Nursing Report: Impaired Skin Integrity - Evidence-Based Interventions

This nursing report analyzes two case studies involving patients with tibial fractures: a septuagenarian, John, and a 7-year-old, Jacob. The primary problem addressed is potential for impaired skin integrity related to altered circulation. The report delves into the anatomy, physiology, and pathophysiology of the condition, supporting evidence-based interventions. It discusses the use of the Braden and Norton scales for assessment, along with interventions like debridement and hydrotherapy. The report emphasizes the importance of regular repositioning, proper nutrition, and effective communication with patients and their families. The goal is to promote wound healing and reduce pain, with specific interventions tailored to each patient's age and condition. The report concludes by summarizing the interventions and assessment tools used to ensure effective recovery and skin integrity.

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Name of the Student
Name of University
Author’s note

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With an increase in age, there occur inevitable biological modifications in the
human body that increase the likelihood of suffering from disability and illness (Taneja
et al., 2016). The case studies to be discussed here involved a septuagenarian John
and 7 year old Jacob Murray, who had been admitted to the emergency department for
the treatment of a fractured tibia. The fracture occurred when they encountered an
accidental fall The priority problem selected is potential for impaired skin integrity
related to altered circulation. The essay will elaborate on the anatomy, physiology, and
pathophysiology of the condition presented by the patients, in order to support evidence
based interventions. It will also apply decision making and chemical resetting framework
that are in accordance to the standards of practice.
The tibia is generally found on the medial portion of the leg, adjacent to the fibula
and is situated close to the central line or the median plane. It is also associated by the
interosseous membrane to the fibula, and leads to the formation of the syndesmosis,
which is a special kind of fibrous tissue joint that shows restricted movement (Schenk et
al., 2018). In addition, it is a component of four joints namely, the ankle, the knee, the
inferior and superior tibiofibular joints, and when present in the knee, it results in the
formation of one of the two major articulations in relation to the femur that is often
known as the tibiofemoral component. According to Smith et al. (2016) this tibiofemoral
component is considered as the weight-bearing region of the nature, and therefore
fracture in the tibia (right or left) will prevent the patients from bearing weight. This is the
reason why both John and Jacob are experiencing problem while walking.
In case of Jacob it is undisplaced spiral fracture and for John it is undisplaced
transverse fracture. In both cases the bone cracks either in parts or all of the way
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through, however it does move and maintains the proper alignment. Since the bone is in
proper alignment, both John and Jacob are able to wiggle their toes. Although there are
no nociceptors present in the bone tissue, this bone fracture resulted in painful
sensation due to oedema of the soft tissues that are located nearby (Hurtgen et al.,
2016). This in turn occurred as a result of fracture of the bone marrow that evoked
pressure pain. In addition, it might also have resulted in a breakage in the continuity of
periosteum that comprises of pain receptors. Furthermore, skin integrity refers to skin
health and impairment in skin integrity in the patient suggests that the fall resulted in
damage to the skin, which made it vulnerable to injury, thus preventing normal healing
process. The breakage in the skin integrity is the reason why both John and Jacob is
experiencing inflammation in the breakage area. Breakage in the bone hampers the
disruption of the blood vessels in the bone that are important for maintaining the skeletal
functioning along with the development of homeostasis and repair (Tomlinson & Silva,
2013).
This disruption of the blood vessel flowing to the bone leads hampers the
vascularisation or the circulation. This disruption in the blood flow hampers the
underlying skin integrity beneath the subcutaneous layer of the skin. This might be the
reason why Jacob and John is experiencing pain at the site of fracture (8/10 and 7/10 in
pain score respectively) along with warm temperature over the affected area of the skin.
John is also having bruise 7cm x 4cm anterior mid shaft. Since he is 72 years old,
Jacob might be suffering from poor skin integrity due to loss of the connective tissue of
the skin and this might lead to delay in wound healing. Jacob is 7 years old and thus
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has firm skin integrity unlike John. He also does not have osteoporosis and thus his
inflamed area of anterior mid-shaft is 5cm x 3cm (Marenzana & Arnett, 2013).
On analysing the case studies it can be suggested that sheer force, friction, and
pressure from immobility have put the patients at a risk for impaired skin integrity. On
conducting a health assessment it was found that John weighed 85 kg, hence signifying
that he was overweight, which in turn put him at a risk (Potes et al., 2017). In addition,
since the patient was aged 72 years, old age resulted in slowing the process of skin
breakdown that lead to normal loss of skin elasticity and vascular insufficiency
(Coleman et al., 2013). The fall from the ladder resulted in mechanical trauma. In
addition, osteoporosis also weakened the bones and increased his risk of suffering from
altered skin integrity. Jacob is much young to John; he is 7 years old and has ideal
weight (26 kgs). Thus his bone and skin healthy is comparatively healthy to John.
However, main risk factor is, since he is child, he might experience problem with the
effective management of pain resulting from bone displacement and breakage of skin
integrity.
Assessment of the level of pain using numeric pain rating scale will be important
in order to determine the intervention that must be given in order to improve the
wellbeing for both John and Jacob. Taking into consideration the age of John, the
overall condition of the skin will be assessed, which will provide baseline data for the
proposed intervention. A healthy skin is expected to have good turgor, which indicates
the presence of moisture, and it must feel dry and warm and be free from any kind of
impairment. In addition the capillary refill time will also be assessed (Foster, Fix &
Bergerhofer, 2018). The bony prominences such as, the sacrum, heels and inner and
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outer knee will also be checked, since these are the specific areas where the skin
remains stretched, thus increasing the risk of breakdown due to the possibility of
ischemia. The patient will be subjected to the Norton scale and the Braden scale. While
the former will help in assessing his mental condition, activity, physical condition,
incontinence, and mobility, the latter will comprise of six sub-categories namely,
moisture, perception, activity, sensory, nutrition, mobility, friction, and shear (López et
al., 2019; Chamblee t al., 2018). For Jacob Braden scale assessment is not importance
as children are not exposed to pressure ulcers and moreover he is not overweight. The
assessment of bony prominences will be done in order to assess the skin integrity.
The most important goal would be to reduce redness over the bony prominences
of the patient and help in completion of capillary refill within 6 seconds, within 50 hours
after admission.
The primary nursing intervention will focus on debridement of the affected
tissues. This process would encompass removal of the necrotic tissue, which has been
identified as an ideal area that promotes bacterial growth, which in turn might
compromise the process of wound healing. Since removal of the injured tissue is
imperative for treatment of John and Jacob’s wound, hydrotherapy will be considered as
the best intervention, which will help in performing selective mechanical debridement.
Also referred to as water cure, this aspect of alternative medicine will involve the
application of water for treatment and pain relief (De Almeida et al., 2017). The
intervention will take advantage of different physical properties of water namely,
pressure and temperature, in order to stimulate blood circulation in the affected region.
This intervention has been found to promote early granulation, rapid cleansing, and
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sustained epithelialization, all of which have been recognized as basic necessities for
effective wound healing (Atkin & Ousey, 2016). Owing to the fact that establishing a
moisture rich environment facilitates the process of wound healing, use of moisture
retentive dressings over the injured region would lead to the creation of a moist bed
environment. This in turn will reduce infection rate, promote epithelialization and
granulation, decrease scarring of the tissue, reduce pain perception, and also enhance
retention of growth promoting factors (Ziwa et al., 2019). This sequential wound
treatment program would typically encompass the implementation of either of the two
wound dressings namely, HydroClean® plus and HydroTac® (Houghton, 2017). For
Jacob it would be cast valving. It will decrease in pressure, preventing discomfort and
complications like compartment syndrome for children (Nguyen, McDowell &
Schlechter, 2016)
Another nursing lead intervention would focus on informing the patient’s daughter
and wife to encourage him to change his position after every 15-20 minutes, once he
has been discharged from the hospital. Regular repositioning will help in decreasing the
shear force and redistribute or alleviate the pressure that is being exerted on the tissues
and cells (Weiner et al., 2017; Coleman et al., 2013). In addition, it will also promote
circulation and help in maintaining the skin healthy. In case of Jacob, his mother will be
educated to provide proper diet as this will help in faster healing of wound. Moreover,
her mother will be educated to forbid Jacob from making frequent movements. Children
are prone to make frequent movements like rolling the legs and moving out of bed after
sudden intervals. Such movements might delay the healing process. Jacob mother will
be educated to stay with Jacob for the majority of the time and monitor him at bed so
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that he maintains a resting posture in bed and thus promoting faster recovery (Dyer,
2015). Effective communication and informed decision will include John as he is an
adult and in case of Jacob, it would only be her mother as he is a minor and this
coincides with the code of professional conduct of Nursing and Midwifery Board of
Australia (2008).
Intact skin integrity and capillary refill time in less than 6 seconds will help in
confirming effectiveness of the intervention for John. The numeric pain rating scale will
also be used and a score near 3-4 will provide evidence for a reduction in pain, which in
turn will be promoted by effective wound healing. For Jacob proper assessment of the
mobility will be important in order to ascertain recovery (Murray, Quigley & Curley,
2014)
The family members of John and Jacob will also be asked to check for the
absence of redness over the major bony prominences that will also determine efficacy
of the applied interventions.
Thus, it can be concluded that also referred to as the shank bone or the shin
bone, the tibia is the stronger, larger, and frontal of the two bones that are situated in
the leg, just underneath the knee, and has the primary responsibility of linking the ankle
bones with the knee. Bone is a highly organised vascular tissue. Impaired skin integrity
due to altered circulation is defined as a damage occurring in the mucous membrane,
integumentary, corneal or the subcutaneous tissues. Impairment in skin integrity in the
patient indicates that the skin has been damaged and exposed to injury, thus
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decreasing its efficiency to recover and repair normally. Therefore, the two interventions
would focus on faster healing and reduction of pain.
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