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Tissue Integrity--Case Study: Pressure Ulcer

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Jessica Etienne

on 3 October 2014

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Transcript of Tissue Integrity--Case Study: Pressure Ulcer

• Localized injury to skin and underlying structures (typically located over boney prominences) caused by pressure, friction and shear

• Usually heal by secondary intention

• Most common sites of pressure ulcer development are on the sacrum and the heels

Tissue Integrity
“Tissue integrity is defined as the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes. The term 'impaired tissue integrity' reflects varying levels of damage to one or more of those groups of cells.”
(Giddens 2013, p. 248)

can range from a superficial abrasion to a deeper wound, which penetrates the skin and subcutaneous tissues and may further extend to muscles, internal organs and bones
Loss of Perfusion
all tissues in the body require a constant supply of oxygenated blood to carry out normal physiological function; extended periods of poor perfusion, or temporary periods of no perfusion can subsequently lead to tissue necrosis and cellular damage
the skin provides a visible sign of an allergic reaction by the body and can be evidenced by manifestation of redness, hives, itching, rashes or other skin irritation; various foreign substances can lead to skin irritation such as soap, fragrances, copper and detergents
Infections &
can result from infections caused by bacteria, viruses or fungi; infestations can be caused by live arthropods such as mites or lice
Thermal or
Radiation Injury
this kind of skin injury can range from minor sunburns to scalding burns and chemical radiation
can range from minor benign skin growths, vascular lesions to more serious invasive malignant tumors
(Giddens, 2013, p.248-250)
Risk Factors
Less subcutaneous fat (higher potential for fluid loss and challenges in regulating temperature for maintaining warmth)

Diaper rash

Injuries to the skin secondary to uncertain mobilization

Inability to protect themselves from environmental dangers

Abrasions, bruises, and lacerations that occur during active play

Communicable skin infections (impetigo)

Older Adults
Decreased muscle mass and skin thickness

Decreased strength

Change in skin moisture

Loss of skin turgor

Decreased peripheral circulation and oxygenation

Diminished sensory perception (pain and pressure on skin)
Risk Factors
• Health conditions (Immunosuppression)
• Poor peripheral perfusion
• Malnutrition
• Obesity
• Fluid deficit/excess
• Impaired physical mobility
• Exposure to chemical irritants, radiation, excessively
hot or cold temperatures.
• Medical treatments, surgical procedures, or invasive
(Giddens, 2013)
Case Study: Yolanda Rodrigus

•Woods lamp: method of inspection involving magnification and special lighting; used to identify infectious organisms and proteins associated with specific skin conditions

•Tissue biopsy: a pathologic evaluation of tissue when skin lesions are suspected to be malignant

•Wound cultures: used to identify the organisms causing infection

•Patch testing: used to identify specific allergens causing dermatitis

(Giddens, 2013, P. 254)
Diagnostic Tests
80-year-old Hispanic woman who lives in a long-term care facility has been admitted to our floor. She is type 1 diabetic, has arthritis, and dementia. She is 5'8 and 110 lbs with a BMI of 16.7 (underweight). She came into the ED complaining of hip pain from a recent fall (the xray shows no fracture). Her aide says she is incontinent of urine and stool. Upon evaluation, pressure ulcers were found on her sacrum and on her ankle.
Nursing Considerations
• Assess patient's skin for acute and chronic
integumentary problems
• Assess patient's risk factors for integumentary
• Document skin condition and risk factor assessment
and develop a plan of care
• Determine whether patient is taking drugs that
increase photosensitivity
• Teach about risks associated with sun exposure and
methods for decreasing exposure to the sun.
• Teach about therapies that are used for
integumentary disorders, including dressings, baths, and oral or topical medications used on an outpatient basis.
• Evaluate treatment for effectiveness and any adverse
Dermal (Pressure) Ulcer
(From Thibodeau GA, Patton KT: Anatomy and physiology, ed 5, St Louis, 2003, Mosby.)
Dermal Layers:
Epithelial cells
Functions of the skin include:
absorption of substances
excretion of wastes
secretion into body cavities

Nerves located in the skin provide sensations of pain, touch, temperature, pressure, as signals about the external environment

Epidermis and dermis layers cover subcutaneous (fat) tissue.

