Endocrine/​Hematology/​Gastrointestinal/​Renal/​Integumentary Study Guide for the CCRN

Integumentary

Breakdowns in the integumentary system put great stress on the body. The integumentary system is the primary defense against infection and disease. When disruption occurs, patients may suffer severe effects from these conditions.

IV Infiltration

IV infiltration occurs when an IV fluid or medication leaks from the vessel through which it was infusing. A severe form of infiltration is known as extravasation. Extravasation is further defined as a medication that causes damage to the surrounding tissues when infiltrated. This damage can include decreased perfusion, cell edema, nerve or tendon damage, and tissue necrosis. Common fluids that cause extravasation include chemotherapy, TPN, IV blood pressure regulators, vancomycin, electrolytes, propofol, phenytoin, and promethazine.

Prevention

Nurses should carefully monitor IV sites, especially when caustic IV solutions are infusing. Monitor for any changes in patient’s pain and erythema or swelling at the IV site. Check for blood return regularly and investigate thoroughly if blood return is unable to be obtained. Peripheral IV sites should be moved at regular intervals to prevent venous breakdown. Central lines should be treated with care to prevent damage to the line.

Treatment

Treatment of infiltrations and extravasations should be implemented as soon as the event is suspected. The first intervention is to stop the infusing medication. Notify a prescribing provider of the event and take measures to minimize the damage. For some medications, additional medications or antidotes may be used to reduce the damage. If the damage extends beyond supportive measures and antidotes are ineffective, surgical evaluation, debridement, skin grafts, or amputation may be indicated.

Necrotizing Fasciitis

Necrotizing fasciitis is a rare, but serious, integumentary condition. It is characterized by the introduction, infection, and spread of flesh-eating bacteria via a cut, scrape, burn, insect bite, puncture, surgical wound, or blunt trauma. The most common bacteria known to cause this condition is group A Streptococcus. When a patient develops necrotizing fasciitis, quick and severe damage can occur to the local skin, muscles, nerves, fat, and surrounding blood vessels.

Symptoms and Diagnosis

While necrotizing fasciitis can occur anywhere in the body, it most commonly occurs in the limbs. Early symptoms of necrotizing fasciitis include edema, warmness, spreading erythema, severe pain, and fever. Symptoms develop rapidly and can quickly turn into visible ulcerations, blisters, poor skin perfusion, blackening of the skin, and weeping or pus drainage. Systemic symptoms include nausea, diarrhea, persistent fever, and fatigue. If not recognized and treated promptly, necrotizing fasciitis can lead to significant tissue damage requiring amputation (if infection present on an extremity), sepsis, and death.

Necrotizing fasciitis is generally diagnosed based on the clinical symptoms of the patient. Lab work and radiographic imaging may be used to identify the offending organism(s) and the extent of damage done by the bacteria but are generally not required for formal diagnosis.

Treatment

If necrotizing fasciitis is suspected, immediate initiation of broad spectrum antibiotics and surgical exploration is recommended. The goal of therapy is to remove as much of the damaged tissue as possible to prevent further spreading of the bacteria. Frequent wound wash-outs, possible fasciotomies to allow drainage, and wound debridements will likely be scheduled until the infection is under control. Tissue cultures obtained during surgical intervention can better identify any offending organisms. Tissue cultures along with any blood cultures that were drawn allow for improving specificity of antibiotic choice and treatment. Some patients may require the use of hyperbaric oxygen chambers to facilitate wound healing.

Pressure Injury

One of the biggest care-associated complications is pressure injury. Pressure injuries develop when patients have consistent pressure on particular parts of the body that reduce perfusion to the tissues and cause tissue death. Common pressure injuries include pressure ulcers, shearing, and friction injuries. Critical care patients are at particular risk for these types of lesions. In critical care settings, patients are often suffering from extreme illness or change in status, decreased level of consciousness, decreased mobility, and have increased machinery and monitoring devices. Sedation, vasopressor medication, and incontinence are also risk factors for the development of pressure ulcers.

