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TISSUE INTEGRITY FROM GIDDENS
Terms in this set (113)
Largest organ of the body and what is its function?
The skin--- serves as a barrier or protective coating and protects us from infections, keeps us from losing fluid, and helps us manage temperature, and the nerves of the skin help us detect pain, temperature, and touch
Why is it important for nurses to understand tissue integrity and the importance of the skin?
The nurses job is to maintain optimal skin integrity/tissue integrity and they work individually and with others to care for management when that integrity is disrupted
Definition of tissue?
Organized groups of cells with common functions
Four types of tissues?
Muscle, neural, connective, and epithelial
Most important of the tissues r/t to tissue integrity?
Impaired skin integrity can affect?
Epidermis and dermis skin layers, but if it gets deep enough, it can damage underlying structures such as bones, joints, muscles, etc.
Definition of tissue integrity?
The ability of the body tissues to regenerate and/or repair to maintain normal physiological processes
Antecedents of tissue integrity?
"GENERALLY LESIONS LIMIT ACTIVITY"
Lack of external trauma
Limited pressure on site
Affected by life cycle (life to death)--- as we age, our body loses to ability to regenerate cells as quickly or as efficiently
Attributes of tissue integrity?
Integument is structurally intact and functioning
Normal healing process
Interrelated concepts of tissue integrity?
Negative consequences associated with tissue integ
"pain is a little devil"
Altered body image
Loss of fluid and electrolyte
Decubiti or amputation
"puff and pass"
protection from infection
Adaptation to environment (sweating); maintenance of F&E
Regulation of acid-base balance
vitamin D production (the sun)
Protection from injury/trauma
Removal of dead, damaged, or infected tissue?
Agents that soften skin or treat dry skin?
Connective tissue that forms on the surface of a healing wound?
Tissue that lines cavities and structure surfaces throughout the body
Elastic state of skin or tissue?
The scope of tissue integrity ranges from?
Intact skin and tissue> partial thickness injury> full thickness injury
Describe the purpose and function of epithelial cells?
Cover all internal cavities and structure surfaces on the external body and their function includes:
protection from external environment
, absorption of needed substances
, secretion into body cavities
, excretion of wasts from the boy
Three types of wound healing process?
Definition of primary intention wound?
Wound margins are approximated; examples include laceration and surgical incisions. This process the has the most rapid healing time
Definition of secondary intention wound healing?
Wound margins are not well approximated; larger wound area requires the formation of granulation tissue to fill in the gap A longer period of time is needed to heal; ulcerations are examples because the edges do not approximate
Definition of tertiary intention wound healing?
Wound healing is delayed and occurs when the wound that was previously open is now closed. This process is usually associated with large infected and contaminated wounds--- wound is sutured closed only after a long period of healing and results in more scarring than wounds closed with primary intention---takes place when a wound close is delayed until resolution of infection or wound contamination, then the clean and partially healed wound is sutured to facilitate continued would healing.
Three phases of wound healing?
Inflammatory phase- lasts 3-5 days; homeostasis develops; macrophages remove debris; blood clots form at the site of injury and platelets release growth factors to begin the healing process
Granulation phase- lasts 5-21 days; new blood vessels and collage structures are formed (new growth)--- results in very vascular pink tissue--- WBC's still working--- epithelium grows from edges towards the center
Maturation phase- lasts for months or years; collagen fiber is remodeled; scar formation and contraction occur
Definition of hematoma?
collection of blood or a blood clot
population most at risk for impaired tissue integrity?
more cases of immobility and bed immobility, cognitively impaired or undeveloped
Individual risk factors?
Poor peripheral perfusion
Malnutrition or obesity
Dehydration or edema
Exposure to irritants such as radiation, temperature extremes, chemical or mechanical trauma, and medical tx
Tissue Trauma include:
Moisture pressure/ incontinence
- adequate nutrition
- burn safety precautions
- dermal ulcer prevention
Collaborative interventions include?
- Nutritional support (protein, vitamin A, and vitamin C are critical
- Phamacotherapy includes: antibiotics, steroids, emollients, chemotherapy agents
- Photo therapy
- Surgical interventions- excisions, debridement, and skin grafts
- Wound care
What must we use to clean the wound? and how?