(Giddens, 2013)
(Giddens, 2013)
Stages of Pressure Ulcers
Boney prominences where pressure ulcers are likely to occur:

Purple or maroon (discolored)
Intact or blood filled blister
Painful, firm, mushy, boggy, warmer, or cooler tissue (compared to adjacent tissue)

Intact skin
Nonblanchable redness
Typically over a boney prominence
Painful, firm, soft, warmer, cooler (compared to adjacent tissue)
**For patients with darker skin tones: color may differ from surrounding tissue color

Partial thickness/loss of dermis
Shallow open ulcer (red/pink wound bed)
No slough or bruising
Intact or an open serum-filled blister
Shiny or dry


Full thickness, tissue loss
Subcutaneous fat could be visible
Slough could be present (won’t obscure tissue depth)
Undermining (wound open under the lip of the boarder) tunneling (tunnel of open tissue formed underneath intact skin)

Full thickness, tissue loss
Base covered in slough (yellow, tan, and green, gray, brown)
Eschar (tan, brown, black)
Exposed muscle or bone could be present

Full thickness
Base covered by slough and/or eschar

(Lewis, 2011, p.200)
Suspected Deep Tissue Injury:
Stage I:
Stage II:
Stage III:
Stage IV:
Initial assessment and daily reevaluation and
Braden Scale for Predicting Pressure Sore Risk

Most common causes:
Sensory perception--maintain & assist
Activity & mobility--maintain & encourage
Nutrition--maintain adequate nutrition &
Pressure--minimize & frequent position
Friction and shear--minimize or eliminate

(Giddens, 2013, P. 254)
Color and presence of lesions:
Normal adult skin is a consistent color, ranging for individuals from light pink, to olive tones, to deep brown, with relatively darker shades in areas of sun exposure.

Oral and eye mucosa may appear pale pink to darker pink, red, or brown.
**Skin findings may vary by natural skin color**

Describe the lesions’

Describe the grouping of multiple lesions in rings, lines, or diffusely scattered arrangements and the color, odor, and consistency of any exudates
Overall health including:
past and current conditions
current medications taken
known allergies
family history
Previous history of skin disease (allergies, hives, psoriasis, eczema)
Change in pigmentation
Change in mole (size or color)
Excessive dryness or moisture
Excessive bruising
Rash or lesion
Hair loss
Change in nails
Environmental or occupational hazards
Self-care behaviors

The skin should be:
smooth and intact
even surface
minimal perspiration or oiliness
There should not be:
**although there may be calluses over the hands, feet, elbows, and knees
Skin folds should not be excessively moist or macerated.
Skin mobility and turgor should move easily when lifted and should return to place immediately when released
(Jarvis, 2008)
basic hygiene measures
protection from excessive sun exposure and other environmental hazards
• Establishing the treatment goal
• Moist wound healing
• Cleansing the wound
• Choosing appropriate topical wound care products
• May include wound debridement or skin grafting
• Consideration of adjunct therapy (negative-pressure wound
therapy, electrical stimulation)
• Pain management
• Management of nutrition (specific nutrient goals, vitamin and
mineral supplement)
• Surgical consultation
• Patient and staff education
• Discharge plan or transfer of care
• Documentation of all items in patient's medical record
Usually a last resort intervention

First line of treatment: topical skin antibiotic such as Aloe Vesta, or Medi-Honey

IV or oral antibiotics:
Vasodilators, Isoxsuprine

(serum protein provides proper blood circulation and metabolism compounds)
(Kee, 2012)
Family Dynamics
“Culture affects family dynamics in terms of the ways in which people cope with stress, the manner in which sick family members receive care, and the beliefs about sharing information with outsiders about a family member's illness”
(Giddens, 2013).

Language: Spanish/English

Religion: Catholic

Family: When sick they usually go to family members, for support, comfort and advice

Health Practice: They may recommend herbal remedies and other non-allopathic treatments used with Western medical care

Value modesty: the area between the waist and knees is considered private
What family involvement does our patient have?
Husband deceased

Son lives out of the state

She lives in a long-term care facility
Thoroughly assess on admission and continue throughout hospital stay

Observe and record wound characteristics such as:

Note the type of drainage

Record consistency, color, odor, or drainage of any kind

Measure the wound

Assess for pain at the sites of impairment

If it is a pressure ulcer stage it, and continue to reassess
Pertinent History:
Past and current conditions: diabetes, malnurished,
arthritis, and dementia
Current medications taken: Prednisone
Known allergies: none
Family history: diabetes
Excessive dryness or moisture: incontinence causes
frequent moisture
Pruritus: none
Environmental or occupational hazards: pt. lives in
nursing home--may not have adequate care
Self-care behaviors: dependent on caregivers for
bathing; needs assistance ambulating (assist x1)
What should we know about our patient's history relevant to her condition?
What will a focused assessment of our patient's condition consist of?
What is the stage of the patient's ulcers?
Sacrum: Stage II

Ankle: Stage I
Two pressure ulcers are noted

Sacrum: There is some partial-thickness loss of the dermis; She has a red wound bed with no signs of slough, but the wound bed is shiny

Right ankle: The tissue is intact, but with some nonblachable redness; The area is firm and warm to touch

Using the 0-10 pain scale, the pressure ulcer on her ankle was ranked a pain of a 4 out of 10 and the pressure ulcer on her sacrum was ranked a 6 out
of 10

There is no drainage or odor noted for either
What would this patient's Braden Scale score be?
What are our goals for our patient?
What will our nursing interventions be?
What is our nursing diagnosis?
Impaired skin integrity R/T extremes in age
Impaired skin integrity R/T medications
Impaired skin integrity R/T moisture and imbalanced nutrition
• Pt will regain integrity of skin surface by discharge.

