammatory phase, then you get into the granulation phase. And that lasts anywhere from the end of the week one to week three. when this is where new blood vessels and tissues are formed by the body.

And then the final phase is that maturation phase, and this can go on for months, where collagen fiber is remodeled, scar formation and contraction can occur, and it really settles into what this scar is going to be in the long run. Now, our skin really keeps the bad things out of our body and also keeps the good things in. So anytime that there's impaired tissue integrity, you risk these complications.

Impaired thermoregulation, because when the body is open, it cannot control its heat as well. Fluid and electrolyte imbalance, as additional fluids can be lost to the environment from open large wounds. Pain certainly can be a problem.

Safety and the risk for infection. Impaired body image, which is something that's really important to our patients. And again, like I said, the risk of infection is a huge consequence of impaired tissue integrity. So what kind of risk factors are we talking about for impaired tissue integrity? Now certainly populations who are at risk include infants and children, especially in talking about kids, they're more likely to have falls and kinds of injuries that can cause tissue integrity.

And then of course the very young and the very old, because they don't have a lot of ability to self-regulate and if there becomes a compromise in their tissue integrity, it can really lead to more risk with things like infection thermoregulation than someone who is maybe middle-aged. So let's think for a minute, why is it that the older population is at more risk for compromise in tissue integrity? Well, as you age, the skin becomes less elastic and more dry. It's got reduced collagen.

And it's more prone to injury. And because of their mobility status often decreasing, there can be an increased risk for pressure in certain areas leading to pressure injuries. Shearing, which is when it's a friction idea, is when one item stays immobile and the other one kind of rubs against it. So think about every time that we boost our patients up in bed, there can be that risk for shearing as where the bed is the bottom.

the patient gets moved up in bed and is rubbing their whole backside against the bed. That's a shearing friction and can cause injury. And so pressure and shearing and friction can lead to breakdown in the elderly population who's already at more risk for it because of the changes in the integumentary skin.

Other contributing factors include things like nutritional and hydration status, poor hydration and poor protein. in the body is going to cause a decrease in repair of the skin. And decreased sensation means the patient might not feel the pressure, might not feel the discomfort. And so they might not recognize the risk for a pressure injury soon until it's too late or until it has gotten too out of hand. Now certainly impaired circulation has negative effects on tissue metabolism.

Because remember, we need oxygen and glucose and white blood cells to all go to the party whenever there's an infection. And if you have poor circulation, then you're not bringing all those people to the party to help fix this area where there's impaired skin integrity. And it can cause decrease in wound healing. This is why our diabetic patients will oftentimes have diabetic ulcers in their feet.

Because they don't have good circulation to their feet. So they don't feel their feet as much. They don't.

feel if there's an injury there. And then when they do get an injury, they don't have good circulation. And so they're not bringing all the WBCs and the protein and the glucose and the oxygen to the party to get that cleaned up. Now, certainly different medications can have side effects like itching and rashes that can cause problems with skin integrity, especially if it becomes so itchy that the patient actually breaks the skin integrity because of the itching.

And finally, moisture leads to maceration. If you've ever, do you ever, are you a cook? Do you like to bake? Have you ever macerated strawberries? You know, you just put some strawberries in some sugar and over time they break out their juice and they become nice and like wet and like juicy and delicious on strawberry shortcake.

Not so great if you have macerated skin, however. It also becomes kind of wet and juicy and then it can lead to easy breakdown. A fever can also cause problems with your metabolic rate and moisture and lead to problems with skin repair.

An infection is going to impede healing because the body's already working on trying to heal the body and its reserves and its ability to fight all this off becomes overwhelmed. And then things like lifestyle choices, tanning, bathing, piercings, and tattoos can have factors on skin integrity. Now, in terms of individual risk factors, patients with specific health conditions are going to have problems with skin integrity. People with poor peripheral perfusion, peripheral meaning not central, not in the middle of their body, but at the ends of their body, like their feet and their hands.

Because again, we need good circulation to have good tissue repair. Patients with malnutrition because they need the nutrients that they need for good tissue repair. Or patients with obesity just because of pressure causes increased tissue damage or increased risk for tissue damage. We need good plump, skin.

And so if you're dehydrated, that can cause tissue damage. But we also need our skin to be not too much, have too much moisture, too much swelling in it, which is called edema. And so if you have either ended the skin in terms of tissue, really dehydrated, or really overly saturated with fluid, you can have risks for impaired skin integrity. And then certainly people with impaired mobility, because that puts them at risk for pressure injuries. And then people who are immunosuppressed.

Immunosuppression means they're unable to fight off infections. They're going to have a harder time with tissue repair because their body doesn't have the right building blocks to really repair and restore their body. And then of course patients who are exposed to specific irritants, like extreme temperatures, frostbite. or burns, either thermal burns or electric burns, chemical or mechanical trauma, medical treatments are all irritants that can cause changes in skin integrity. And then of course, tissue trauma itself.