Diagnosis and Stages

Pressure ulcers are diagnosed based on staging. Early signs of ulcer development include persistent erythema, tenderness, and firmness at the pressure site. This can quickly develop into tissue ischemia that erodes through the layers of the skin and exposes underlying structures. Prevention of pressure ulcers is the gold standard. Patients should be repositioned every two hours, with a focus on reducing pressure on the high-pressure points. The Braden scale may be used to help assess the extent of the patient’s risk for ulcer development. Turning boards, positioning wedges, and slide boards should be used to reduce friction and shearing when positioning the patient. Moisture barriers help to prevent skin breakdown from urine and feces. Patients with existing ulcers should be monitored closely and all measures should be taken to prevent worsening of the existing wound or creation of new wounds.

Treatment

Treatment of pressure injury includes early identification and staging of the lesions. Depending on the severity, patients may require supportive measures for the involved wound care. Patients should be positioned away from the area of injury, making sure that other high-pressure areas are supported. Wet-to-dry dressings may be used to facilitate healing in deeper wounds. High stage ulcerations may require the use of a Wound Vac® to provide stimulating healing to the area. In some cases, especially if patients have several skin lesions and ulcerations, hyperbaric oxygen therapy may be indicated.

Wounds

Critical care nurses will find themselves caring for a variety of wounds. Some patients present with wounds that are the root cause of their hospitalization, while others may have wounds as a result of secondary trauma, infection, or surgical procedures.

Infectious

Cellulitis is a type of infection when the skin itself becomes infected. This usually occurs due to a break in the skin in which bacteria are introduced. Cellulitis may have rapid onset or develop slowly. It is most commonly due to Staphylococcus or Streptococcus bacteria. Patients may experience signs of localized pain, erythema, edema, and warmth at the site. It progresses rapidly and may result in fever, fatigue, and tissue or underlying organ damage. Treatment for cellulitis involves systemic antibiotics. If there is an associated open wound, irrigation and debridement may be necessary.

Nursing Care

Nurses should pay considerably close attention to all patient wounds. Any wound can easily become infected and cause severe illness, sepsis, multisystem organ failure, and even death if not treated appropriately. Know the early signs of infection, including erythema, site warmth, fever, increasing pain, drainage, and leukocytosis. Wound cultures can be performed to help identify the offending organism and improve the choice of antibiotic for treatment. Wound care is also important to ensure that the wound edges remain healthy for improved healing. Nurses may be responsible for frequent dressing changes and debridement or may help with surgical irrigation, debridement, and closure when indicated.

Surgical

Surgical wounds are purposefully created wounds in the operating room to address complications or conditions within the underlying structures. While the preparation for surgery is sterile, sterile wounds, just like any break in the skin, have increased risk for secondary infection.

Classes of Surgical Wounds

Four classes of surgical wounds exist. Class I is a clean, simple surgical wound. Class II is a clean, contaminated surgical wound. This means that some parts of the wound may have been exposed to gastric, infectious, or intestinal contents which have been controlled and appropriately managed while in the surgical suite. Class III wounds involve traumatic injuries, such as gunshot wounds, that are contaminated but not necessarily dirty. Finally, Class IV wounds are dirty wounds. These wounds occur due to a traumatic event in a “dirty” environment or by a “dirty” instrument. If the source of the wound or the environment in which the wound occurred is unknown, it may be classified as a Class IV surgical wound.

Continued Care

Surgical wounds should be monitored closely for signs of infection. Changes in erythema, edema, patient vitals, fever, and increasing pain and purulent drainage are all signs of infection. Closed surgical wounds should be monitored for dehiscence. If the wounds are unable to be closed either primarily or secondarily, vacuum-assisted closure may be indicated. Patients with surgical wounds are often treated with a short course of prophylactic antibiotic therapy as well as strict regulations on wound care guidelines to prevent secondary infection or complications.

Trauma

Traumatic wounds may be due to blunt, penetrating, or forced trauma. Patients may present to the emergency department with cuts, punctures, lacerations, ecchymosis, bites, gunshot wounds, crush injuries, degloving, or contusions. Each wound should be assessed thoroughly to identify severity and any underlying cause of injury. Basic wound care, including irrigation and debridement, should be performed as soon as possible to ensure decreased risk for infection. Nurses should monitor for changes in patient status, erythema, edema, bleeding, pain, respiratory changes, cardiac rhythms, hypotension, and level of consciousness. These may be early or late signs of significant underlying trauma or infection. Treatment measures are similar to both surgical and infectious wound care. Patients may need foreign body removal, stitches, fibrin glue, antibiotics, Tetanus injection, or surgical reconstruction depending on the extent of the injury.