Tissue Integrity

Susan Fowlersfowler@tricountycc.edu

Objectives p. 4The concept of tissue integrity will be discussed as well as tissue damage.Tissue damage will be demonstrated by the exemplars of pressure ulcers and wound care.

Tissue IntegrityDefined 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 DamageWide variety of disease processes (mental and physical)Nutritional stateAgeImmobilityMoisture Shear and frictionWritten as “Risk for Altered Tissue (or Skin) Integrity

Actual Tissue DamageMay be surgical wound or traumaSurgical wounds can be open or closedTraumatic wounds can be intentionally inflicted or unintentionally inflicted. Risk factors coupled with neglect can cause a kind of tissue damage called pressure ulcers.

Pressure UlcerA localized area of tissue necrosis caused by unrelieved pressure that occludes blood flow to tissues.Usually located over body prominencesMost common sites are sacrum and heels

Influencing FactorsAmount of pressureLength of time pressure is exertedAbility of tissue to tolerate externally applied pressure

Contributing FactorsShearing 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 otherExcessive moisture

Risk FactorsImmobility Incontinence Impaired

circulation Obesity/Malnutrition

Pain Prolonged surgery

Fever Mental deterioration

Advanced age

Contractures Low blood pressure

Poor hygiene

Neurological disorders

Vascular disease

Diabetes mellitus

Anemia

Clinical ManifestationsUlcers are graded or staged according to the deepest level of damage Stage I (minor) to Stage IV (severe) p. 1283Slough or eschar may need to be removed to accurately stage some ulcersUlcers also may be classified as red, yellow, or black to help determine the best tx. p. 1285

Stage IPersistent redness in lightly pigmented skinRed, blue, or purple in darker skinMay be warm to touchMay have poor sensationDoes not blanchSkin may be boggy, swollen, or thin over site, but no skin break is evident

Stage IISkin is broken with partial thickness loss of epidermis, dermis or bothPresents as an abrasion, skin tear, intact or ruptured blister, or shallow crater

Stage IIIFull-thickness loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fasciaPresents as a deep crater with possible undermining of adjacent tissue

Stage IVFull-thickness loss can extend to muscle, bone, or supporting structuresBone, tendon, or muscle may be visible or palpableUndermining and sinus tracts may also exist

ComplicationsRecurrence is most commonInfection—fever, leukocytosis, pain, increase in size, odor, or drainageCellulitis—surrounding tissue infectionChronic infection—may persist for monthsSepticemia (blood infection)Osteomyelitis (bone infection)

AssessmentOn admission (RN) and periodically according to protocolUse assessment tool such as Braden ScaleUse inspection and palpation to assess color, breakdown, and temperatureUse natural or halogen light rather than fluorescent to assess dark skinAsk patient how it feels—is it painful, itchy, or numb?

Expected OutcomesNo deteriorationReduce contributing factorsNo presence of infectionHeal without complications or recurrence

Interventions: PreventionIdentify risk factorsImplement prevention strategies:

Remove excessive moistureGood skin and incontinence careAvoid massage over bony prominencesTurn every 1 to 2 hours and avoid shearingUse lift sheetsPillows, heel and elbow protectorsSpecialty beds

Prevention cont’dCaloric intake elevated to 30 to 35 cal/kg/d or 1.25 to 1.5 g protein/kg/daySupplements, enteral (GI), or parenteral (IV) feedings may be necessaryKeep patients as mobile as possible

Interventions: TreatmentDocument size, stage, location, exudate, infection, pain, and tissue appearanceKeep ulcer bed moistCleanse with nontoxic solutions (saline)Debride by medications or refer for surgical debridementAdhesive membrane, ointment, moisture-retentive dressingsTeach self-assessment and self-care

Interventions: Operative RepairSkin graftsSkin flapsMusculocutaneous flapsFree flapsSurgical debridement

Interventions: Patient/Family Education

Assess resourcesExplain risk factors and causesTeach incontinence careDemonstrate correct positioning, turningTeach daily inspectionTeach wound careStress good nutrition

EvaluationPrevention strategies implementedWound has not deterioratedNo complicationsWound healed with no recurrencePatient/family understands instructions

Wound HealingPrimary—straight line with all layers well-approximated, free of infection, no separation, fast healing, minimal scarringSecondary—healing from inside out by granulation, increased infection risk, slow healing, extensive scarringTertiary—delay of 3-5d between injury and suturing, increased chance of infection and separation

Healing PhasesInitial (3-5d)—approximation, epithelial cell migration, mesh and initial capillary growthGranulation (5d-4wk)—fibroblast migration, collagen formation, capillary beds formed, fragile tissueScar contracture (7d-mos)—remodeling of collagen, strengthening of scar

Factors Affecting HealingAge—younger heals quickerNutritional status—malnourished and obeseSystemic disorders—DM, circulatory probs, immunosuppressionPresence of foreign bodiesInfectionMeds—corticosteroids, antibiotics, anticoagulants

Factors cont’dIrradiationTreatment of woundWound stressors—coughing, straining, vomiting, traumaType of woundPresence of drainsRace—keloid formation in darker races

Complications of HealingHemorrhageInfectionDehiscence and evisceration

Nursing Responsibilities R/T Wound Care

Goal is for wound to remain intact with no complicationsAssessment-size, color, drainage p. 1287Dsg change may be simple or complexRemove staples and apply steri-stripsDon’t forget patient education and documentation

Documentation of Wound Care“Sterile dsg change performed on abd wound. Old 4x4 dressing clean and dry. Wound 10 cm, closed, edges well-approximated, 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’dGranulation 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.”