Transcript Tissue Integrity

Tissue Integrity
Taylor, ch 32
Objectives p. 3
The concept of tissue integrity will be
discussed as well as tissue damage.
Tissue damage will be demonstrated by the
exemplars of contact dermatitis, pressure
ulcers, and wound care.
Tissue Integrity
Defined by intact skin and mucous
membranes with no evidence of damaged or
destroyed tissue.
When tissue is damaged or destroyed, it is
said to have lost its integrity.
Even when there is no damage evident,
there may be a risk d/t factors present in the
client’s internal or external environment.
Risk Factors for Tissue Damage
Wide variety of disease processes (mental and
physical)
Nutritional state
Age
Immobility
Moisture
Shear and friction
Actual Tissue Damage
May be surgical wound or trauma
Surgical wounds can be open or closed
Traumatic wounds can be intentionally
inflicted or unintentionally inflicted.
Risk factors coupled with neglect can cause
a kind of tissue damage called pressure
ulcers.
Contact Dermatitis
A cell-mediated hypersensitivity immune
reaction caused by contact with an external
agent to which a person is allergic.
Poison ivy
Meds
Metals
Pathophysiology
Sensitized T cells react with an antigen at
an injection site or contact site by attaching
to it and destroying it or sending
lymphokines to bring macrophages to
destroy the antigen.
The macrophages release lysozymes which
cause tissue damage. Cell mediated
reactions occur hours to days after exposure
to the antigen.
Contact Dermatitis
May be transmitted by direct, indirect
contact, from one part of body to another, or
in air (smoke)
Assessment:
Weeping
Papular rash on exposed area
Pruritis
Inflammation
Dx by hx, PE, patch testing
Contact Dermatitis
Contact Dermatitis
Tx & Nsg Care:
Wet dsgs with Burow’s solution (aluminum
acetate)
Topical steroids, antihistamines, calamine, po
antibiotics or steroids if severe or secondarily
infected.
Avoid substance, learn to recognize plant,
protect skin with clothes or gloves, wash for 15
min if exposed.
Pressure Ulcer
A localized area of tissue necrosis caused
by unrelieved pressure that occludes blood
flow to tissues.
Usually located over body prominences
Most common sites are sacrum and heels
Influencing Factors
Amount of pressure
Length of time pressure is exerted
Ability of tissue to tolerate externally
applied pressure
Contributing Factors
Shearing force—pressure exerted on the
skin when it adheres to the bed and the skin
layers slide in the direction of body
movement.
Friction—two surfaces rubbing against each
other
Excessive moisture
Risk Factors
Immobility
Incontinence
Impaired circulation
Poor hygiene
Contractures
Advanced age
Obesity
Malnutrition
Mental deterioration
Diabetes
Vascular disease
Neurological disorders
Clinical Manifestations
Ulcers are graded or staged according to the
deepest level of damage
Stage I (minor) to Stage IV (severe) pp.
933-934
Slough or eschar may need to be removed
to accurately stage some ulcers
Ulcers also may be classified as red, yellow,
or black to help determine the best
treatment p. 939
Stage I
Persistent redness in lightly pigmented skin
Red, blue, or purple in darker skin
May be warm to touch
May have poor sensation
Does not blanch
Skin may be boggy, swollen, or thin over
site, but no skin break is evident
Stage I
Stage II
Skin is broken with partial thickness loss of
epidermis, dermis or both
Presents as an abrasion, skin tear, intact or
ruptured blister, or shallow crater
Stage II
Stage III
Full-thickness loss involving damage or
necrosis of subcutaneous tissue that may
extend down to, but not through, underlying
fascia
Presents as a deep crater with possible
undermining of adjacent tissue
Stage III with undermining
Stage IV
Full-thickness loss can extend to muscle,
bone, or supporting structures
Bone, tendon, or muscle may be visible or
palpable
Undermining and sinus tracts may also exist
Stage IV
Unstageable Pressure Ulcers
Pressure Ulcer—Ear
Pressure Ulcer—heel
Complications
Recurrence is most common
Infection—fever, leukocytosis, pain,
increase in size, odor, or drainage
Cellulitis—surrounding tissue infection
Chronic infection—may persist for months
Septicemia (blood infection)
Osteomyelitis (bone infection)
Assessment
On admission (RN) and periodically according to
protocol
Use assessment tool such as Braden Scale
Use inspection and palpation to assess color,
breakdown, and temperature
Use natural or halogen light rather than
fluorescent to assess dark skin
Ask patient how it feels—is it painful, itchy, or
numb?