You know, we see a lot of avocado cuts in the ER where patients come in and they wanna get the avocado pit out and they pop the knife in so they can twist it to get the seed out. and they miss and they get their hand instead and that's a common one we see in the er and it's a tissue trauma related to an injury so all of these concepts of friction and shearing moisture and pressure are things you really want to think about especially with your bed bound hospitalized patients because all of those things really put them at risk for poor skin integrity so you don't want your patients to be sitting there wet in soiled briefs you want to watch how much your moving them around in bed, you can use pressure reducing mattresses so that they don't get these pressure points on their bodies. So what are the things we can do to really reduce those pressure and reduce the risk of tissue trauma? But we're getting ahead of ourselves. That part is for the intervention part, which is coming a little bit later here.

So how do we recognize when an individual has impaired skin integrity? Well, first we're going to want to do a health history, talk about past and current conditions, and kind of be alerted in your mind on which ones might put your patient at risk for impaired skin integrity. Ask about allergies and what kind of skin reactions they've had. Talk about current and recent medications and any history of skin disorders they might have. When you're inspecting the body, inspecting means looking.

We're looking at the general color and skin condition of the skin. And if there are any lesions, meaning any wounds or any areas that are abnormal, we're going to be noting the location, the size, the shape, the color, any patterning, and any characteristics like is it raised or is it flat? Is it dry or does it have exudate? And then we can palpate. Palpate means feel.

So we look, we inspect, and then we palpate with our hands. We feel. We can feel the skin for surface characteristics, temperature, and texture. And we can also pinch the skin to do a skin turgor test to see if it has tenting.

Remember, if the skin stays up pinched after you let go, it means that the skin is very dehydrated. And when we're assessing wounds and ulcers themselves, we're going to Think about, is this acute? Is it a new, fresh wound? Or is it chronic?

Something that the patient has dealt with for a long time is having a hard time getting healed. We're going to talk about the location, the size, both in the length, the width, and the depth of the wound. What's the color?

Is it red, yellow, or black? What's the cleanliness? Is the wound clean or contaminated?

I've had patients come in. No joke with maggots in their wounds. Sometimes that can be put in as a therapeutic measure by a surgeon, or sometimes patients just get maggots in their wounds at home, which is super disgusting, but also sort of helpful because the maggots actually eat the dead tissue. I'm sorry.

I hope you're not eating while we're talking about this. It's not the best conversation to have while you're trying to eat lunch. We'll just keep going.

You're going to think about odor. Are there any drains in place for that wound? And then is there any drainage or exudate?

And then if there is drainage, you're going to want to kind of assess that and determine what kind. So is it serous drainage? Serous meaning very clear. Serosanguinous, sanguine means blood.

So serosanguinous would be like pink tinged where it's serous fluid mixed with a little bit of blood. Is it just sanguinous where it's very red exudate? Or is it purulent and it looks infected? And then finally, you can stage wound ulcers by stage one, two, three, or four, or non-stageable if based on the type of assessment you're unable to tell. And so here's a quick example of what each of those stages of pressure injuries are.

And so you can see a description here, along with an infographic, and then an actual picture. And so you'll see stage one means the skin is intact. but the redness is non-blanchable meaning when you push on that area of redness when you let go it stays red it doesn't turn white for a second um and so it intakes with a non-blanchable redness to a localized area usually over a bony provenance over kind of an area that there's a very you know harder bone underneath with not as much cushion stage two is the next one there's a partial thickness loss of the dermis creating a very shallow open ulcer.

So now the skin is not intact. Uh, and then the stage three is a full thickness. And so you're going to start seeing that, uh, adipose tissue layer.

So you're going to start seeing little bits of the subcutaneous fat, but also, um, remember that bone tendon and muscle are not exposed in this layer. And then finally, the fourth stage is when you're actually seeing exposed bone tendon or muscle. That's how deep that wound has gotten.

Now sometimes the ulcer can be covered with sloth and or eschar. Sloth meaning like exudate, just stuff that's coming out of the wound. And eschar meaning like a black scab that has formed over the wound. And either way, when it's covered with the sloth or covered with the eschar, you can't see what's going on underneath that. So you don't know what stage that one is, which is why it's called unstageable.

And then finally, you can see a deep tissue injury where the skin is intact, and it might be even like a blood blister, but you don't know what's going on underneath. You know that there's some kind of deeper injury, but the skin on top is intact. And it may look like a blood blister, or it may look kind of purplish, but you just won't know what kind of deep tissue injury you're dealing with because that first layer is still intact. And as we're talking about wounds, we can classify them by different things.

They can be open wounds where the skin is no longer intact, or they can be closed. They can be acute, meaning happening just now, or chronic, that's happened over the long term. They can be clean, they can be contaminated or infected. You can see superficial or partial thickness or full thickness wounds. And then you can have penetrating wounds.

