Download Concept Definition

Tissue Integrity
RNSG 1471 Health Care Concepts 1
Tissue Integrity
• Objectives
– Explain the concept of tissue integrity (including definition,
antecedents, and attributes).
– Analyze conditions which place a patient at risk for impaired
tissue integrity.
– Identify when Tissue Integrity imbalance (negative
consequence) is developing or has developed.
– Discuss exemplars of common Tissue Integrity disorders.
– Apply the nursing process (including collaborative
interventions) for individuals experiencing Tissue Integrity
imbalance and to promote normal Tissue Integrity.
Anatomy and Physiology Review
• Structure of the skin
–Epidermis
–Dermis
–Subcutaneous tissue
–Hair
–Nails
–Sebaceous, sweat, and mammary glands
Normal Skin and Tissue
Tissue Integrity
• Concept Definition
• The ability of body tissues to regenerate
and/or repair to maintain normal
physiological processes
Tissue Integrity
• Antecedents
–Good nutrition
–Lack of external trauma
–Adequate perfusion
–Limited pressure on site
• Attributes
–Structurally intact and functioning
integument
Risk Factors
• Prolonged pressure
• Poor hygiene
• Poor nutrition and hydration
• Incontinence
• Breaks in the skin
• Resistance to injury
–Age, amount of underlying tissues, illness
Age Related Changes (Older Adult)
• Subcutaneous and dermal tissue becomes thin
• Activity of the sebaceous and sweat gland decreases
• Healing time is delayed
• Melanocytes decline in number
• Skin loses elasticity
• What are the nursing strategies for each age related
change?
Pg. 921 (Taylor)
Age Related Changes (Older Adult)
• Skin lesions
–Skin tags (soft brown or fleshcolored papules), benign
–Seborrheic Keratosis
•Overgrowth of the horny layer
of keratinocytes, benign tumors
•In people of color, multiple
small lesions on the face are
termed dermatoses papulosa
nigra
Age Related Changes (Older Adult)
• Actinic keratosis
–Most common premalignant skin lesions
–develops on sun exposed areas, appears
as dry, brown, scaly areas, reddish tinge
–20% convert to squamous cell carcinomas
• Solar lentigines
–Small (5-10 mm) benign, oval or round,
tan-brown macules or patches
–Referred to as “liver spots,” appear on sun
exposed areas
–Weber, pgs. 266-267
Vascular Lesions
Cherry angiomas
smooth, cherry-red or purple, dome-shaped
papules, occur in nearly all people > 30,
usually appear on the trunk, benign
Telangiectases
single dilated blood vessels, capillaries that
appear on areas exposed to sun or harsh
weather such as the cheeks and nose
Venous lakes
small, dark blue, slightly raised papules, have a
lake like appearance; occur on exposed
body parts, i.e., backs of the hands, ears, and
lips
Age Related Changes (children)
• Children < 2 years, the skin is thinner and weaker
• An infant’s skin and mucous membranes are
injured easily and are subject
• A child’s skin because increasingly resistant to
injury and infection
State of Health
• Very thin and very obese more susceptible to skin
irritation and injury
• Fluid loss through fever, vomiting or diarrhea
• Excessive perspiration
• Jaundice (excessive bile pigments), skin is itchy and
dry
• Diseases of the skin such as eczema and psoriasis (may
have a genetic disposition, may cause lesions)
Tissue Integrity Imbalance - Assessment
• How does the nurse recognize when an
imbalance is developing or has developed?
–Comprehensive History
–Skin and overall health assessment; risk
assessment
• Weber, Health Assessment, Ch. 14, Assessing skin, hair
and nails, pgs. 239-270
Tissue Integrity Imbalance Assessment
• What is a risk assessment?
–Braden Scale (Weber, pg. 259, Taylor, pg. 936)
–PUSH tool (Weber, pg. 260-261)
–Focused Assessment (Taylor, pg. 935)
•Identify questions to ask in a focus assessment
Physical Clinical Manifestations
What would you expect to see
in a patient at risk for skin
breakdown?
