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Welcome to your custom deep dive.
Today, we're doing a really focused synthesis looking at core concepts in medsurg nursing related to tissue integrity.
Our mission is basically to give you what you need for assessment, safety and care, covering everything from pressure injuries to burns, even skin cancers.
Exactly.
And it's so vital because skin is our largest organ, right?
When its integrity is lost, it immediately throws other systems off balance.
So the key concepts we're hitting today are tissue integrity, obviously, and pain.
But you also have to immediately think about the related concepts like fluid and electrolyte balance and gas exchange, lose that barrier and things get critical fast.
Okay, so let's unpack the main example for tissue integrity, the pressure entry or PI.
The basic idea is straightforward.
Compression cuts off blood flow, tissue gets starved of oxygen and cells die.
Right.
But the nuance, the thing we really need to grasp is the type of mechanical force involved.
You mean friction versus shearing?
Precisely.
They're often confused, but shearing is much more insidious.
Friction is just surfaces rubbing, like dragging someone up in bed.
It damages the top layer, the epidermis, painful, yes.
But shearing, that's different.
That's when the skin sort of sticks to the sheets, maybe.
But the deeper tissues, the fat and muscle slide down over the bone.
Ah, okay.
So it's an internal movement.
Yes.
And that internal sliding kinks the blood vessels deep down.
That's what leads to the really severe ischemia, the necrosis, often worse than what you see on the surface initially.
And where do we typically see these injuries?
Sacrum, hips, heels.
Those are the classic spots, definitely.
But don't forget medical devices,
nasal cannulas behind the ears, tubing, splints, anywhere there's pressure.
Got it.
So who's most at risk for this, especially the shearing type?
Well, immobility is the biggest factor, no question.
If you can't shift your own weight, the pressure just builds.
But then you layer on other things.
Excessive moisture, like from makes the skin weaker, more prone to breakdown.
Undernourishment is huge, too.
Particularly low protein.
You need protein for tissue repair.
Makes sense.
And then, you know, aging skin is naturally thinner and more fragile.
Cognitive decline means patients might not feel or report the discomfort.
And underlying conditions, like PVD or diabetes?
Oh, absolutely.
Those conditions impair circulation to start with, so any pressure injury heals much, much slower, if at all sometimes.
It compounds the problem significantly.
So assessment is key.
Recognizing the early cues,
we need to inspect the whole body, not just the obvious spot.
The entire body, especially those bony areas, but also skin folds under devices, anywhere moisture collects.
And the critical assessment, the one you have to do, is checking for blanching.
Blanchable versus non -blanchable erythema.
Exactly.
Press on a reddened area.
If it stays red, if it doesn't lighten or blanch, that's non -blanchable erythema.
That's your flashing red light.
It means capillary blood flow is already impaired.
That's a stage one PI.
Damage has begun.
Okay, but what about patients with darker skin tones?
Redness can be really hard to see.
That's a critical point.
You can't rely solely on visual redness.
You must use palpation.
Feel for changes in temperature.
Is it warmer or cooler than the surrounding skin?
Check for edema, swelling, and feel for induration.
That's a
Sometimes gently moistening the skin can help subtle color changes, like purple or bluish hues, become more apparent against the person's baseline tone.
Good tip.
And when we find a wound, we need specific terms for documentation, right?
Like tunneling.
Yes.
Precise language is vital.
Undermining is where the tissue separates under the skin edge, like a little lip or shelf.
And tunneling is a channel or tract that extends from the wound into deeper tissue.
You often use the clock concept to describe the location, like tunneling noted at three o 'clock.
Right for clear communication.
Okay, so that's assessment.
How do we systematically prevent these APIs,
hospital acquired pressure injuries?
This is where quality improvement bundles come in, like the STANDS skin care bundle.
It's a great way to remember the evidence -based steps.
STAND.
Okay, what does that stand for?
S is for score using a risk assessment tool, like the Braden scale, on admission and regularly.