Expected Outcomes
No deterioration
Reduce contributing factors
No presence of infection
Heal without complications or recurrence
Interventions: Prevention
Identify risk factors
Implement prevention strategies:
Remove excessive moisture
Good skin and incontinence care
Avoid massage over bony prominences
Turn every 1 to 2 hours and avoid shearing
Use lift sheets
Pillows, heel and elbow protectors
Specialty beds
Prevention cont’d
Caloric intake elevated to 30 to 35 cal/kg/d
or 1.25 to 1.5 g protein/kg/day
Supplements, enteral (GI), or parenteral
(IV) feedings may be necessary
Keep patients as mobile as possible
Interventions: Treatment
Document size, stage, location, exudate, infection,
pain, and tissue appearance
Keep ulcer bed moist
Cleanse with nontoxic solutions (saline)
Debride by medications or refer for surgical
debridement
Adhesive membrane, ointment, moisture-retentive
dressings
Teach self-assessment and self-care
Interventions: Operative Repair
Skin grafts
Skin flaps
Musculocutaneous flaps
Free flaps
Surgical debridement
Interventions: Patient/Family
Education
Assess resources
Explain risk factors and causes
Teach incontinence care
Demonstrate correct positioning, turning
Teach daily inspection
Teach wound care
Stress good nutrition
Evaluation
Prevention strategies implemented
Wound has not deteriorated
No complications
Wound healed with no recurrence
Patient/family understands instructions
Test Your Knowledge
Go to :
http://reference.medscape.com/features/slidesho
w/staging-pressure-ulcers#1
Wound Healing
Primary—straight line with all layers wellapproximated, free of infection, no separation, fast
healing, minimal scarring
Secondary—healing from inside out by
granulation, increased infection risk, slow healing,
extensive scarring
Tertiary—delay of 3-5d between injury and
suturing, increased chance of infection and
separation
Primary Intention
Secondary and Tertiary
Healing Phases
Initial (3-5d)—approximation, epithelial
cell migration, mesh and initial capillary
growth
Granulation (5d-4wk)—fibroblast
migration, collagen formation, capillary
beds formed, fragile tissue
Scar contracture (7d-mos)—remodeling of
collagen, strengthening of scar
Factors Affecting Healing
Age—younger heals quicker
Nutritional status—malnourished and obese
Systemic disorders—DM, circulatory probs,
immunosuppression
Presence of foreign bodies
Infection
Meds—corticosteroids, antibiotics,
anticoagulants
Factors cont’d
Irradiation
Treatment of wound
Wound stressors—coughing, straining,
vomiting, trauma
Type of wound
Presence of drains
Race—keloid formation in darker races
Complications of Healing
Hemorrhage
Infection
Dehiscence and evisceration
Result of Wound Infection
Wound Dehiscence and Evisceration
Nursing Responsibilities R/T
Wound Care
Goal is for wound to remain intact with no
complications
Assessment-size, color, drainage p. 938
Dsg change may be simple or complex
See pages 965-985
Remove staples and apply steri-strips
Don’t forget patient education and
documentation
Wound Drainage Systems
Applying Steri-strips
Wound Packing
Wound Vac
Documentation of Wound Care
“Sterile dsg change performed on abd
wound. Old 4x4 dressing clean and dry.
Wound 10 cm, closed, edges wellapproximated, staples intact, without
redness or drainage. Cleaned with 4x4 and
normal saline and sterile 4x4 applied. Pt
tolerated without complaints.”
Documentation of Complicated
Wound Care
“Patient premedicated with Lortab ii tabs po for
dsg change. Sterile dsg change performed on abd
wound after 30 minutes. Outer ABD pad with 4x3
cm area of serosanguineous drainage. Removed
two 4x4s 50% saturated with serosanguineous
drainage. Removed 12 cm of serosanguineous
saturated NuGauze packing. Incision open,
8(L)x4(W)x3(D)cm. No signs of infection
present….”
Documentation cont’d
Granulation noted in wound bed. Incision
irrigated with 60 mL sterile saline. Aerobic
culture taken as ordered. Wound packed
with 12 cm saline soaked NuGauze, covered
with 2 sterile 4x4s and ABD pad. JP drain
emptied of 45 mL of serosanguineous
drainage. No odor or clots present. Pt
tolerated with minimal discomfort. Culture
taken to lab.”