Skin Tissue Integrity & Pressure Injuries PDF

Tissue Integrity Pressure Injuries: - Patho: - Loss of tissue integrity caused when skin & underlying soft tissue are compressed between a bony prominence & external surface - (v) Localized damaged to skin or underlying tissue, usually under b...

Tissue Integrity Pressure Injuries: - Patho: - Loss of tissue integrity caused when skin & underlying soft tissue are compressed between a bony prominence & external surface - (v) Localized damaged to skin or underlying tissue, usually under bony prominence as a result of pressure or combination w/ shear - Shear: - Mechanical force that acts on an area of skin in a direction parallel to the body’s surface - Not seen at the skin lvl d/t occurrence beneath the skin - Friction Injuries: - Mechanical force exerted when skin is dragged across a coarse surface - Looks like an abrasion or a superficial lateration - Can occur on any body surface - (TEST) HOB should not be elevated more than 30 degrees to prevent this type of injury - Can occur on any body surface - Etiology/Genetic Risk: - Dependent upon mechanism & timing - Friction - Shearing force - Promotion/Maintenance: - Recognize risk & implement interventions to prevent injury - Early intervention - Key health team members can assist - Cues/ Assess/ s/s: - Hx: - Conduct w/ risk factors in mind - Identify cause for any existing injury - Contributing factors: - Bedrest, immobility - Incontinence - Diabetes mellitus &/or peripheral vascular disease - Malnutrition - Decreased sensory perception or cognitive problems - (v) Develop pretty fast & w/in first hr of that pressure. - Especially bony prominences - Afterwards, Between 4-6 hrs of sustained loading - Turn Q2 hrs - Physical Assessment/Signs & Symptoms: - Inspect entire body, especially bony prominences: - (v) Heels, between heels, in toeas - Wound assessment: - identify areas of skin damage, note the length, width, & depth, - presence of tunneling, necrotic tissue, exodate, & any evidence of healing. - Stage I, II, III, IV - (TEST) Pain may be an early indicator of a developing wound. Stage 1 Pressure Injury: Intact skin w/ localized area of (TEST) non-blanchable erythema (may appear differently in skin w/ darker pigmentation). - May be preceded by changes in sensation, temperature or firmness. - Color changes are not purple or maroon. - Purple/maroon= deep pressure injury - (TEST/v)Will not blanched if pressed - (v) Staging a pressure injury does not imply that there is progression or regression as healing does/doesnt occur Stage 2 Pressure Injury: Partial-thickness loss of skin w/ exposed dermis. - Wound bed is visble, pink or red, & moist. - May look like intact or ruptured serum-filled blister. - (TEST/v) Adipose or fat is not visible & deeper tissues are not visible either. - (TEST/v) There is NO granulation tissue, slough, or eschar. - (TEST/v) This stage is not used to describe moisture-associated skin damage, including: - Incontinence-associated dermatitis - medical-adhesive-related injury - traumatic wounds such as skin tears, burns, or abrasions. Stage 3 Pressure Injury: Full-thickness skin loss w/ adipose (fat) visible in the ulcer/ injury - Granulation tissue & rolled wound edges are often present. - Slough &/or eschar may be present. - (TEST/v) The depth of damage varies by anatomical location - (TEST/v) Areas w/ large amounts of adipose can develop deep wounds - Ex: Wound Elbow will be thinner - Undermining & tunneling may be present. - Subcutaneous tissues may be damaged or necrotic. - (TEST/v) Fasha, muscle, tendon, ligament, cartilage & or bone are not exposed in a Stage 3 pressure injury - (TEST/v) If slough or eschar obscures the extent of tissue loss → Considered an unstageable pressure injury Stage 4 Pressure Injury: Full-thickness skin loss w/ exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. - May have slough or eschar. - Rolled edges, undermining, or tunneling may be present. - (TEST/v) If slough or eschar obscures the extent of tissue loss → Considered an unstageable pressure injury (TEST/v) Unstageable & Suspected Deep-Tissue Injury: - Characterized by full-thickness skin & tissue loss. - The extent of tissue damage cannot be confirmed because it’s obscured by slough or eschar. - If slough or eschar is removed, we will see a Stage 3 or a Stage 4 pressure injury. - Has intact or non-intact skin w/ a localized area of persistent, non-blanchable, deep red, maroon, purple discoloration or epidermal separation, revealing a dark wound bed or blood-filled blister. - Results from intense or prolonged pressure & sheer forces.  - Can feel firm, spongy, boggy, warm, cool & painful. Pressure Injuries: - Cues/ Assess/ s/s: - Document location, size, color, extent of tissue involvement, cell types in wound base & margin, exudate, condition of surrounding tissue, presence of foreign bodies - Record by length, width, depth (using mm or cm) - “Clock concept” - Top is 12 o'clock then go clockwise to describe - (v) Describe to its deepest extent - Psychosocial Assessment: - Body image - Refer to social service or case worker if financial barrier - Refer to home care nurse if pt or caregiver can’t safely carry out plan of care - Labs: - Wound culturing is not routinely performed - (TEST/ v) Not routinely performed unless there are systemic signs of an infection such as a fever or luchocytosis. - If infx present there is: - Erythema, local tenderness, purulent drainage, & the presence of a foul odor. - If performed, tissue culture is done (not just wound swab) - Arterial blood flow studies if arterial occlusion is suspected - Duplex ultrasound imaging: - (v) Rules out status in lower extremities - Blood tests for nutritional deficiencies - (v) Inhibits ability of wound to heal - Analysis/ Priority: - Compromised tissue integrity due to vascular insufficiency & trauma - Potential for infection due to insufficient wound management - Interventions: - Improving tissue integrity - Dressings - Physical therapy - Drug therapy - Nutrition therapy: (v): - Needs sufficient calories & protein. - Protein for healing - Vitamins & minerals - Esp w/ stage 3 & 4 - Increase caloric intake to 30 calories/kg - Increase dietary protein to 1.25 to 1.5 grams/kilogram/day. - (v) vitamin C & zinc - Efficacy of those therapies are inconclusive so may or may not see a pt use them - Adjuvant therapies:  - (v) Wound vac - Wound care: - Debrivement if necrotic tissue present - Surgical management: (v): - Removal of necrotic tissue - Skin grafting - Use of muscle flaps to close wounds that do not heal - Planning: - Preventing infection: (v): - All open injuries are colonized w/ bacteria - Important to teach the pt how to prevent the infection & s/s - Monitor for s/s of infection - Report changes to primary health care provider - Maintain safe environment - Care Coordination & Transition Management: - Home care management: (TEST/ v) - Turn & reposition Q2 - Lie on the side w/ the upper body slightly elevated. - Use pillows between the knees & the ankles. - Check the skin often. - Use pressure redistribution devices & wash the skin regularly w/ warm water & mild soap. - Self-management education - Health care resources - (TEST/v) “Remember that there is an expectation that the injury will heal.” - Outcomes: - Experience progress toward wound healing by second intention as evidenced by: - Granulation, epithelialization, contraction, & reduction or resolution of wound size - Re-establish skin tissue integrity & restore skin barrier function - Remain free from local or systemic infections (TEST) Albumin measures protein, which is necessary for healing. - Increased serum albumin indicates successful collaboration w/ the dietitian. Calcium, hematocrit, & WBC readings do not relate to successful pressure injury management. Skin Irritations: Pruritus: Def: Itchy Skin - Common in older adults - Example: detergent chemical/lotion that irritates skin - Address dry skin & keep nails short - Tx: - Antihistamine may be prescribed for itchyness Urticaria: Def: Intensely pruritic acute or chronic disorder - Presents w/ transient, erythema, the edematis plaques & often w/ central pallor - How you distinguish from other prblems - Examples: drugs, temperature extremes, foods, infection, diseases, cancer, insect bites - Remove triggering substance - Tx: - Antihistamine Inflammatory Skin Disorders: - Identify causative agent, & then avoid it - Steroid therapy - Antihistamines - Comfort measures Eczema Atopic dermatitis Drug eruption Contact dermatitis: (v): Def: Localized inflammatory skin response to a wide range of chemical or physical agents. - Response to