Tissue Integrity & Pressure Injury PDF

Tissue Pressure Injury and Wound Integrity Healing Unit Outcomes  Wound Healing  Differentiate among healing by primary, secondary, and tertiary intention.  Describe wound healing principles.  Explain the nursing process in caring for individuals experienci...

Tissue Pressure Injury and Wound Integrity Healing Unit Outcomes  Wound Healing  Differentiate among healing by primary, secondary, and tertiary intention.  Describe wound healing principles.  Explain the nursing process in caring for individuals experiencing a wound.  Describe factors that delay healing or result in complications. Unit Outcomes Pressure Injury  Explain the etiology and clinical manifestations of pressure injury.  Discuss using the Braden Scale to assess for pressure injury risk.  Identify measures used to prevent pressure injury development.  Explain the nursing and collaborative management of pressure injury with or without infections of the integument. Warning  Graphic pictures used to illustrate concepts and facilitate learning Nursing Problems  Impaired tissue integrity  Skin integrity Tell me what you know. Pressure Injury Concept: Pressure Injury A localized injury to the skin and/or underlying tissue due to pressure Cause tissue necrosis Usually over boney prominence Cause of Pressure Injury  OXYGENATION: If tissue is under pressure against the bone are the cells receiving oxygen? Influencing Factors  Length of time  Ability of tissue to pressure is exerted tolerate externally (duration) applied pressure  * Age  * Density  * Collagen  * Co-morbidities Contributing Factors  Shearing force: Pressure exerted on the skin when it adheres or sticks to the bed linen and the skin layers slide in the direction of body movement.  Pulling a diaphoretic patient up in bed can create a shearing force Contributing Factors Contributing Factors  Friction: Two surfaces rubbing against each other: Sheet and skin when pulling a patient up in bed.  Shear: Pressure exerted on the skin, skin sticks to bed, skin moves in direction of body movement, opposite of bone.  Moisture: Excessive diaphoresis, urine, stool  Case Study Case Study  E.A., an 88 year-old woman, has hypertension.  Brought to the clinic by her daughter for routine evaluation of her hypertension treatment on Monday at 0800  Case Study iStockphoto/Thinkstock E.A. lives alone and sits in recliner throughout the day. She does not leave the house most days. E.A.’s daughter visits once a day to help with meals and medications. E.A. states, “my name is EA, what time is dinner?” Case Study  Temperature oral 38.7  Skin moist and sticky  Pedal pulses weak +1  BP 88/64  Hemoglobin and Hematocrit below normal range for female  What “cues” cause you concern?  Analyze cues…. What are your conclusions? Cue Recognition  Advanced age Evidence older adult thin skin, less subcutaneous tissue  Anemia Evidence  Elevated body temperature Evidence  Moisture Evidence  Impaired mobility Evidence  Impaired circulation/perfusion Evidence  Diastolic blood pressure