T is for turn repositioning the patient frequently, at least every two hours, and shifting medical devices.
A is for apply using barrier creams for moisture protection or prophylactic foam dressings on high risk areas like the sacrum.
N is for nutrition ensuring adequate hydration and, crucially, protein intake.
And D is for discuss involving wound care specialists early, collaborating with the team.
That makes so much sense.
A systematic approach.
It really works.
And tied into that turn aspect are some crucial safety alerts, like keeping the head of the bed elevated.
Yeah, you mentioned not keeping it above 30 degrees.
Why is that specific angle so important?
Because anything higher significantly increases the risk of the patient sliding down in bed.
Even a little slide creates massive shearing forces on the sacrum and cosychex.
So limit elevation unless medically necessary, like for tube feeding or respiratory distress.
Okay, that makes sense.
And the alert about not massaging red areas, that one feels counterintuitive.
You think massage improves circulation.
I know it seems backwards, but it's so important that red in tissue is already damaged, the capillaries are fragile.
Massaging it directly actually increases the damage, breaks those tiny vessels, and can lead to necrosis faster.
Wow.
Okay, no massage on red spots.
Absolutely not.
Same goes for those donut shaped pillows.
They seem like a good idea.
Right, taking pressure up the center.
But what they actually do is concentrate all the pressure on the ring of tissue around the hole.
This cuts off circulation even more effectively in that surrounding area.
They cause more harm than good.
Avoid them.
Got it.
So if an injury does occur, sometimes debridement is needed.
Can you quickly run through the types?
Sure.
Sharp debridement is surgical, using scalpels or scissors.
Mechanical use is physical force, like wet to damp dressings, though that's less favored now as it can harm healthy tissue too.
Topical chemical use is prescribed enzyme preparations to break down necrotic tissue.
And then there's autolysis, or natural chemical debridement.
Autolysis, using the body's own processes.
How do we support that?
Exactly.
The body has its own enzymes and white blood cells that liquefy and digest dead tissue.
We support it by using dressings like hydrocolloids or transparent films that keep the wound bed moist.
That moist environment allows those natural processes to work.
It's slower, but very selective for just the dead stuff.
Okay, interesting.
Let's shift gears slightly.
What about skin issues that aren't from pressure, but more from irritation or inflammation, like itching?
Ugh, pruritus.
Intense itching, it's subjective, right?
But it can be maddening, often worse at night.
The big danger is the itch -scratch -itch cycle.
The scratching provides temporary relief, but damages the skin, which then causes more inflammation and itching.
Breaking that cycle is key, then.
Absolutely.
Management focuses on comfort.
Simple things help a lot.
Use tepid, not hot, water for bathing.
Use mild non -alkaline soaps, maybe oatmeal baths.
Pat the skin dry gently, don't rub.
Apply moisturizer generously.
And urticaria or hives, that's more of an allergic thing.
Right.
Urticaria is usually triggered by histamine release from an allergen, causes those itchy wheels, the raised red patches.
For both of these, sometimes antihistamines are used, right?
And some can be sedating.
Yes, and that brings up a safety point, especially for older adults.
If you're giving a sedating antihistamine… Fall risk.
Big time.
You absolutely need fall precautions in place.
And educate the patient, no driving, no operating machinery until they know how it affects them.
Good point.
Okay, let's talk about psoriasis now.
That's autoimmune, right?
With a rapid cell turnover.
Exactly.
Psoriasis is a chronic autoimmune condition.
Normally, skin cells turn over about every 28 days.
In psoriasis, it speeds up to maybe every 4 days.
This hyperproliferation causes those characteristic thick silvery scales, or plaques, on reddened skin.
And the treatments can have some serious side effects.
You mentioned tazeratine.
Yes.
Topical vitamin A derivatives like tazeratine.
Very effective, but highly teratogenic.
That means it can cause severe birth defects.