Normal saline, irrigate from the center outwards (center of least contamination to most)--- we clean for the removal of debris and exudate
Types of dresses include:
- vacuum assisted systems
Areas of the body when a relatively minor blunt or penetrating injury with can extend directly through the skin layers to the muscle or bone
areas with little to no subcutaneous skin, such as back of the hand, top of the foot, or the skull
An example of an intentional injury inflicted to reach deeper structures for a therapeutic purpose?
Prolonged poor perfusion or a short period of no perfusion can lead to?
Examples of poor perfusion?
Loss of toes r/t diabetes
peripheral arterial disease
Examples of short term or temporary disruptions of perfusion to tissue caused by unrelieved pressure include?
dermal or pressure ulcers--- dermal ulcers are described as bedsores, pressure sores, or pressure ulcers
Common substances that lead to skin irritation and/or local allergic response that should not be used on patients at risk for impaired tissue integrity?
soaps, detergents, cleaning products, fragrances, and metals such as nickel, silver, and copper
A recurrent inflammatory disease that affects 2% of the population in the U.S.
Definition of psoriasis?
An autoimmune disorder with an over production of skin cells, exacerbations and remissions do occur--- a scaling disorders with underlying dermal inflammation "remember shallow hall"
Most common type of psoriasis?
What is exfoliative psoriasis?
an explosively eruptive and inflammatory form of the disease
How to treat psoriasis?
Other topical therapies
UV light therapy
Systemic therapy: immunosuppressants (stops the body from destroying itself)
Emotional support (many people with psoriasis develop altered body image)
Skin and mucous membrane infections can be the result of?
bacteria, fungi, and viruses (that's why when pulmonary secretions stay in the respiratory system, pt is at risk for stasis pneumonia
Which kind of bacteria can cause superficial or deep infection?
How do opportunistic or pathogenic infectious organisms get into our bodies?
through portals of entry, such as small abrasions or lesions--- why it's important to cover open wounds immediately and disinfect
superficial skin infections involve only?
What is cellulitis?
an inflammation of the subcutaneous and potentially muscle tissues.
What is impetigo and who does it affect most?
The most common superficial bacterial infection caused by staphylococci or staphylococci bacteria and is most common among children bc it's spreads easily among small children on contact
How does impetigo occur?
Occurs when a break in the skin allows bacteria to enter causing inflammation and infection; can also be spread through direct contact with honey color fluid in blisters
Clinical manifestations (s/s) of impetigo?
- one or more blisters that itch
- blisters are filled with yellow, honey colored fluid
- blisters ooze and crust over
- can spread on the patient by the patient scratching and then touching another part of the body; can also spread through the fluid inside the blisters
Diagnostic tests associated with impetigo?
physical exam (assessing skin--- wear PPE)
Treatments for impetigo?
If MRSA, you will need antibiotics that the infection is sensitive to
If left untreated, impetigo will usually clear on it's own, but may lead to glomerulonephritis.
- Dressings include: mechanical debridement, natural chemical debridement, hydrophobic material, hydrophillic material
- Drug therapy
- Nutrition therapy
- Surgical debridement
What is glomerulonephritis?
acute inflammation of the kidney, typically caused by an immune response.
What is MRSA?
Methicillin-resistant Staphylococcus aureus is a bacterium responsible for several difficult-to-treat infections in humans. It is also called oxacillin-resistant Staphylococcus aureus
How to prevent impetigo?
- Keep skin dry and clean
- Cleaning minor cuts and scrapes with SOAP AND WATER
- If infection, avoid sharing personal care items with family members or anyone outside
After touching infected skin, you MUST WASH HANDS WITH SOAP AND WATER
Where do fungi live that cause superficial fungal infections live?
on dead skin cells of the dermis
What is Candida?
A fungal infection often called a yeast infection
- can occur orally or vaginally
- occurs on the skin from prolonged wetness (that's why incontinent patient's usually develop yeast infections)
Clinical manifestations of Candida?
