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. 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

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 Tissue Integrity

Risk Factors Prolonged pressure Poor hygiene Poor nutrition and hydration Incontinence Breaks in the skin Resistance to injury – Age, amount of underlying tissues, illness

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 flesh- colored 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 Age Related Changes (Older Adult)

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 Vascular Lesions

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 Age Related Changes (children)

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) State of Health

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

Tissue Integrity Imbalance - Assessment What is a risk assessment? – Braden Scale (Weber, pg. 259, Taylor, pg. 936) – PUSH tool (Weber, pg ) – Focused Assessment (Taylor, pg. 935) Identify questions to ask in a focus assessment

Stage I to IV pressure ulcer Tear in skin, abrasions, lacerations Depression, low self- esteem Changes in skin color, skin temperature Fluid and electrolyte imbalance Itching Burning Pain Excessively dry skin, peeling skin Draining wound Physical Clinical Manifestations What would you expect to see in a patient at risk for skin breakdown ?

– 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 Tests

Diagnostic Testing Patch TestingWoods Lamp

– Lab work such as chemistry and CBC – Doppler if suspected perfusion issue – MRI and CT scans to detect deep tissue injury Diagnostic Tests

Pain medications Topical Antibiotics Topical Antifungals Topical Steroids Medicated lotions or powders Sprays and aerosols Bleach solutions Drug Therapy

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. Positive Consequences

Pain Infection Altered body image Loss fluid and electrolytes Skin breakdown (dermal ulcers) Negative Consequences

Intact skin is interrupted by – Wounds (traumatic or surgical) – Dermal Ulcers – Impetigo – Tinea pedis – Candida – Pediculosis – Psoriasis Exemplars for Tissue Integrity

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 Traumatic or Surgical

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

 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 Wounds- traumatic or surgical

 Phases of wound healing: – Inflammatory phase – Fibroblastic or connected tissue repair phase – Maturation or remodeling phase Wound Healing Process

Primary intention Second intention (granulation) and contraction Third intention (delayed closure) 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 Wound Healing Process

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

 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 Healing by Tertiary/Delayed Primary Closure

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 Presentations

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 Ulcers/Pressure Ulcers

Location Size Extent of tissue involvement Cell types in the wound base and margins Drainage Condition of surrounding tissue Dermal Ulcer/Wound Assessment

Dressings: – Mechanical debridement – Natural chemical debridement – Hydrophobic material – Hydrophilic material Drug therapy Nutrition therapy Surgical debridement Treatment

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 Impetigo

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 Tinea Pedis

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. Candida

 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 Pediculosis

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 Psoriasis

Corticosteroids Other topical therapies Ultraviolet light therapy Systemic therapy: – Immunosuppressants Emotional support Treatment of Psoriasis