TISSUE INTEGRITY NOTES

• Roles of nurses with Integumentary and Nutrition

  • Do focused assessments
  • Identify actual/potential risks
  • Prevent complications
  • Implement interventions
  • Evaluate effectiveness
• Nutrition: FNHA BC Elders Guide
• Nutrition topics in the FNHA BC Elders Guide

  • Traditional food fact sheets
  • Alcohol: increased sensitivity & can be confused with normal change of ageing
  • HCC and PH nutrition support and nutritionist services
  • "Good oral health also enables you to choose from a greater variety of foods while you age, which can positively impact your health and decrease your risk for malnutrition"
• Canada's Food Guide recommendations

  • 50% vegetables or fruits
  • 25% whole grain foods
  • 25% protein foods

  
• Other recommendations to support healthy nutrition habits

  • Try not to eat alone
  • Be mindful of habits
  • Limit processed food & cook more
  • Use resources- dietician is available 811

  
• Recommendation for intake can depend on: quality of food, personal goals, and activity
• Carbohydrates


  Controls blood glucose and insulin metabolism
• Types of carbohydrates


  • High glycemic index
  • Soluble fiber
  • Simple carb
  • Complex carb
  • Low glycemic index
  • Starch
  • Insoluble fiber
• Proteins


  Essential and nonessential amino acids
• Complete protein


  Animal protein
• Incomplete protein


  Plant protein
• Proteins


  Contribute with nitrogen balance
• Fats (lipids)


  Saturated or unsaturated fatty acids
• Types of fats


  • Monounsaturated fatty acids
  • Polyunsaturated fatty acids
  • Trans fatty acids
  • Cholesterol
  • Triglycerides
• Water


  Cells depend on a fluid environment, helps regulate body temperature and is a solvent, most adults need 3L/day
• Patients with heart failure and chronic kidney disease are recommended to have fluid restriction to prevent fluid overload
• Mechanisms that allow the body to lose fluid

  • Sweating
  • Eliminated
  • Respiration
• Vitamins


  Essential to metabolism, include antioxidants, fat soluble (A, D, E, K) and water soluble (B, C)
• Minerals


  Catalysts for biochemical reactions, include macrominerals (Ca, Na, K) and microminerals (Fe, Mg)
• Nutrition considerations for older adults

  • Follow nutritional advice that aligns with health status
  • May need more fiber and vitamins
  • Changes that occur to the body impact eating
  • Social – economical challenges
  • Change in senses (taste, smell)
• Older adults have increased risk of malnutrition
• Integumentary Healing and Wounds

  Impact of nutrition on wound healing, Stages of wound healing, Healing process- primary, secondary and tertiary intention, Pressure injury (PI), Incontinence associated dermatitis (IAD)

  
• When triglyceride levels are high and LDL cholesterol levels are elevated


  It increases the risk of atherosclerosis
• The combination of high triglycerides and LDL cholesterol contributes to the formation of plaque in the arteries, leading to atherosclerosis
• Wound Classifications


  • Acute - sudden onset, heal rapidly (eg surgery wound, skin tear)
  • Chronic - chronic healing, cause of wound is often not removed (eg venous ulcers, diabetic ulcers, can become chronic)

  
• Skin tear


  Epidermis is thin = risk for tear, dehydration, poor nutrition, certain illness & steroid use can increase risk of breakdown, careful when transferring, any open area is at risk for infection
• Wound Healing Process


  • Primary - tissue surfaces are closed, little tissue loss, increased healing speed, lower risk of infection (eg surgical incision)
  • Secondary - great loss of tissue/edges can't be brought together, longer repair/healing time, greater chances of scarring, increased chance of infections (eg burn, pressure injury, severe laceration, skin tear, surgical wound - ALL COULD LEAD TO TERTIARY)
  • Tertiary - needs to be kept open, contaminated, great risk of infection, more connective scar tissue, require surgical closure (eg PI with infection. Wounds kept open to allow for drainage)