So any woman of childbearing potential using it, even topically, must be on strict, reliable contraception, and be counseled about the risks.
That's a critical alert.
What about systemic treatments, like biologics?
Biologic agents, like a tannercept, target specific parts of the immune system.
They can be life -changing for severe psoriasis.
But because they suppress the immune system, there's a major risk of serious infections.
The nursing safety priority drug alert highlights this.
Especially reactivation of latent tuberculosis, TB.
Patients need TB screening before starting, and must be taught to immediately report any signs of infection, fever, cough, fatigue, stop the drug, call the provider.
Wow.
Okay.
And because psoriasis can be so visible, the psychosocial aspect is huge, too.
It's immense.
Patients can face stigma, social isolation, depression.
As nurses, our professional acceptance is crucial.
How do we show that?
Simple things.
Make eye contact.
Don't act shocked or repulsed by the lesions.
And use therapeutic touch appropriately.
Shake their hand.
A gentle pat on the shoulder without gloves for that kind of social interaction.
Assuming your hands are clean, and there's no open weeping lesion, of course.
It communicates acceptance of the person.
That's really important.
Okay, quickly touching on infections, hygiene is key, right?
Especially with things like MRSA.
Crucial.
Basic hygiene, like daily showering with antibacterial soap if indicated.
Not sharing towels or razors.
Standard MRSA prevention helps prevent spread.
And briefly, parasitic things like pediculosis, lice, and scabies.
The mite infestation that causes that intense nighttime itching and those characteristic linear burrow tracks.
And there's a drug alert for lindane.
Yeah, lindane used to be common for lice and scabies, but it has potential for neurotoxicity, though rare.
It's generally not first line anymore due to resistance and safety concerns.
Other agents are preferred.
Okay, so before we hit the high acuity stuff, let's frame wound healing itself, the phases.
Right.
Normal healing follows three overlapping phases.
Inflammatory phase first cleanup crew arrives.
Then proliferative phase rebuilding with granulation tissue.
Finally, maturation phase scar tissue forms and remodels.
And wounds close in different ways.
Three main ways, or intentions.
First intention is when the edges are nicely brought together, like a clean surgical cut.
Minimal scarring.
Second intention is for wounds with significant tissue loss, like a deep pressure injury.
It has to fill in slowly from the bottom up with granulation tissue.
Scarring is usually greater.
And third intention, or delayed primary closure.
That's when a wound is initially left open, maybe due to high infection risk, and then closed surgically later once it's cleaner.
Got it.
Okay, now for the really high acuity topics.
Burns.
Huge loss of tissue integrity.
Extreme loss.
We classify them by depth, superficial, partial thickness, full thickness, and size, often using the rule of nines in adults to estimate the percentage of total body surface area affected.
And electrical burns have that iceberg effect.
Yes.
Always remember the iceberg effect with electricity.
The surface wounds, the entry and exit points might look small, but the current travels internally, damaging muscles, nerves, organs along its path.
The internal damage can be massive and unseen initially.
Okay.
Burn care is divided into phases, right?
What are the priorities in each?
Three main phases.
First is emergent or resuscitation.
That's the first, say, 24 to 48 hours.
Priority number one, two, and three is ABC.
Airway, breathing, circulation.
Plus fluid resuscitation and aggressive pain management.
Then comes the acute or healing phase.
This starts around 48 hours and goes until the wounds are closed or nearly closed.
Focus shifts to meticulous wound care, preventing infection, ensuring adequate nutrition for healing, and ongoing pain control.
Finally, the rehabilitative or restorative phase.
This begins as wounds close and continues potentially for years.
Focuses on maximizing function, preventing scars and contractures, psychosocial adjustment, and reintegration.
In that first emergent phase, you said airway is key.
What are the critical respiratory assessment keys we need to watch for?
This is a nursing safety priority.
Critical rescue area.
Inhalation injury is a major killer in burns.
You must look for signs.
Burns on the face, neck, or chest.
