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Tissue Integrity Susan Fowler [email protected] Objectives p. 4 The 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 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 Written as “Risk for Altered Tissue (or Skin) Integrity 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. 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 Obesity/ Malnutrition Pain Prolonged surgery Fever Mental deterioration Advanced age Contractures Low blood pressure Poor hygiene Neurological disorders Vascular disease Diabetes mellitus Anemia Clinical Manifestations Ulcers are graded or staged according to the deepest level of damage Stage I (minor) to Stage IV (severe) p. 1283 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 tx. p. 1285 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 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 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 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 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 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 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 Nursing Responsibilities R/T Wound Care Goal is for wound to remain intact with no complications Assessment-size, color, drainage p. 1287 Dsg change may be simple or complex Remove staples and apply steri-strips Don’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 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.”