•Itching
•Burning
•Pain
•Excessively dry skin,
peeling skin
•Draining wound
• Stage I to IV pressure ulcer
• Tear in skin, abrasions,
lacerations
• Depression, low selfesteem
• Changes in skin color, skin
temperature
• Fluid and electrolyte
imbalance
Diagnostic Tests
–Wound culture
–Tissue (skin) biopsy
–Black light or immunofluorescence (antibodies
can be made fluorescent by attaching to a dye)
• Detects autoantibodies directed against portions of
the skin
–Patch Testing
• Identifies substances patient has developed allergy
–Fragrances, nickel, dog/cat dander)
Diagnostic Tests
–Skin scraping
• Scraped from fungal lesions, identify spores as well as
infestations such as scabies
–Tzanck Smear
–Examine cells from blisters to identify herpes zoster,
varicella, herpes simplex
–Woods light
• Produces long wave ultraviolet rays (blue to purple
fluorescence) to differentiate epidermal from dermal
lesions and hypo and hyperpigmented lesions
Diagnostic Testing
Patch Testing
Woods Lamp
Diagnostic Tests
–Lab work such as chemistry and CBC
–Doppler if suspected perfusion issue
–MRI and CT scans to detect deep tissue
injury
Drug Therapy
Pain medications
• Topical Antibiotics
• Topical Antifungals
• Topical Steroids
• Medicated lotions or powders
• Sprays and aerosols
• Bleach solutions
•
Positive Consequences
• Protection from infection (first line of
defense)
• Adaptation to the environment
• Maintenance of fluid and electrolyte
balance
• Regulation of acid-base balance
• Vitamin D production.
Negative Consequences
• Pain
• Infection
• Altered body image
• Loss fluid and electrolytes
• Skin breakdown (dermal ulcers)
Exemplars for Tissue Integrity
• Intact skin is interrupted by
–Wounds (traumatic or surgical)
–Dermal Ulcers
–Impetigo
–Tinea pedis
–Candida
–Pediculosis
–Psoriasis
Wounds Traumatic or Surgical
• Degree of contamination
• Clean or dirty
• Contaminated
–A wound that is exposed is always contaminated but
not always infected.
–the presence of organisms without any manifestations
of infection.
• Infected
–contamination with pathogenic organisms to the
degree that growth and spread cannot be controlled
by the body’s immune defenses
Wounds
• Classified as:
–Intentional or unintentional
–Open or closed
• Occurs from intentional or unintentional
–Acute or chronic
• In chronic wounds the healing process is impeded,
risk of infection increases
–Partial-thickness, full-thickness or complex
Wounds
•Partial thickness
–Involve damage to the epidermis and upper layers of the
dermis
–Heal by re-epithelialization within 5 to 7 days
–Skin injury immediately followed by local inflammation
•Full thickness
–Damage extends into the lower layers of the dermis and
underlying subcutaneous tissue.
–Removal of the damaged tissue results in a defect that
must be filled with granulation tissue to heal
Wounds
Wounds- traumatic or surgical
Care of wound
•Untreated
–Control bleeding
–Prevent infection
–Control swelling and pain
–Assess for signs of shock
•Treated
–Observe wound and dressing
–Assess and manage pain
–Prevent infection
Wound Healing Process
Phases of wound healing:
–Inflammatory phase
•http://youtu.be/Un9-vubdtmY
–Fibroblastic or connected tissue repair phase
–Maturation or remodeling phase
Wound Healing Process
• Primary intention
• Second intention (granulation) and
contraction
• Third intention (delayed closure)
• http://youtu.be/QgLyxnmJ4o4 Dr. John
Campbell, wounds and healing, 6 primary
and secondary healing
Wound Healing Process
• First intention
–Edges well approximated
–Healing occurs with
minimal granulation tissue
& scar formation
–Surgical incision, cut
Wound Healing Process
• Second intention
–(granulation) and contraction
–Extensive tissue loss
–Have large amounts of exudate and wide,
irregular wound margins; edges cannot be
approximated.