Penetrating wounds are things that went into the body. like a stab wound, a gunshot wound, or even a kitchen knife can cause this, or a puncture wound. Anything that goes through the body would be considered a penetrating wound. As I mentioned previously, here's the types of wound drainage.

You can pause right here and read this for yourself. You might want to make flashcards on these. These are types of wound drainage that you should be able to understand. Now, not all wounds heal the way we hope they will or the way that we want them to, and so you can have some complications of wound healing, and your Davis text talks specifically about these, but the first type is dehiscence, where that top layer of skin...

actually opens up after it's already been closed. And so the muscle's intact, but you can see the adipose tissue, that fatty layer, and that wound has split open, which had previously been closed. And then you can see the evisceration where not only does that first layer of skin split open, but the muscle itself splits open and the bowel can actually come through the wound causing evisceration. Now, pressure injuries are one of our main conversations this week, main exemplars, and it's because nurses play such a huge role in prevention and treatment of these pressure injuries. Unfortunately, pressure injuries are going to affect 15% of hospitalized patients, and it's really due to just nursing not doing what we, we own pressure injuries, we really do, and so getting patients on a good turning schedule, keeping them dry, assessing their nutritional status.

getting them out of bed if they're able to get out of bed are all areas things that we can do to prevent pressure injuries from happening and they're really pressure injuries are caused by unrelieved pressure to an area which results in ischemia meaning a lack of blood flow to that area get lack of blood flow you're not going to get good tissue repair and you're going to end up with a wound so not only do we need to be really good at preventing any pressure ulcers or pressure injuries from happening, but we need to be aware of who is at risk for these types of injuries. And one of the ways we do that is doing a skin and wound assessment, a focused assessment to identify patients'risk factors for impaired tissue integrity. And one of the things that we look for is this thing called the Braden scale.

Now, we're going to be using this in class and practicing using a Braden scale tool, but anyone who scores less than an 18 on this scale is going to be at increased risk for skin breakdown. And it's going to assess for things like the patient's ability to perceive pain, their nutritional status, the risk for friction and shear and moisture. Are they able to be mobile?

What's their activity level? Because all of these things are the types of areas that create increased risk for skin breakdown. I got so excited that we started talking about interventions before we even got here, so you might already recognize a few of these. Just get into it, I guess, today.

But let's talk about what those interventions are, both for nursing and collaborative, to promote optimal tissue integrity. So the first thing is prevention. Prevention is worth a lot more than treatment, so we really want to focus our efforts on prevention of skin breakdown.

And that includes things like making sure our patients have good skin hygiene. have adequate nutrition, that we advise avoiding excessive sun exposure or using good sunscreens when possible. We're going to talk about preventing burns in the home and then talk about dermal ulcer prevention.

How do we prevent people from getting these kind of ulcers to begin with? And in terms of pressure injuries specifically, again, it's about preventing, it's about turning our patients, keeping them dry. making sure they have adequate nutrition and skincare, giving them a therapeutic mattress, which is going to reduce pressure, and teach the patient and family what they can do to be involved in the care as well.

Now, in terms of collaborative interventions, antibiotics to treat infections, steroids to treat inflammation, different creams, chemotherapy if it is a skin cancer. Phototherapy can be used for things like jaundice to break up the bilirubin in the skin that's used for babies with jaundice. Surgical interventions, they can do things on wounds surgically to remove the area that is infected, or even do skin grafts to replace skin on areas that don't have skin on them. Excellent wound care is important.

And then nutritional support. So there's specific macro and micronutrients that are critical to wound care and to tissue integrity. And specifically, we're talking about protein, vitamin A and vitamin C. Make sure you write those down because you'll really wanna know if your patients are getting adequate protein and vitamin A and C in terms of wound healing.

Now there are some things we need to talk about in terms of wound care. So you'll need to do initial and ongoing assessments of all wounds to track how they started and how they're progressing. In terms of cleaning, irrigating is when we are really flushing out an area of a wound and that's typically used with just a normal saline solution. We really avoid harsh solutions because they're very harsh and can damage the wound bed itself.

So typically just a normal saline to flush things away is appropriate. There's a bunch of different dressings out there and you know each wound is going to have very specific instructions either by the wound care nurse or by the doctor on which type of dressing is appropriate. And then sometimes they use vacuum assisted systems, a wound vac, to help increase circulation in the area because remember we got to get all the players in the body to the party. to try to help clean up that wound and so a wound vac actually helps to encourage better circulation to that area. Here are all your interrelated concepts, both the causes of impaired tissue integrity and the effects of having poor tissue integrity are all listed here on this map.

A number of featured exemplars in your Giddens text but for the sake of this week's lesson, we're going to be focusing especially on pressure injuries or pressure ulcers as the featured exemplar.

Transcript for:Understanding Tissue Integrity and Wound Care

Transcript for:
Understanding Tissue Integrity and Wound Care