- oral candida is also known as thrush and gives the tongue a white coated appearance that cannot be removed
- Candida of the skin, usually seen in the skin folds, may appear red and scaly (remember pt from CCNR)
How to treat oral candida?
- Assess patient's skin and oral mucous membranes
- Treat with medicated powders or creams for skin form. Medicated mouthwash such as Nystatin for the oral form
What is tinea pedia?
Common fungal infection known as athlete's foot that's spread through direct contact or by inanimate objects--- shoes, socks, shower floors, etc.
How to treat and teach patient with tinea pedis?
Treat with antifungal sprays and creams
Teach patient about meds, hygiene practices, and how to prevent infection
--- include that fact that pruritis is a common symptom
Warts that develop orally and in the genitalia?
Herpes simplex virus--- HSV-1 found on the face and HSV-2 found on the genital mucosa
What is pediculosis?
Lice that commonly infect the body, head, or pubi hair. Lice lay eggs along the hair shafts and are transmitted by personal contact, clothing, and bedding , and shared hair care items or hats.
Head lice is called?
Body lice is called?
Pubic or crab lice are called?
Most common symptom of lice?
How to treat lice?
Laundering of clothing and bed linen
Teach patient how to prevent infestation
Teach patient hygiene practices
Initial tissue response to burns is?
Inflammation and vasoconstriction; edema lasts for several days
Examples of lesions?
Benign skin growth
Invasive malignant tumors
Most common types of skin cancers?
Why are infants and children a population at risk for impaired tissue integrity?
Infants are at risk because of their age and developmental level--- i.e. diaper rash, uncertain mobilization, affinity for grasping and placing various objects in their mouth, and the inability to protect themselves from environmental dangers--- at risk for impetigo (superficial skin infection) due to skin-skin contact at day care centers
School age children may experience minor tissue injuries, such as abrasion, bruises, and lacerations that occur durig active play
Why are older adults at risk for impaired tissue integrity?
Changes r/t aging process:
- loss of lean muscle mass
- decreased skin thickness, strength, moisture, and elasticity
- decreased arterial and venous blood flow
- diminished perception of pain and pressure that may prevent early recognition of tissue injury
- prolonged sun and environmental exposure with age
- decreased hair/nail growth causing a decrease in sebaceous gland activity, which can result in dry, rough, itchy skin
Skin cancer most commonly found in light skinned people and often found in places most commonly exposed to the sun, such as the face?
Basal cell carcinoma
Skin cancer most commonly found in dark skinned people and often found in places less exposed to sun such as legs and feet
Most deadly form of skin cancer that begins in the pigment cells or melanocytes can grow on any skin surface and is mostly found in men on the head, neck, and torso and in women, the torso and lower legs
subcutaneous layer of the skin is also known as?
The fat layer of the skin below the dermis
Relationship b/w thermoregulation and impaired tissue integrity?
The skin provides the body with regulation of body temp through constriction/dilation of piloerector muscles and blood vessels in the dermis and the production of sweat--- i.e. an overwhelming burn surface the ability to regulate body heat and prevent excess fluid loss is impaired, requiring external maintenance of temperature and massive fluid replacement.
Relationship b/w skin integrity and sensory perception?
The loss of deep tissue structures such as nerve endings prevents normal sensation that provides cues about the environment and helps promote safety in active movement
Difference b/w cyanosis in a light skinned person and a dark skinned person
light skinned persons appear blue-gray whereas dark skinned persons appear as an ashen gray color and it is particularly visible in the nail beds and mucosa
Because infants contain less subq fat and their skin is more permeable, they have a higher potentional for?
increased fluid loss and challenges in regulating temperature for maintaining warmth
Why is acne around the face and neck common in adolescents?
increased sebum and sweat production
Where should you assess for hydration in older adults?
under the clavicle
Due to thin, fragile texture, skin tears on minimal contact or pressure may occur in whom?
How are dermal ulcers assessed?
as well as level of tissue injury
Suspected deep tissue injury
localized area of discolored (purple or maroon) intact skin or blood-filled blister due to underlying soft tissue damage resulting from pressure or shear--- may be difficult to detect among darker individuals
Stage I pressure ulcer?