Cinched nasal hair, eyebrows, eyelashes, soot in the mouth or nose, or black sputum.
Listen for hoarseness, a brassy cough.
Notice any drooling or difficulty swallowing.
These all suggest potential airway edema.
And you mentioned something really ominous before, wheezing that stops.
Yes.
That is the most critical rescue cue.
If a patient was wheezing, indicating narrowed airways and the wheezing suddenly disappears.
Sounds like they got better.
No.
It means the airway has likely swollen, completely shut.
They can't move air at all.
That demands immediate preparation for intubation.
It's a true emergency.
Wow.
Okay.
What about carbon monoxide poisoning?
Another silent killer in fires.
CO binds to hemoglobin way more tightly than oxygen, about 200 times more.
It forms carboxyhemoglobin or COHB.
And that messes with oxygen delivery.
Totally.
The problem is, the standard pulse oximeter reading, SpO2, might look normal, and even the PO2, the oxygen dissolved in blood plasma, might be normal.
Do you get false reassurance?
Exactly.
Because the hemoglobin is saturated, but it's saturated with CO, not O2.
The oxygen isn't getting delivered to the tissues.
The patient is functionally suffocating despite potentially normal numbers.
What's the classic sign then?
That cherry red skin?
Sometimes, yes.
The cherry red color is due to vasodilation caused by the CO, but it's not always present, especially in darker skin.
High suspicion, checking COHB levels via blood gas and giving 100 % oxygen are key.
Okay.
Intense.
Last major topic, skin cancer.
Main cause is UV exposure, right?
Overwhelmingly, yes.
Chronic sun exposure is the biggest risk factor.
We see actinic keratosis, which is precancerous.
Then squamous cell carcinoma, SEC, which can metastasize.
Basal cell carcinoma, BCC, is the most common type, but luckily, it rarely metastasizes.
And then the most serious, melanoma, often arises from a mole or nevus, and it's highly metastatic.
Early detection is critical.
So prevention and early detection are key.
The ABCDE guide.
Absolutely essential.
Teach all patients monthly self -exams using ABCDE.
A for asymmetry, one half doesn't match the other.
B for border, irregular, notched, or blurred edges.
C for color, varied shades of brown, black, tan, sometimes red, white, or blue within the same lesion.
D for diameter, usually larger than six millimeters, about the size of a pencil eraser, though smaller ones occur.
And E for evolving any change in size, shape, color, elevation, or symptoms like itching or bleeding.
Everyone should know that guide.
And treatments are mainly surgical.
Surgical excision is the mainstay for most types.
Mohs surgery offers high cure rates for BCC and SEC by microscopically examining tissue margins during the procedure.
For melanoma, depending on the stage, treatments now also include immunotherapy and targeted therapies, which have really improved outcomes.
Okay.
Quite a journey through skin integrity issues.
Let's recap the big takeaways.
For PIs, prevention is systematic.
Use those bundles like STAND.
Be hyper vigilant about sharing, especially with bed elevation.
And remember that critical safety alert.
Never massage red areas.
Right.
For burns, respiratory assessment is paramount in the emergent phase.
Watch those inhalation injury signs, especially the sudden stop of wheezing.
And don't be fooled by a normal PA2 if you suspect CO poisoning.
And for skin cancer, lifelong vigilance with self -exams using the ABCDE guide is the best defense.
Absolutely.
And maybe one final thought.
Across all of these conditions, whether it's a chronic PI, disfiguring psoriasis, or a major burn, the impact on the patient's self -concept and psychosocial wellbeing is profound.
It changes how they see themselves, how they interact with the world.
So remember that our professional acceptance, demonstrated through respect, communication, and yes, appropriate therapeutic touch, is a powerful nursing intervention.
It goes way beyond just managing the wound itself.
That's a perfect note to end on.
Thank you for taking this deep dive with us today.
Hopefully you feel more equipped with the priorities and safety knowledge for truly excellent patient -centered care.