Tissue Integrity Overview and Care
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Questions and Answers

What is tissue integrity?

The ability of body tissues to regenerate and/or repair to maintain normal physiological processes.

Which of the following are attributes of tissue integrity? (Select all that apply)

  • The skin is structurally sound and functioning (correct)
  • It has impaired healing processes
  • It is non-functional
  • It has normal healing and restorative processes (correct)
  • What are the antecedents for good tissue integrity?

    Good nutrition, lack of trauma, adequate perfusion, limited pressure on site.

    What are some positive outcomes from maintaining tissue integrity? (Select all that apply)

    <p>Protection from infection</p> Signup and view all the answers

    What are the negative outcomes of not maintaining tissue integrity? (Select all that apply)

    <p>Decubiti</p> Signup and view all the answers

    What are the components of tissue integrity care?

    <p>Primary prevention, self-care behaviors, 4 stages of wound healing.</p> Signup and view all the answers

    What are the four stages of wound healing?

    <p>Hemostasis, inflammation, proliferation, maturation.</p> Signup and view all the answers

    What are risk factors for poor tissue integrity?

    <p>Prolonged pressure, poor hygiene, poor nutrition, incontinence, breaks in the skin.</p> Signup and view all the answers

    How does the nurse recognize when a tissue integrity imbalance is developing or has developed?

    <p>Comprehensive history, skin and overall health assessment, risk assessment.</p> Signup and view all the answers

    How can you diagnostically test for tissue integrity? (Select all that apply)

    <p>Wound culture</p> Signup and view all the answers

    What would patient education include for primary prevention of negative tissue integrity?

    <p>Identifying risk factors for impaired skin integrity, importance of nutrition, mobility, and keeping skin clean and dry.</p> Signup and view all the answers

    What are some examples of secondary prevention to help with tissue integrity?

    <p>Providing pain management, repositioning, using barrier creams, checking incontinent patients frequently.</p> Signup and view all the answers

    What are some examples of tertiary prevention to help with tissue integrity?

    <p>Teach patient and caregiver about home care, wound care, hygiene, nutrition.</p> Signup and view all the answers

    What drug therapy can be used to improve tissue integrity? (Select all that apply)

    <p>Topical antifungals</p> Signup and view all the answers

    What age-related changes can affect tissue integrity?

    <p>Skin becomes more fragile, delayed wound healing, decreased vitamin D production, greater risk of dry skin.</p> Signup and view all the answers

    Which of the following are exemplars of tissue integrity issues that interrupt intact skin? (Select all that apply)

    <p>Dermal ulcers</p> Signup and view all the answers

    What nutrients are necessary to rebuild cells and tissues?

    <p>Calories and protein.</p> Signup and view all the answers

    Which vitamins are essential for epithelialization and collagen synthesis?

    <p>Vitamin A and C.</p> Signup and view all the answers

    What nutrient plays a role in the proliferation of cells?

    <p>Zinc.</p> Signup and view all the answers

    What types of alterations can occur in the integument? (Select all that apply)

    <p>Burns</p> Signup and view all the answers

    What physical and psychological clinical manifestations can occur in the tissue? (Select all that apply)

    <p>Itching</p> Signup and view all the answers

    Study Notes

    Tissue Integrity Overview

    • Tissue integrity is the ability of body tissues to regenerate and maintain normal physiological processes.
    • Attributes include structurally sound skin and effective healing processes.

    Antecedents for Good Tissue Integrity

    • Requires good nutrition, absence of trauma, sufficient blood flow, and minimal pressure on areas of the body.

    Positive Outcomes of Maintained Tissue Integrity

    • Protection from infections, adaptation to environments, fluid and electrolyte balance, acid-base regulation, vitamin D production, and trauma protection.

    Negative Outcomes from Poor Tissue Integrity

    • Pain, risk of infection, altered body image, fluid and electrolyte loss, and tissue breakdown, such as decubiti.

    Components of Tissue Integrity Care

    • Encompasses primary prevention, self-care behaviors, and understanding the four stages of wound healing: hemostasis, inflammation, proliferation, and maturation.

    Risk Factors for Poor Tissue Integrity

    • Prolonged pressure, inadequate hygiene, poor nutrition, incontinence, and skin breaches.

    Recognition of Tissue Integrity Imbalance

    • Identified through comprehensive health history, skin assessment, and risk evaluation.

    Diagnostic Testing for Tissue Integrity

    • Includes wound culture, tissue biopsy, blacklight/immunofluorescence, lab tests, Doppler for perfusion issues, and imaging (MRI, CT) for deep tissue injury.

    Primary Prevention Through Patient Education

    • Focuses on recognizing risk factors, emphasizing nutrition and mobility, maintaining skin cleanliness, and promoting safety behaviors.

    Secondary Prevention Strategies

    • Pain management, regular repositioning, barrier creams, hygiene management for incontinent patients, and using soothing lotions to relieve itching.

    Tertiary Prevention Approaches

    • Instructing patients and caregivers on home care for pressure relief, wound care, hygiene, incontinence care, and nutritional support.

    Drug Therapy for Tissue Integrity

    • Utilizes pain medications, topical antibiotics, antifungals, steroids, and medicated lotions or powders.
    • Skin fragility, delayed healing, lower vitamin D production, dry skin susceptibility, sensory perception decline, and decreased elasticity and perspiration.

    Exemplars of Tissue Integrity Issues

    • Conditions include surgical/traumatic wounds, dermal ulcers, impetigo, tinea pedis, candidiasis, pediculosis, and psoriasis.

    Nutritional Needs for Tissue Regeneration

    • Essential nutrients include calories and protein for cell and tissue rebuilding.

    Vitamins Essential for Healing

    • Vitamins A and C are crucial for epithelialization and collagen synthesis.

    Nutrient Role in Cell Proliferation

    • Zinc is vital for cellular replication and growth.

    Types of Alterations in Integument

    • Can include burns, excessive cold exposure, open/closed wounds, inflammation, injections, hematomas, decreased circulation, and cancer-related changes.

    Clinical Manifestations of Tissue Integrity Issues

    • Intact tissue integrity shows no manifestations; other signs can include itching, excessive dryness, skin peeling, tears/abrasions/lacerations, altered body image perceptions, and changes in skin color and temperature.

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    Description

    This quiz covers the fundamental concepts surrounding tissue integrity, including the physiological processes necessary for maintaining healthy tissues. It explores the antecedents for good tissue integrity, positive and negative outcomes, and effective care components, such as wound healing stages. Test your knowledge on how to promote and protect tissue health.

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