–Scarring is greater
–More susceptible to infection
–Occur from trauma, ulceration, and infection
Healing by secondary intention
 Healing is
essentially the
same as primary
 Healing and
granulation take
place from the
edges inward and
from the bottom
of the wound
upward until the
defect is filled
Healing by Tertiary/Delayed Primary Closure
Delayed primary intention due
to delayed suturing of the wound
Occurs when a contaminated
wound is left open and sutured
closed after the infection is
controlled
Requires skin grafting
Presentations
• Divide into groups
• Pick from the following exemplars:
–Dermal Ulcer (group 1)
–Impetigo (group 2)
–Psoriasis (group 3)
–Tinea Pedis
(group 4)
–Candida Pediculosis (lice)
• Complete presentations based on grading rubric
• Due on November 17, 2014
Dermal Ulcers/Pressure Ulcers
• Tissue damage caused when the skin and underlying
soft tissue are compressed between a bony
prominence and an external surface for an extended
period.
• Mechanical forces that create ulcers:
–Pressure
–Friction
–Shear
Dermal Ulcers/Pressure Ulcers
• High Risk Patients
–Impaired mobility
–Poor Nutritional status
–Incontinence
Dermal Ulcers/Pressure Ulcers
• Pressure ulcers are classified and assessed in four
stages:
–Stage I
–Stage II
–Stage III
–Stage IV
Dermal Ulcer/Wound Assessment
• Location
• Size
• Extent of tissue involvement
• Cell types in the wound base and margins
• Drainage
• Condition of surrounding tissue
Treatment
• Dressings:
–Mechanical debridement
–Natural chemical debridement
–Hydrophobic material
–Hydrophilic material
• Drug therapy
• Nutrition therapy
• Surgical debridement
Impetigo
• Is a common skin infection usually caused by
streptococcus or staphlococcus bacteria
• Most common in children
• Occurs when a break in the skin allows bacteria to
enter causing inflammation and infection.
Impetigo
• Clinical Manifestations include
–One or many blisters that itch
–Filled with yellow to honey colored fluid
–Blisters ooze and crust over
–Spread by direct contact with fluid in blisters
–Can spread on the patient by patient scratching and then
touching another part of body
Impetigo
• Diagnostic test
–Physical exam
–Wound culture
• Treatment
–Topical antibiotics
–If MRSA will need antibiotics that infection is
sensitive to.
–If left untreated will usually clear on it’s own but
may lead to glomerulonephritis
Impetigo
• Prevention includes
–Keeping skin clean and dry
–Cleaning minor cuts and scrapes with soap and
water
–If infection, avoid sharing personal care items
with family members
–After touching infected skin wash hands with
soap and water
Tinea Pedis
• Fungal infection commonly called athletes foot.
•Spread through direct contact or by inanimate
objects
•Lesions may be scaly patches with raised borders
•Pruritus common symptom
• Treated with antifungal sprays and creams
• Teach patient about medications, hygiene practices,
and how to prevent infection
Candida
• Fungal infection commonly called a yeast
infection
• Can occur on skin, orally or vaginally
• Occurs on the skin due to prolonged wetness
• Occurs orally or vaginally usually due to use of
antibiotics
• Assess patient’s skin and oral mucous
membranes
Candida
• May appear red and scaly on skin
• Oral form know as thrush; the tongue will have a
white coating that cannot be removed
• Treated with medicated powders or creams for
skin form.
• Medicated mouthwash such as Nystatin for the
oral form.
Pediculosis
Pediculosis—infestation by human lice:
• Head lice—pediculosis capitis
• Body lice—pediculosis corporis
• Pubic or crab lice—pediculosis pubis
Pruritus most common symptom
Laundering of clothing and bed linen
Teach patient how to prevent infestation
Teach hygiene practices
Psoriasis
• Autoimmune disorder with over production of skin
cells, exacerbations and remissions do occur.
• Scaling disorder with underlying dermal
inflammation
• Psoriasis vulgaris most often seen
• Exfoliative psoriasis—an explosively eruptive and
inflammatory form of the disease
Treatment of Psoriasis
• Corticosteroids
• Other topical therapies
• Ultraviolet light therapy
• Systemic therapy:
–Immunosuppressants
• Emotional support