an irritating substance - Possible Cause Examples: Eye makeup, Poison Ivy Atopic Dermatitis (AKA Ecezema): (v): Def: Chronic pruritic inflammatory skin disease. - Identified by: - Skin dryness - Erythema, oozing - Cresting - Tx: - Topical corticosteroids, hydration & skin moisturization Inflammatory Skin Disorders: - Identify causative agent, & then avoid it → Then use steroids to tx (antihistamines) → Comfort after Psoriasis: - Multiple system Chronic autoimmune disorder - Exacerbations & remissions - Scaled lesions w/ underlying dermal inflammation from epidermal cell growth abnormality - (v) well demarcated red plaques w/ overlying coarse scale - Triggers: - Environmental factors, stress, skin injuries, medications, infections - Types: Psoriasis vulgaris  - History: - Ask about family history due to genetic component - Flares & precipitating factors - Treatments that have helped in the past - ie sunshine (v) - Cues/ Assess/ s/s: (TEST/v) - Plaque (most common); (v) Symmetrical, guttate; inverse; pustular; erythrodermic: - Found on scalp elbows, knees & the gluteal crease - Guteate: - Abrupt appearance of multiple small, psoriatic, papules & plaques. - Strong association between infection & guttate psoriasis. - Infection = strep pharyngitis - Inverse: - Inguinal, perineal, genital, intergluteal & axillary regions. - Pustular: - Widespread at erythema - Scaling & superficial pustules. - (TEST) Can be LIFE THREATENING - Arithrodermic: - Has general erythema - Scaling that covers most of the body. - Uncommon - Interventions: - Topical therapy - Light therapy: - (v) ie tanning bed or sunshine - Systemic therapy - Emotional support Common Skin Infections: (v) - Bacterial - Cutaneous anthrax: - Uncommon but: - Most common form: - Naturally occurring after being exposed to b anthracis - Found in infected animals or animal products. - Cuts & abrasions increase susceptibility to infection. - Folliculitis: - Furuncles & carbuncles: - Inflammation of one or more hair follicles - Cellulitis: - Common in the hospital setting. - Has skin erythema edema & warm - d/t: Bacteria that breaches the skin barrier. - Presents w/ fever, chills, severe malaise, headache - (TEST) outline the very outer edges w/ skin pen to know if: - reseeding or growing  - MRSA (community acquired methicillin-resistant Staphy. Aureus): - Presents w/ cellulitis & abscess or w/ both - Viral: - Herpes Simplex: - Transmitted from person to person via infected oral secretions during close contact - ie kissing, oral to oral, genital to genital, genital contact - Can look like cold sores - (TEST/v) Can occur in eye/ ocular - Has skin & mucous membrane lesions - Including genital lesions - (TEST/v) Contact ABD st&ard precautions until the lesions are dry & crested. - Herpes Zoster (AKA Shingles): - To develop, must have had primary infection w/ varicella (AKA chickenpox) - d/t reactivation of the latent varicella zoster virus that has gained access to sensory ganglia during varicella. - Very painful - Unilateral, the vesicular eruption, & will follow a dermatome (sensory axons) - Risk factors to develop shingles is immune status - Immunocompromised is the largest risk factor - Older than the age of 50 - Can receive vaccine after 50 - HIV - Pt w/ shingles in hospital = St&ard precautions - Depending on hospital policy, if it crosses many dermatomes, →Airborne precautions - Can develop shingles in your lungs - Fungal: - Tinea - C&idiasis Herpes Simplex 1 Chronic Herpes Simplex Infection Herpes Zoster (Shingles) Candida Albicans: - Fungal infx in mouth - AKA Thrush - Part of our normal flora, but will invade when the right conditions exist - Opportunistic - Risks: - AIDs carrier - Uses inhaled glucocorticoids & do not rinse mouth afterwards - Uses chronic antibx - Chemotherapy & radiation of head & neck. - S/S: - Dry mouth “ Cotton Mouth” - Loss of taste - Pain w/ eating or swallowing as it develops down throat - (TEST/v) See white patches? Chart this as oral lesions or white patches. NOT as C&ida, not dr & cant dx Common Skin Infections: - Promotion/Maintenance: - Avoidance of offending organism - Practice of good hygiene: - H&washing - Do not share personal items - Vaccination - Cues/ Assess/ s/s: - History: - Risk factors - Living conditions, sanitation, hygiene, activities - Physical Assessment/Signs & Symptoms - Signs & symptoms of specific disorder - Laboratory assessment - Interventions: - Drug therapy - Avoid spread of disorder - Skin care Parasitic Disorders: - Pediculosis - Scabies - Bedbugs - Scabies: - Infestation of the skin by an eight legged mite - Intensely pruritic(itchy) w/ a characteristic distribution - Common sites: - Web of the fingers, the wrists, your axilla, the areola, & genitalia. - Any age & Any SDOH - Transmitted → Direct & prolonged skin to skin contact - NOT transmitted from animals to humans - Bedbug Bites: - Blood feeding insects that invest human dwellings & inflict fights. - Do not remain on the human to complete their life cycle. - Size of a tick. - Lives for up to a year w/out feeding - Cannot starve - Prefer more temperate or tropical climates, but international travel disperses them around the world. - (TEST/v) Can l/t an infection & extreme infestations can lead to anemia - 2-5mm red papule or wheal w/ central hemorrhagic ??(video) phantom? - Pruritus is common - (TEST) Do not scratch, Can lead to contact dermatitis (NOT TESTING) Skin Trauma - Phases of wound healing:  1. Inflammatory: a. Increased vascular permeability & cellular recruitment b. Begins at time of injury c. Lasts 3-5 days 2. Proliferative: a. Basal self proliferation & epithelial cell migration occurring in the fibering bridgework inside a clot b. Begins on 4th day c. Lasts 2-4 weeks 3. Maturation: a. Collagen crosslinking, collagen remodeling wound contraction & repigmentation b. Begins as early as 3 weeks c. Lasts for a yr or longer Phases of Wound Healing: - First intention: - Edges brought together w/ skin lined up in correct anatomical position - AKA Proximated - Held in place until healing occurs - Second intention: - Requires gradual filling in of dead space w/ connective tissue - Third intention: - Delayed closure; high risk for infection w/ resulting scar - High infection risk especially surgical into a non sterile body cavity or contaminated wounds, traumatic wounds - Closed once the debris & exudate are removed by debreavement & inflammation has subsided (NOT TESTING) Mechanisms of Wound Healing: - Partial-thickness wounds: - Superficial w/ the minimal loss of tissue integrity - Damage to epidermis, upper layers of dermis - Heal by re-epithelialization w/in 5 to 7 days - Full-thickness wounds: - Damage extends into lower layers of dermis, underlying subcutaneous tissue - Both do this - Must be filled w/ granulation tissue to heal - Contraction develops in healing process - Most of the epithelial cells at the base of the wound are destroyed. - & it must be filled in w/ granulation tissue to heal & contraction develops in the healing process. - Fiber blast will begin to pull the wound edges inward along the path of least resistance. Re-epithelialization (TEST/v) Burns: - Range in severity from minor sunburns to life-threatening trauma - Changes: - Anatomic - (v) Skin can regrow if parts of the dermis is present. - Functional:  - (v) Maintains normal body temperature - Activates vit D when exposed to the sun - Maintains fluid & electrolyte balance - Sensory perception - (TEST) Psychosocial: - Major burn can cause a reduced self concept & other psychosocial concerns about appearance (NOT TESTED) Extent of Burn Injury: - Burn classification: - Depth of destruction - Degree of burn; degree of thickness (v- context info for types of burn slide)Differences in skin thickness & various parts of the body: - Affects burn depth - Skin areas exposed to high temperatures can quickly cause a deep burn injury. - Third & fourth degree burns are full thickness burns w/ tissue destruction that can lead to fluid & electrolyte imbalance & other systemic disturbances. (TEST) Uncomplicated Burn: - Patho: - Chemical: - Caused by homes & manufacturing industries - Electrical: - When electrical current enters the body - Iceberg effect: - Small on the outside, but very large on the inside - Radiation: - From the sun & x-rays & ionizing radiation, which is nuclear smoke related - Smoke-related: - (TEST) Smoke related occurs on inhalation & can cause a edema that impairs breathing. - PROTECT AIRWAY - Thermal (heat-related): - Contact w/ flames, hot liquids or hot objects Burn Injury: - Promotion/ Maintenance: - Prevention: - (TEST) Safest hot water temperature = 120 degrees - Use home smoke & carbon monoxide detectors - (TEST) Phases: - Emergent (resuscitation): - The onset & continues 24 to 48 hours - Acute (healing): - Begins 36 to 48 hours after injury when fluid shift resolves - Lasts until wound closure is complete - Assess & protect the cardiovascular & respiratory system - Improve nutrition  - Provide wound care - Offer pain control & psychosocial care - Rehabilitative (restorative): - Begins when wound closure & ends when the pt achieves their highest level of functioning - May take years to a lifetime - History: - Circumstances surrounding burn injury - Age, weight, height - (TEST)Edema development risk - (TEST) Impaired healing risk - Full health history - Allergies, medications, immunizations - Other injuries that took place at time of burn - Cues/ Assess/ s/s: - Respiratory: - Black carbon particles in nose, mouth, sputum - (TEST) Does their breath smell smoky - Lung sounds - (TEST) Respiratory pt w/ severe inhalation injuries may have such rapid destruction that w/in a short time, they cannot force air through narrowed airways. - Wheezing sounds may disappear. - This finding indicates airway obstruction & requires immediate intubation. - Many pt intubated immediately when inhalation injury is suspected - PREPARE TO INTUBATE - - Skin: - Extend & depth (compared w/ TBSA) - Labs: - Drug & alcohol screen, if anticipated - (TEST) Ophthalmic evaluation: - Corneal damage - Interventions: - Airway maintenance - Pain control: - Tailored to pt tolerance lvl - Medicate 30 minutes prior to any dressing change - Infection control - Wound healing: (v but dont need to know) - From topical anti microbial drugs to compression garments used to prevent contractures & tight hypertrophic scars - Can prevent edema Skin Cancer: Cause: Exposure to sunlight - Etiology/Genetic Risk: - Actinic keratoses:  - Sun-damaged skin - Pre-malignant - Squamous cell carcinoma: - Chronic skin damage - Cancer of epidermins - Invades locally & can Metastasize - Basal cell carcinoma: - Causes: Genetic predisposition, UV exposure - Melanomas: - Causes: Genetic predisposition, UV exposure, chemical carcinogens - Can have precursor lesions - Arises from melanin producing cells - Highly metastatic & survival depends on early diagnosis & treatment - Incidence & Prevalence: - Melanoma is the most common in non Hispanic white people - Difficult to discern (not reportable) - Often occurs in people who spend time outdoors, use tanning beds - Promotion/Maintenance: - Avoid or reduce exposure to sun or tanning beds - Sunscreen - Wear hats & opaque clothing - Sunglasses - Monthly skin checks - Report skin changes - (TEST) ABCDE guide for melanoma: - A st&s for asymmetry. - B st&s for border. - We're looking for uneven or scalloped edges. - C is color. - Multiple colors are a warning sign. - D is diameter or dark. - Warning sign if it's the size of a pencil eraser. - E is for evolving - This is a change in size shape color elevation. - We're also looking for a new symptom which could be bleeding itching & cresting. - Hx: - Family history of skin cancer - Past surgery for removal of skin growths - Recent changes in moles, birthmark, wart, scar - Demographic information: - Sunny regions= higher risk (ie Cali/Arizona) - Occupational & recreational activities (sun exposure) - Interventions: - Surgical: - Cryosurgery: - Local application of liquid nitrogen - Curettage & electrodesiccation:  - Removal of cells w/ the curette followed by an electric probe - Excision: - Surgical removal - Mohs’ surgery: - Specialized form of removal. - Used w/ melanoma - Wide excision: - Deep resection removing full thickness skin - Nonsurgical: - Topical therapies - Targeted therapy: - Radiation - Immunotherapy: - For squamous cell carcinomas - Radiation (usually palliative) Life-threatening skin disorders: - Stevens–Johnson Syndrome (SJS): - Detachment of less than 10% of skin - Toxic Epidermal Necrolysis (TEN): - More than 30% of skin has necrolized - Disorders usually triggered by a drug - Classified by percentage of body surface affected - Treatment involves discontinuation of the drug, & supportive care - S/S: - Fever - Extensive necrosis - Epidermal detachment - Mucous membrane involvement - Meds: - Allopurinol, carbamazepine, lamotrigine, phenobarbital, phenytoin, & sulfas - SULFAS=