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 into the surrounding tissue. This can cause the area to feel cool to the touch and become swollen. If the fluid was a vesicant (irritant), it 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, nerve or tendon damage, and tissue necrosis. Common fluids that cause extravasation include chemotherapy, TPN, vasopressors, vancomycin, electrolytes such as potassium, propofol, phenytoin, and promethazine.

Prevention

Nurses should carefully monitor IV sites, especially when vesicant IV solutions are infusing. Monitor for any changes in the patient’s pain and erythema or swelling at the IV site. Ensure the catheter is properly secured with a transparent dressing to allow visualization of the site and prevent dislodgment. Routinely flush IVs with saline to assess for patency before starting any infusions. Although less common, central lines can infiltrate as well.

Treatment

Treatment of infiltrations and extravasations should be implemented as soon as the event is suspected. The first intervention is to stop the infusion of medication and remove the catheter. Notify a prescribing provider of the event and take measures to minimize the damage. Elevate the extremity and use warm or cold compresses depending on the medication that was infused. New IV access should be established in the opposite extremity of the affected site, or at least proximally to the infiltration. 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, warmth, spreading erythema, severe pain disproportionate to the injury, 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 is present on an extremity), sepsis, organ failure, 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. Vacuum-assisted closure (VAC) devices may be used after surgical debridement to aid in healing. 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 the 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 hospitalized care-associated complications are pressure injuries. These may also be referred to as bed sores or pressure ulcers. Pressure injuries develop when patients have consistent pressure on particular parts of the body that reduces perfusion to the tissues and causes 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, malnutrition, 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.

• Stage 1—skin intact, localized area of non-blanchable erythema

• Stage 2—partial-thickness loss of skin with exposed dermis

• Stage 3—full-thickness loss of skin with visible adipose tissues

• Stage 4—full-thickness skin and tissue loss with muscle, tendon, ligament, or bone visible

• unstageable—full-thickness skin and tissue loss in which the extent of the wound cannot be confirmed due to slough or eschar obstructing the ulcer

• deep tissue injury—can be intact or non-intact with non-blancable deep red or purple discoloration

Treatment

The prevention of pressure ulcers is the standard of care.

• The Braden scale may be used to help assess the patient’s risk for pressure ulcer development. A score less than 12 indicates a patient who is at high risk for skin breakdown.

• Patients should be repositioned every two hours, with a focus on reducing pressure on the high-pressure points.

  • Off-loading devices such as heel boots and dressings can provide cushion on bony prominences.

  • Speciality mattresses can help redistribute pressure on the skin. Turning boards, positioning wedges, and slide boards should be used to reduce friction and shearing when positioning the patient.

• Moisture barriers and frequent perineal care help to prevent skin breakdown from urine and feces. In critically ill patients, malnutrition increases the risk of pressure injuries and delays healing.

• For those who cannot eat, nutrition through a G-tube, TPN, or vitamin supplementation should be considered. Patients who can take oral intake may benefit from high-protein drinks to support skin integrity.

Patients with existing pressure ulcers should be closely monitored, with all measures taken to prevent worsening or the development of new wounds. Care may include wound irrigation and dressing changes to promote healing.

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 common type of infection in which the skin itself becomes infected. This usually occurs due to a break in the skin in which bacteria are introduced. Cellulitis may have a 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 assess all wounds frequently. 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. Imaging, such as X-rays, CT, and MRI, can be used to assess the severity of the infection and determine if it has spread to the bone. This is referred to as osteomyelitis and, if suspected, is confirmed with a bone biopsy. 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 take care of patients after 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, these wounds still have an 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. This also includes surgical wounds that have been contaminated with break in sterile technique or gross spillage of gastric contents.

• Class IV wounds are dirty wounds. These wounds occur due to a traumatic event in a “dirty” environment or by a “dirty” instrument. This includes surgical abscess drainage or bowel perforation.

Continued Care

Surgical wounds should be monitored closely for signs of infection. Changes in erythema, edema, vital signs,and increasing pain and purulent drainage are all signs of infection. Closed surgical wounds should be monitored for dehiscence (separation). If the wounds are unable to be closed either primarily or secondarily, vacuum-assisted closure may be indicated. In certain cases, surgical wounds are intentionally left open, either because there is a concern for infection or because the patient is expected to require additional surgeries to allow for easier re-entry. 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 result from blunt, penetrating, or forced trauma. Patients can present with cuts, punctures, lacerations, bite wounds, crush injuries, or contusions, and each injury should be assessed thoroughly to determine severity and identify any underlying damage. In trauma cases, patients often have multiple injuries so the external wound may not be the first priority.

The initial focus is on stopping any active bleeding with direct pressure, performing imaging to assess for internal bleeding, and evaluating for any signs of shock. Basic wound care, including irrigation and debridement, should be performed as soon as possible to reduce the risk of infection. Nurses should monitor for changes including erythema, edema, bleeding, pain, respiratory changes, cardiac rhythm abnormality, hypotension, and altered level of consciousness.

Treatment measures are similar to both surgical and infectious wound care. Depending on the extent of the injury, patients may require foreign body removal, sutures, staples, tissue adhesive, antibiotics, tetanus prophylaxis, or even surgical reconstruction.