  
• Factors affecting wound healing stages


  • Bleeding (hemostasis) - blood clotting mechanisms, platelet function, vascular integrity, medications that affect blood clotting, medical conditions like hemophilia
  • Inflammatory - presence of infection, foreign bodies, immune response, chronic diseases like diabetes and autoimmune disorders, proper wound care and infection control
  • Proliferative - availability of growth factors, oxygenation, nutrient supply, chronic conditions like peripheral artery disease, malnutrition or deficiencies in vitamins and minerals
  • Remodeling - collagen synthesis and remodeling, wound tension, age, smoking, medications

  
• Factors that can delay the inflammatory response

  • Necrotic tissue
  • Repeated pressure
  • Trauma
  • Foreign bodies
  • Infection
  • Poor nutrition
  • ETOH
  • Drug use
  • Cigarette use
• Partial thickness wounds


  Affect epidermis and maybe dermis, regeneration occurs through hemostasis, inflammation, epithelial proliferation, migration (eg superficial skin tear, stage 2 PI, abrasions, IAD)

  
• Full-thickness wounds


  Extend into dermis, regeneration occurs through hemostasis, inflammation, proliferation, remodelling (up to 2 yrs) (eg stage 3, and 4 PI)

  
• Pressure Injury (PI)


  A change in or break in the skin caused by an injury or trauma related to pressure, localized to skin and underlying tissue, usually over a bony prominence, result of pressure, shear, or friction or all 3, affected by moisture, perfusion, comorbidities
• Types of pressure injuries

  • Low pressure over a long period
  • High pressure over a short period - occludes blood flow, occludes nutrients, and cell death
• It costs 44,000-90,000 to treat a pressure injury
• Risk factors for pressure injuries

  • Immobility
  • Poor nutrition
  • Decreased sensation
  • Moisture
  • Friction and shear
  • Dehydration
  • Smoking
  • Advanced age
• Characteristics of a Stage 1 pressure injury

  • An area of intact skin with a localized red area with non-blanchable erythema, which may be more difficult to assess in darkly pigmented skin
  • Color changes do not include purple or maroon discolouration
  • The area may have changes in sensation such as pain or numbness, firm, soft, warmer or cooler as compared to adjacent tissues
• Characteristics of a Stage 2 pressure injury

  • An area with partial thickness skin loss with exposed dermis and the wound bed is viable, pink or red, and moist, or an intact./non-intact (ruptured) serum-filled blister
  • Adipose (fat) tissue and deeper tissues are not visible
  • Granulation tissue, slough and eschar are not present
  • Stage 2 Pressure Injury should not be used to describe Moisture Associated Skin Damage(MASD), Incontinence Associated Dermatitis (IAD), intertrigo, adhesive/tape related skin injuries, skin tears, burns, or abrasions

  
• Characteristics of a Stage 3 pressure injury

  • An area of full-thickness loss of skin in which adipose (fat) tissue is visible and fascia muscle, tendon, ligaments, cartilage and or bone are not exposed
  • Slough and/or eschar may be visible but does not obscure the base of the wound
  • The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds
  • Undermining and tunneling may occur
  • Granulation tissue is often present
  • Epibole (rolled edges) may occur
• Characteristics of a Stage 4 pressure injury

  • An area of full-thickness skin and tissue loss with exposed or directly visible and palpable fascia, muscle, tendon, ligament, cartilage, bone or hardware in the wound bed
  • Depth varies by anatomical location
  • Slough and/or eschar may be visible but does not obscure the base of the wound
  • Undermining and/or tunneling often occurs
  • Granulation tissue is often present
  • Epibole (rolled edges) may occur
• Characteristics of an Unstageable pressure injury

  • An area of full-thickness skin and tissue loss in which the depth of the wound bed is not visible due to the presence of slough or eschar
  • When boggy slough or eschar is debrided a Stage 3 or Stage 4 PI will be revealed
  • Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed