Fundamentals – tissue integrity PDF

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Kristen Needler...

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Fundamentals – tissue integrity & wound care 

Tissue integrity is the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes o Remember: Pink, Warm, Dry, and Intact

Epidermis 

Cells are flattened and dead

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Protects underlying cells and tissues from dehydration

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Prevents entrance of certain chemical agents

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Allows evaporation of water from the skin

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Permits absorption of certain topical medications

Dermis 

Inner layer o Provides tensile strength, mechanical support, and protection to the underlying muscles, bones and organs o It contains mostly connective tissue and few skin cells

Alterations in tissue integrity -Pressure ulcers 

A localized injury to the skin and other underlying tissue

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Usually over a bony prominence, as a result of pressure or pressure in combination with shear and or friction o Can appear in an hour time frame

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Pathogenesis of Pressure Ulcers o Pressure intensity 

Tissue ischemia

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Blanching 

If it doesn’t blanch, its stage one

o Pressure duration

o Tissue tolerance  

Nutritional status, hydration, disease process?

Risk factors o Prolonged pressureunable to reposition self independently 

Interventions 

Turn Q 2 hour

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Relieve pressure on bony prominences

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Prevention tactics like changing dressing

o Shearforce that is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary 

Lift up and move, don’t drag

o Frictionforce of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens 

Classifications of Pressure Ulcers o I  intact skin with nonblanchable redness 

Discoloration of the skin, no open area

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warmth, edema, hardness, or pain may also be present

o II  partial-thickness skin loss involving epidermis, dermis, or both 

Shallow, open ulcer with a red-pink wound bed without slough

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may also be a serum/fluid filled blister

o III  full-thickness tissue loss with visible fat

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Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed

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Some slough may be present; may include undermining and tunneling 

Underminingarea of tissue injury beneath intact akin around the margins of a wound

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Tunnelinga tract of injury occurring in any direction from surface or edge of wound

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Must fill the patch/tunnel to promote healing

 o IV  full-thickness tissue loss with exposed bone, muscle, or tendon 

Slough or eschar may be present often with undermining and tunneling

o Unstageable  full-thickness skin or tissue loss-depth unknown

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Base of wound cannot be visualized and depth of injury is unknown because necrosis

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Can be either stage 3 or 4

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Eschar on the heels serves as “the natural (biological) cover of the body” and should not be removed

Deep Tissue Injury o Full-thickness skin or tissue loss-depth unknown o Stable (dry, adherent, intact without erythema) o May also present as a blood-filled blister

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Braden scale for pressure ulcer risk score

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SKIN interventions o S  surface appropriate o K  keep turning o I  incontinence management o N  nutrition assessed

-Wounds and Wound Care 

Granulation tissuesoft, pink, fleshy projections of tissue that form during the healing process in a wound not healing by primary intention o Primary intentionfrom the outside down/outside in o Secondary intentioninside out; leave open o Escharthick layer of dead, dry tissue that covers a pressure ulcer or thermal burn

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May be allowed to be sloughed off naturally, or is may need to be surgically removed

o Exudate fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes 

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Complications of wound healing o Hemorrhageinitial trauma; normal during and immediately after 

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After hemostasis (stopping the flow of blood): 

Slipped surgical suture

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Dislodged clot

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Infection

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Erosion of a blood vessel

May be internal or external 

Internal o Distention or swelling of the affected body part o Type and amount of drainage o Signs of hypovolemic shock o Hematomalocalized collection of blood underneath the tissue

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External

o Obvious o Risk of hemorrhage is great during first 24-48 hours after surgery or injury o Infectionwound infection is the second most common health-care associated infection 

A wound is infected if purulent material drains from it

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Wound infection is greater when 

Wound contains death or necrotic tissue

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There are foreign bodies in or near the wound

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Blood supply and local tissue defense are reduced

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Bacterial wound infection inhibits wound healing

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Signs and symptoms of a wound infection

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Contaminated or traumatic wounds: 2-3 days

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Post-op surgical wound: 4-5 days

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Fever, tenderness and pain at wound site

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Elevated WBC counts

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Wound edges appear inflamed

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Drainage may be present: odorous and purulent (yellow, green, or brown)

Infection drainage 

Serous o Clear, watery plasma

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Purulent o Thick, yellow, green, tan, or brown

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Serosanguinous o Pale, pink, watery o Mixture of clear and red fluid

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Sanguineous o Bright red: indicates active bleeding; thick

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Dehiscencepartial or total separation of wound layers 

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Sutures/staples pop open

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Eviscerationwith total separation of wound the visceral organ protrudes through the wound opening

-Wound care, dressings, and drains 

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Principles to maintain a healthy wound environment o Prevent and manage infection o Clean the wound o Remove nonviable tissue o Manage exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ especially in inflammation o Maintain the wound in a moist environment o Protect the wound o Must have an order to change dressings

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Prevent and manage infection o Cleaning the wound 

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Pressure ulcers: use noncytotoxic wound cleaners

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NSpreferred cleaning agent, does not harm tissue

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Commercial wound cleaners

Other wounds: cytotoxic wound cleaners 

Dakin’s solution

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Acetic acid

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Povidone-iodine

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Hydrogen peroxide

Irrigation is a common method of delivering wound-cleaning solution to the wound if ordered

Debridementremoval of nonviable, necrotic tissue o Wet to dry dressings o Autolytic debridement o Chemical debridement o Surgical debridement

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Protection o Protect the wound by applying a sterile or clean dressing o For surgical wounds that heal by primary intention, it is common to remove dressings as soon as drainage stops o For wounds healing by secondary intention, the dressing material becomes a means for providing moisture to the wound or assisting in debridement

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Purposes of dressings o Protect a wound from microorganism contamination o Aid in hemostasis o Promote healing by absorbing drainage and debriding a wound o Support or splint the wound site o Protect patients from seeing the wound (if perceived as unpleasant) o Promote thermal insulation of the wound surface

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Dressings o Dry or moist 

Gauze

o Film dressing

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o Hydrocolloidprotects the wound from surface contamination o Hydrogelmaintains a moist surface to support healing o Wound vacuum assisted closure (V.A.C.)uses negative pressure to support healing o Changing 

Know which type, placement of drains, and equipment needed

o Prepare the patient for a dressing change 

Evaluate pain

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Describe procedure steps

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Gather supplies

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Recognize normal signs of healing

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Answer questions about procedure or wound

o During a dressing change: 

Assess the skin beneath the tape

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Perform thorough hand hygiene before and after wound care

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Wear clean gloves before directly touching an open or fresh wound

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Remove or change dressings over closed wounds when they become wet or if the patients has signs or symptoms of infection, and as ordered

o Packing a wound 

Assess size, depth, and shape

o Securing tape, ties, or binders o Comfort measures

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Carefully remove tape

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Gently clean the wound

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Administer analgesics before dressing change

Cleaning skin o Clean in direction from the least contaminated to most contaminated area 

Such as from the wound or incision to the surrounding skin

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Or from an isolated drain site to the surrounding skin

o Use gentle friction when applying solutions locally to the skin

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When irrigating, allow the solution to flow from the least to the most contaminated area...