• Pt will report any pain, using the 0-10 pain scale, at the site of skin impairment until discharge.

• Pt will report any altered sensations at the site of skin impairment until discharge.

• Assess the site of skin impairment daily

• Determine the stage of pressure ulcers

• Monitor the site of skin impairment at least once per shift for color changes, redness, swelling, warmth, pain or other signs of infection

• Monitor the client’s skin care practices, noting the type of soap used, temperature of water used, and frequency

• Monitor the client’s continence status and minimize exposure of skin impairment
-Because the client is incontinent and incontinence management plan should be implemented to prevent exposure to stool and urine

• Turn and position client q2h

• Do not position client on site of skin impairment

• Place pillows under right leg to elevate ankle

• Assess the client’s nutritional status

• Monitor albumin levels

• Promote adequate hydration and nutrition-- include foods high in protein
Inflammatory phase: Lasts 3-5 days; swelling and/or redness occurs
accompanied with pain

Granulation phase: Lasts 5-21 days; new blood vessels and collagen
form, resulting in a pink vascular wound

Maturation phase: Few months to years; involves remodeling of collagen
fibers and contraction of the scar

(Giddens, 2013).

3 Phases of Wound Healing

Various factors interfere with proper wound healing, such as:
decreased blood flow
tissue trauma
drugs (ex: corticosteroids or chemotherapy)
necrotic tissue

(Lewis 2013, p. 194)
of Wound Healing
Increased interstitial fluid pressure from compression of soft
tissues between two rigid surfaces
Decreased arteriole circulation, leads to decreased nutrient
and oxygen supply to tissues
Capillary collapse results from pressure exceeding capillary
closing pressure
Fluid loss through capillaries
Inflammation leads to localized tissue edema, which further
impairs perfusion
Autolysis (cell death) of tissue
The body’s inflammatory response leads to tissue ischemia,
which leads to tissue necrosis, which consequentially leads to ulceration if left untreated

(Hamm & Rappl, 2009)

Your turn to stage these ulcers!
Risk Factors
What puts our patient at risk of developing pressure ulcers?
• Elderly

• Lives in a long-term care facility

• Limited family involvement –Husband is deceased and son lives
out of state

• Malnutrition/Low BMI/Emaciated-Decreased muscle mass and
skin thickness

• Bruised hip, Arthritis- Decreased mobility

• Dementia, Diabetes-Decreased sensory perception

• Incontinent to urine and stool– Increased moisture on skin

Ackley, B.J., & Ladwig, G. (2014).
Nursing diagnosis handbook: An evidence-based guide
to planning care
(10th ed). Retrieved from https://evolve.elsevier.com/

Transcultural Nursing. (2012).
The Hispanic American community.
Retrieved from

Giddens, J. F. (2013).
Concepts for nursing practice
(1st ed.). Retrieved from

Hodgson, B. (2014).
Saunders nursing drug handbook 2014
(1st ed). Saunders.
Retrieved from https://evolve.elsevier.com/

Kee, J.L., Hayes, E.R., McCuistion, L.E., (2008).
Pharmacology: A nursing process approach
(7th ed.). Philadelphia, PA: Elsevier Health Sciences.

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. A. (2011).
Medical-surgical nursing: Assessment and management of clinical problems
(8th ed.). Retrieved from https://evolve.elsevier.com/

(Transcultural Nursing, 2012)
(Lewis 2010, p. 468)
(Giddens, 2013, P. 252-253)
(Giddens, 2013)
(Giddens, 2013, P. 255)
Were our goals met?
The stage 1 pressure ulcer on the patient’s heel had completely healed, showing no signs of redness or further impairment. Her heels are being elevated every shift to prevent a relapse in tissue integrity. The goals set to heal this pressure ulcer were met.

The stage 2 pressure ulcer on the patient’s sacrum also healed, but there is still red skin at the site of impairment. The nurses concluded that the ulcer has progressed from a stage 2 to a stage 1, as the epidermis was intact and there was no break in the skin, and the ulcer was nonblanchable. The goals set to heal this ulcer were considered partially met. The nurses’ interventions aided in healing, but need to be continued until full tissue integrity has been achieved. Goals were partially met.

All findings were documented, including the stage of both ulcers, their progress, and need for further assessment.

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