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Fundamentals Of Nursing (NURS-B260) Tissue Integrity

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John Marsh
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Indiana University – Purdue University Indianapolis

Fundamentals Of Nursing (NURS-B260)

Fundamentals – tissue integrity

Fundamentals – tissue integrity & wound care
 Tissue integrity is the state of structurally intact and physiologically functioning
epithelial tissues such as the integument (including the skin and subcutaneous tissue)
and mucous membranes
o Remember: Pink, Warm, Dry, and Intact
Epidermis
 Cells are flattened and dead
 Protects underlying cells and tissues from dehydration
 Prevents entrance of certain chemical agents
 Allows evaporation of water from the skin
 Permits absorption of certain topical medications
Dermis
 Inner layer
o Provides tensile strength, mechanical support, and protection to the underlying
muscles, bones and organs
o It contains mostly connective tissue and few skin cells
Alterations in tissue integrity
-Pressure ulcers
 A localized injury to the skin and other underlying tissue
 Usually over a bony prominence, as a result of pressure or pressure in combination with
shear and or friction
o Can appear in an hour time frame
 Pathogenesis of Pressure Ulcers
o Pressure intensity
 Tissue ischemia
 Blanching
 If it doesn’t blanch, its stage one
o Pressure duration
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o Tissue tolerance
 Nutritional status, hydration, disease process?
 Risk factors
o Prolonged pressureunable to reposition self independently
 Interventions
 Turn Q 2 hour
 Relieve pressure on bony prominences
 Prevention tactics like changing dressing
o Shearforce that is the sliding movement of skin and subcutaneous tissue while
the underlying muscle and bone are stationary
 Lift up and move, don’t drag
o Frictionforce of two surfaces moving across one another such as the
mechanical force exerted when skin is dragged across a coarse surface such as
bed linens
 Classifications of Pressure Ulcers
o I  intact skin with nonblanchable redness
 Discoloration of the skin, no open area
 warmth, edema, hardness, or pain may also be present
o II  partial-thickness skin loss involving epidermis, dermis, or both
 Shallow, open ulcer with a red-pink wound bed without slough
 may also be a serum/fluid filled blister
o III  full-thickness tissue loss with visible fat
 Subcutaneous fat may be visible, but bone, tendon, or muscle is not
exposed
 Some slough may be present; may include undermining and tunneling
 Underminingarea of tissue injury beneath intact akin around
the margins of a wound
 Tunnelinga tract of injury occurring in any direction from
surface or edge of wound
 Must fill the patch/tunnel to promote healing

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Fundamentals Of Nursing (NURS-B260) Tissue Integrity

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