Tissue Integrity

(upbeat music) - Hey there everyone, this is Melanie and welcome back to the nursing school week by week. Well, I just finished my first week of nursing school and it was just so much. I felt like I was already behind before school even started. I studied pretty much anytime I wasn't in an actual Zoom class or in lab or spending a small amount of time with my family. I keep thinking about a nursing t-shirt that I've seen and that I might have to get that says, "I can't, I'm in nursing school." 'Cause that is just so true. All right, so each week I'm gonna talk to you about the most high-yield topic for that week in nursing school. Now, this is the topic that you'll get the most questions from on your test. Now, of course, your school might be a little different or put a little more emphasis on something else so just keep that in mind. Okay, so for the first week of nursing school, the most high-yield topic is tissue integrity. Well, what is tissue integrity? It's your skin's ability to repair itself and stay healthy. Now, some skin has a harder time with this than others. If you've been around an elderly person lately, you may have noticed some band-aids on their arms or hands. That's because as people get older, they don't make as much collagen, which makes their skin thinner and less stretchy. A lot of things slow down as people get older, including their ability to heal. So an older person might take months to heal from just a little scratch. Another group of people who have thin skin are newborn babies. Until they're about two years old, their skin is more similar to the delicate skin under an adult's eyes. Also, the protective barrier function of skin hasn't yet developed in babies. So they absorb a lot more of any kind of lotions or topical cream medications. Another difference in baby skin is that they don't shiver until they're about six months old. Now, as we know, one way our body warms up when we're cold is by shivering. A baby can't shiver, but it does have a special type of brown adipose fat that makes heat when they're cold. There are some differences in dark skin compared to Caucasian skin. When dark skin becomes irritated and then inflamed, it can have a harder time getting rid of that inflammation. We see the consequence of this in something called a keyloid. A keyloid is a raised ugly scar that shows up after an injury, like a surgical incision, after that's healed, it might get a real big ugly scar. And it's much more common in African-Americans. So how does a nurse know if someone has good healthy skin or if their tissue integrity is not so great? Well, a nurse's most important job is to assess. Assess, assess, assess. What does that mean? It means to look and feel and listen and even smell. To assess a patient's skin, you're gonna look for any colors that don't match the rest of their skin. You'll look for cuts and scars. If they have any openings in their bodies, like catheters or tubes or stomas, you'll inspect those. If you notice any strange smells, you'll investigate that. Then you're gonna use your hands to palpate or touch the patient to test for a dima. A dima is swelling that's caused by extra fluid that's trapped in the body's tissues. And to test for a dima, you'll press down on the top of the patient's foot with your thumb. And if the thumb print goes away quickly, that's good. That means they don't have any or much of any swelling. But if you lift your thumb away and you can still see a dent or a pit where your thumb was, then they have swelling or you would say they're a dimatis. You would document their a dima as being either one plus, two plus, three plus or four plus with four plus being the most a dimatis. Another test you would do is to see if the patient is dehydrated. This is called the skin turgor test. You would pinch the skin over the back of the hand, maybe on the abdomen or if they're elderly, you'd pinch them right under the collarbone. And if they're dehydrated, it'll take longer for the skin to bounce back from that pinched position. All right, so you've assessed the skin, but now you have to assess the hair and nails. You're gonna run your gloved hands through the hair, looking for things like lice or bald patches. The bald patches could mean they have a fungal infection and you could look for cradle cap if it's on a baby or a toddler. Cradle cap is very common and can usually be cleared up by just carefully combing out the dead skin off the scalp. When you're looking at the patient's nails, you wanna make sure the nail colors even if the nails are yellow or too thick, they could have a fungal infection or psoriasis. You may also see pigmented bands on nails. This is a dark stripe that goes down the nail towards the tip of the finger and this is caused by melanin being deposited into the growing nail, but it's actually normal for African-Americans to have this. So just remember that about 90% of African-Americans just naturally have pigmented bands. You also want to look at the curvature of the nails. So if you hold up your finger at eye level, so you're looking at the side of your finger, the spot where your finger meets your nail should make a 160 degree angle, meaning there's a little dip where your finger and your nail meet and then your nail goes up a little bit and curves. But with something called nail clubbing, there would be no angle there, just a straight line where the finger and the nail meet. This is usually a sign of hypoxia, which means not enough oxygen is getting to the tissues. All right, so you've done your assessment, you've looked, felt and smelled, and you have some suspicions that the tissue integrity is not so great. So what are