Tissue Integrity

Question 1

What is tissue integrity?

Answer 1

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

Question 2

Scope of tissue integrity

Answer 2

1. Intact skin and tissue: beautiful skin with no problems
2. Partial thickness injury: partial injury where it may be injured under epidermis
3. Full-thickness injury: injury all the way to the bone

Question 3

Define epithelium

Answer 3

Elastic state of skin and tissue

Question 4

Define debridement

Answer 4

Removal of dead, damaged, or infected tissue

Question 5

Define granulation

Answer 5

Connective tissue that forms on the surface of a healing wound

Question 6

Define turgor

Answer 6

Elastic state of skin and tissue

Question 7

Define emollient

Answer 7

Agents that soften skin or treat dry skin

Question 8

Physiological Processes: Skin Function

Answer 8

Epithelial cells cover all internal and external body surfaces
Functions are: protection, absorption, secretion, excretion

Question 9

What is primary intention?

Answer 9

think of a surgical wound where there is a straight cut with a nice, clean wound; can be sutured or stapled; cleaner healing; may have a small scar
- Wound margins well approximated
- Lacerations and surgical incisions.
- The most rapid healing.

Question 10

What is a secondary intention?

Answer 10

pressure ulcers; almost like a crater; think of a road rash; granulation tissue forms on the bottom and works its way up; leads to big scars because it is a lot of scar tissue and granulation
- Wound margins not well approximated.
- Larger wound area requires the formation of granulation tissue to fill gap.
- Longer period of time needed to heal.

Question 11

What is a tertiary intention?

Answer 11

dirt biking and you crash into the cactus and all the dirt so you have a dirty wound full of dirt, sand, cactus, etc. and cant close wound up right away, let it drain, flush it, let it heal, and LATER we will close it with a suture if it is still not coming together
- Wound healing delayed and occurs when wound previously open is now closed.
- Usually associated with large infected/contaminated wounds.

Question 12

What populations are at greatest risk for impaired tissue integrity?

Answer 12

• Infants: cannot move as much when they’re new and have sensitive skin; recommend to parents draft baby detergent; less subq fat so they have thinner skin; get pee and poop all over them leading to diaper rash; change their diaper as soon as you notice
• Children: are at risk because they get into everything, fall, climb on things they are not supposed to; don’t know boundaries yet; more prone to accidents
• Older adults: are at risk because they may be incontinent, less skin elasticity; thinner skin; 65+ community; reduced mobility; fall risks; long term meds (corticosteroids) that can thin out the skin a lot

Question 13

Risk factors for impaired tissue integrity

Answer 13

• Health conditions: poor peripheral perfusion, malnutrition or obesity, dehydration or edema, impaired mobility, immunosuppression
• Exposure to irritants: Radiation, temperature extremes, chemical, mechanical trauma, medical treatments, occupation (miners), detergents and softeners
• Tissue trauma: Friction, shearing, moisture, pressure, sun exposure (tanning)

Question 14

Health History

Answer 14

General health history: past and current conditions, family history, allergies, current and recent medications, history of skin disorders
- Problem-based history: Changes in skin condition and color, new rash or lesion; changes in previous lesions, excessive bruising, loss of hair; changes in condition of nails, wounds slow to heal

Question 15

Examination

Answer 15

Inspection: General color and condition of skin
Lesions: location, size, shape, color, pattern, characteristics (e.g.,raised versus flat, dry versus exudate)
Palpation: feel skin for surface characteristics, temperature, and texture, pinch skin for turgor
- Pink tinge to skin, look at mucous membranes
- Always look for lesions, is there a pattern, how deep is it, something abnormal on skin
- Perfusion!! Cap refill on both extremities
- Take off socks when doing pedal pulses

Question 16

Assessment of Wound Ulcers

Answer 16

• Acute wound or chronic wound
• Location
• Size (length, width, depth)
• Color (red, yellow, black)
• Cleanliness (clean, contaminated)
• Odor
• Presence of wound drains (type)
• Presence of drainage and exudate: Serous (clear fluid), serosanguineous (blood mixed with clear, pinkish), sanguineous (blood), purulent
• Staging wound ulcers
• Stages I, II, III, IV, nonstageable

Question 17

Primary Prevention

Answer 17

Skin hygiene
Adequate nutrition and hydration
Avoidance of excessive sun exposure-suncreen
Burn safety precautions
Dermal ulcer prevention
Activity restriction

Question 18

Prevention of Pressure Ulcers

Answer 18

• Inspect skin daily
• Minimize pressure
• Frequent position changes-reposition at least every 2 hours
• Protect skin during turning and repositioning-lift devices, draw sheets
• Manage Moisture
• Incontinence care
• Bathing-soaps: warm water NOT HOT, do not burn them
• Lotion and massage-do not massage over bony prominences: (can decrease circulation)
• Linens

Question 19

Principles of Wound Care Depending on Wound

Answer 19

• Initial and ongoing assessment
• Cleansing and irrigation: Cleaning is performed for the removal of debris and exudate; Normal saline solution is used; harsh solutions are avoided
• Dressings: Gauze, non-adherent dressings, occlusive, semiocclusive, hydrocolloid, hydrogel, and alginate are applied; Vacuum-assisted systems are used (Hemovacs, JP drain)

Question 20

Clinical Management

Answer 20

• Pharmacotherapy: antibiotics, steroids, emollients, chemotherapy agents
• Phototherapy
• Surgical Interventions: excisions, debridement, skin grafts/flaps, bypass/angioplasty
• Wound care
• Nutritional Support: protein, vitamin A, and vitamin C are critical

Question 21

ABCDE screening for malignant melanome

Answer 21

• Melanoma spreads quickly
• It digs deeper and takes edges around as it is invasive
  A: asymmetry
  B: border
  C: color
  D: diameter
  E: evolving