Tissue Integtrity Flashcards
(32 cards)
What is tissue integrity?
State of structurally intact and physiologically functioning epithelial tissues such as the integument (skin) and mucous membranes
What is impaired skin integrity?
-focused on damage to the epidermal and dermal layers of epithelial tissue, deep damage to skin integrity is associated with disruption of under lying tissues
What is impaired tissue integrity?
-varying levels of damage to one or more of those groups of cells
What is the scope of tissue integrity?
- intact skin and tissue
- partial thickness injury
- full thickness injury
What is Debridement?
Remove dead or infected tissue, usually from a wound
What is granulation?
-new connective tissue and blood vessel that form on the surface of a wound during the healing process (from base of wound)
What is turgor?
-sign of fluid loss (dehydration)
Normal=snap back
What is an emollient?
Agent that softens and smooths the skin
What are age related changes in skin?
- epidermis less proliferative (slow healing)
- dermis losses elasticity, strength, moisture
- dermis becomes less vascular
- dermis slow to clear foreign material
- decline in melanocytes
- decrease in subcutaneous fat
- less pacinian and Meissen receptors
- decreased sebaceous glands (skin touch, dry, itchy)
- hair and nail growth slows
What is trauma and injury to skin?
-superficial abrasion or scrape to a deep wound penetrating the skin and subcutaneous layers
What is loss of perfusion to skin?
-could lead to necrosis
What is immunologic reaction of skin?
-redness, rash hives, allergies
Soap, detergents, cleaning products acute slough
What are types of infections/infestations of the skin?
- bacterial (cellulitis, impetigo (streptococci)
- fungal infections (candida), like moist areas, skin folds, tines capitis (head), Inet pedis (althetes foot)
- viral infections: wart, HSV, HSV2
- infestations: mites, lice
What are thermal radiation injuries?
-sunburn, scald burn, radiation burns
What is the process of wound healing?
Primary: margins well approximated
Secondary: ulcer action, distinct edges, granulation tissue fill in gap wound
Tertiary: sutured closed much later, scarring
Inflammatory (3-5)
Granulation (vascular pink wound)
Maturation (fibre remoulding and scar contraction may continue)
What happens when tissue integrity is impaired?
-thermoregulation, elimination, fluid/electrolyte balance, protection from infection, safety, comfort affected
What are individual factors for skin integrity?
Poor peripheral perfusion Malnutrition/obesity Dehydration/Edema Impaired mobility Immunosuppression Exposure to irritants Radiation, temp extremes Tissue trauma
What are factors for dermal ulcer risk?
- impaired cognition
- sensory perception
- immobility
- friction/sheering
- poor nutrition
- impaired perfusion
- oxygenation
- impaired sensation
- incontinence /moisture
What are diagnostic tests?
Patch testing: allergies
Wound cultures
Tissue biopsy
Woods lamp: magnification/special lighting
What are dermal ulcers?
-localized area of necrosis over a honey prominence caused by pressure for a sufficient period causing tissue ischemia
(Greater risk: decreased mobility or sensation)
What is a stage 1 pressure ulcer?
- erythema not resolving within 30mins of pressure relief
- epidermis intact
- IS REVERSIBLE AT THIS STAGE
What is stage 2 ulcer?
-partial thickness loss of skin layers, involving epidermis and penetrate into but not through dermis
-blistering with erythema
-wound base moist and pink
-painful,
FREE of necrotic tissue
What is stage 3 pressure ulcer?
- full-thickness loss tending though dermis to involve subcutaneous tissue
- shallow crater unless covered by Escher
- necrotic tissue, undermining, sinus tact formation, exudate, infection
- wound base not usually painful
What is stage 4 pressure ulcer?
- deep tissue destruction extending through subcutaneous tissue to fascia, involve muscle layers, joint and bone.
- deep crater
- necrotic tissue, undermining, sinus tract formation, educate, infection
- wound base not painful