(NOT OPEN) Skin intact; nonblanchable erythema; usually over bony prominence
Stage II pressure ulcer
(THINK 2- 2 LAYERS)Partial thickness skin loss involving epidermis or dermis presenting as a shallow open ulcer with a red-pink wound bed without slough; could also be on intact skin as a ruptured serum-filled blister
Stage III pressure ulcer?
(SUBCUTANEOUS---REACHES FAT---GOES PAST FIRST TWO LAYERS) Full-thickness skin loss involving damage or necrosis of subq tissue that may extend to, but not through, underlying fascia, may include undermining and tunneling
Stage IV pressure ulcer?
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structure (GOES PAST SUBCUTANEOUS MEMBRANE AND REACHES BONE/MUSCLE/ORGANS)
Unstageable pressure ulcer?
Full-thickness tissue loss in which base of ulcer is covered by slough (yellow, tan, gray green or brown) and or eschar (tan, brown, black). True depth of the wound cannot be determined until the slough and/or eschar is removed to expose the base of the wound by pharmacologic, mechanical, or surgical debridement
What is the wood's lamp test used for?
Black light or immunofluorescense is an enhanced method of inspection involving magnification and special lighting. Used to identify presence of infectious organisms and proteins associated w/ specific skin conditions (ringworm)
Pathologic evaluation of tissue when skin lesions are suspected
Cultures that identify the organisms of infection?
Wound cultures--- clean wound of debridement first and collect from bed of wound
A test used to identify specific allergens causing dermatitis--- one or many potential allergens can be tested simultaneously by applying a small amount of the substance to a marked area of the skin, usually on the back
Basic hygiene measures
nutrition (adequate protein, minerals,, vitamins, and hydration)
protection from excessive sun exposure and other environmental hazards
tool for assessing pressure ulcer development using six subscales: sensory perception, mobility, moisture, activity, nutrition, and friction/shear--- adults scoring 18 or 23 are at risk
At home assessments include
minimizing or eliminating friction or shear (sliding on sheets)
Minimize pressure through frequent repositioning and use of pressure relieving devices
Managing moisture on skin surfaces
Maintaining adequate nutrition and hydration
When should we use topical and parenteral antibiotics?
whenn a specific organism is identified through culture; common fungal infections can use OTC antibiotics; antibiotic shampoo or lotion for anthropod infestations
When should we use topical steroids? oral and parenteral sertoids?
often used to treat allergic dermatitis and the irritating symptom of pruritis (itching); oral/parenteral for systemic allergic reactions such as when a child breaks out in hives
If there is excessive moisture, what kind of emollient should be used?
gel or powder
may be used to retain moisture in the skin?
ointments, lotions, creams (emollients)
Goal of wound cleansing?
removing debris and excessive exudates--- shallow wounds can be cleaned with soap and water, whereas deeper wounds should be cleaning with NS
How do wounds heal?
in a moist, but not soggy environment
Used to absorb excessive exudates
Used to maintain a slightly damp environment to promote tissue repair
When are nonadherent dressings useful?
when the wound drainage is slight and may dry b/w dressing changes, causing the dressing to stick to the fragile wound surface and then disrupt the wound during dressing removal--- not good
Occlusive and semi-occlusive dressings?
used for clean wounds that have minimal drainage, but need to be protected from environmental pathogens, such as a central IV cath puncture hole
Hydrocolloid, hydrogel, and alginate dressings are used when?
To absorb exudates while maintaining a therapeutically moist would surface environment to promote healing
Vac assist closure?
special dressings for complex wounds attached to a device that maintains negative pressure at the wound surface, aiding in the removal of large amounts of exudates
When is phototherapy used?
To treat some skin disorders such as psoriasis and atopic dermatitis that response to controlled phototherapy with UV light. Protection from excessive UV exposure is important to prevent tissue damage
Why are vitamins A and C critical for wound healing?
Required for collagen synthesis--- in the absence of adequate nutrition, delayed wound healing and infection are likely outcomes
Nurse's role in tissue integ
Assessment of skin
A super wom man!
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