some specific tests that you can do in order to be able to say this person has this condition? If you've found a lesion, a tumor, or some kind of suspicious mass, then a biopsy could be done. This is taking a sample of tissue from that area and it's usually done to look for cancer. Another diagnostic test is a culture. This is when you would take a sample from an open or close sore from the nails or hair and you'd culture it, much like you did back in your microbiology lab. And this can tell you what type of bacteria or fungus that you're dealing with. Another test is the Woods Lamp Test, or it's also called the Black Light Test. And this shines a black light on the skin to detect tinia. Tinia is another name for a fungal infection. The area with the fungus will have a bright orange glow when you shine the woods lamp on it. The last diagnostic test you need to know concerning the skin is the patch or scratch test. If you suspect someone might be allergic to something, these tests will tell you what they're allergic to. With the patch test, the patient will have 20 or more substances taped to the skin of their upper back or their arm for 48 hours. Then their skin will be examined for allergic reactions like redness or swelling. The scratch test is similar, but instead of taping the substances to the skin, the allergens are injected into the top layer of the skin with tiny little needles. All right. So let's say someone does not have good tissue integrity. What are some problems that we might see with them? First, we might see skin lesions. This just means part of the skin looks weird compared to the skin around it. There are two types or two categories of skin lesions. There are primary lesions and secondary lesions. So let's say you got an ant fight, you would get a bump or a pushtule, and that would be the primary skin lesion. Now let's say it's super itchy, and the more you itch, the more you scratch and you scratch this pushtule so much that you wind up with a scar. That scar would be the secondary lesion. And some of the main primary lesions are called macules, which are flat spots like freckles or measles and papules, which feel like a solid mass. This would be like a mole or a wart. Secondary lesions are, some common ones are a fissure. This is like, if you've ever had really dry skin on the back of your heel, it's like a crack in the skin of your heel. Another secondary lesion is a scar, and also that key loy that we talked about, and that's the big ugly scar that some people get after an incision heals. Another problem that nurses see that definitely involves the skin is wounds. As nurses, you will need to know how to describe wounds so you can document them. Wounds are described as intentional or unintentional. Was it an incision from surgery? Then it was intentional. Was it a gunshot wound? Hopefully, unintentional then. Next, you'll say if the wound is open or closed, an open wound would be anything that has broken skin. So even a paper cut would be considered an open wound. Closed wound would be like a hematoma, which is a fancy word for a bruise. We also describe how clean or dirty the wound is. If it's a closed wound, it's called clean. If it's open and it has the potential for infection, but it's not visibly infected yet, then we say it's clean contaminated. If you look at the wound and it looks inflamed, or you see other early signs of infection, you would call it contaminated. And then finally, if the wound is like draining yellow posts and it's obviously infected, you would say it's dirty or infected. Another skin-related problem that you will hear so much about is the pressure ulcer. This is when patients lay in bed in the same position for too long and they get a bed sore. These develop overbony prominences like heels or hips. The tailbone is a very common place for a pressure ulcer. And also the ankles or elbows. The pressure causes eschemia, which is a restriction of the blood supply to the tissues. And this causes necrosis, which is the death of the tissue in that area. And that forms a pressure ulcer, which is also called a pressure injury. This is why it's so important that you turn the patient to a new position every two hours, at least. And that you look over their skin once every shift for signs of redness. If you do find a red spot, press it with your finger. If it turns white and then goes back to red, it's not actually a pressure ulcer. But if it's non-blanchable, which means it doesn't turn white at all, but just stays red, that is a stage one pressure ulcer. And these things can get serious and nasty very quickly. A stage four pressure ulcer is where the skin is worn away and there's actually exposed muscle and even bone. Hospitals use a tool called the braiden scale to determine how at risk a patient is for pressure ulcers. The patient is graded on how good their nutrition is, how active and mobile they are, and how moist their skin is. Since if they're urinating on themselves a lot, they're gonna have a higher risk of skin breakdown because healthy skin is usually dry skin. On the braiden scale, a score of 12 or under is considered high to severe risk. Some things that we as nurses can do to minimize this risk is to turn them every two hours, keep their skin clean and dry, keep the head of the bed at least 30 degrees or less. So this would be the semi-fallars position. And also we want to avoid shearing the skin or creating any unnecessary friction on their skin. Okay, and that's all I have for you on the topic of tissue integrity. I hope this was really helpful to you. Thank you so much for joining me and I will talk to you again next week. Have a great day. (upbeat music) (upbeat music)