Tissue Integrity, Hair and Nail Anatomy

• The study notes cover concepts related to tissue integrity, infection, bowel elimination, nutrition, metabolism, and urinary elimination.

Anatomy of Hair and Skin

• The hair within the follicle is known as the root, while the portion emerging is the shaft.
• The hair shaft goes through cycles of growth and rest.
• Dead keratinocytes are tightly packed in the follicle during the hair growth cycle and pushed towards the skin surface.
• Alopecia or baldness occurs when there is complete death of a hair follicle; it can be caused by heredity, stress, or illness.

Nail Health and Growth

• Basal keratinocytes constantly divide within the nail matrix under the skin to form the nail root.
• The visible part that adheres to the nail bed is the nail body.
• Nail bed coloration reveals information on the body's perfusion status, specifically in distal locations.

Skin Assessment Health History Questions

• Any skin allergies should be assessed.
• Check for allergic reactions to foods, medications, and chemicals.
• Note any previous skin problems.
• Inquire about exposure to animals or others with skin problems, and also about skin cancer history.
• A skin assessment involves inspecting and palpating the entire skin area, including mucous membranes, scalp, hair, and nails.
• Braden Scale is used.
• Assess skin integrity, color, turgor, texture, moisture, temperature, and the presence of lesions.
• Erythema is the skin's redness from capillary congestion, usually linked with inflammation.
• Cyanosis is bluish skin color due to lack of oxygen.
• Jaundice is yellowing from high serum bilirubin.
• Vitiligo is depigmentation in specific areas.
• Albinism is generalized depigmentation.
• Striae are stretch marks.
• Rashes should be examined under bright light for color, redness, heat, pain, swelling, location, size, pattern, and distribution.

Primary vs Secondary Lesions

• Primary lesions arise directly from an infectious disease, allergic reaction, or environmental factor.
• Secondary lesions are transformations of primary lesions, often due to manual disturbance like itching, treatment, or underlying disease progression.

Braden Scale Interpretation

• The Braden Scale assesses pressure-related skin damage risk.
• It is a risk assessment tool to predict small skin changes caused by immobility, moisture, and inadequate nutrition.

Age-Related Skin Changes

• As the body ages, the 5 basic functions of skin become less efficient.
• The skin becomes more fragile.
• Healing takes longer.
• There is increased susceptibility to age-related skin conditions.
• Temperature regulation and excretion are less efficient.
• Decreased perception of injury occurs due to less sensory receptors in the skin layers.
• Hair and nail growth rates decreases as well.

Bacterial Skin Infections

• Types of bacterial infections include cellulitis, abscess, folliculitis, impetigo, and simple wound infections.
• Skin and soft tissue infections are categorized by depth of infection, tissues involved, and interventions needed.
• Uncomplicated infections respond to antibiotic therapy or surgical drainage with or without antibiotics.
• Uncomplicated infections include superficial cellulitis, folliculitis, impetigo, furuncles, simple abscesses, and minor wound infections.
• Complicated infections involve deeper tissues and require debridement.
• These are caused by invasion of deeper tissue by microorganisms that needs surgical debridement, or also infections as the result of systematic disease and response to treatment.

Cellulitis Diagnostic Criteria

• Uncomplicated cellulitis includes superficial cellulitis, folliculitis, impetigo, furuncles, simple abscesses, and minor wound infections.
• Clinical manifestations of non-necrotizing cellulitis includes erythema, warmth, edema, and localized pain.
• It is characterized by rapidly spreading erythema, warmth, localized pain, edema, and potential inflammation of regional lymph nodes.

Wound Assessment

• A wound assessment should include examination of the wound bed and edges, as well as measurement of the wound.
• Examine the surrounding skin for vascularity, presence of changes such as angiomas/petechiae, or blanchable vs. non-blanchable areas.
• Note the color (pale, pink, red, or purple) and if the wound is macerated (white and moist).
• Assess for wound undermining and tunneling, and if it is calloused.
• Induration (firm to touch) can be compared to fluctuance (boggy with pus underneath).

Nursing Interventions

• Provide an aggressive approach for patients with systemic clinical manifestations of infection.
• It is usually unnecessary to do blood cultures, needle biopsies, and punch biopsies for localized skin and soft tissue infections like cellulitis.
• A quantitative tissue biopsy is considered the gold standard. It is an invasive test which tests a tissue sample from below the surface of a wound via Gram stain and culture to identify wound pathogens.
• Wounds with necrosis or eschar require debridement to reveal viable tissue for culturing.

Herpes Simplex Virus

• Herpes Zoster (Shingles) is a painful vesicular eruption along the sensory nerves from one or more posterior ganglia:
• Medical treatment involves antivirals such as acyclovir, valacyclovir, and famciclovir, which have shown clinical benefit in treating GH.
• Virological testing is appropriate for those with mucocutaneous lesions or ulcers.
• Serological type-specific glycoprotein G-based assays can distinguish HSV-1 from HSV-2 using blood samples.

Fungal Infections

• Fungal infections - Tinea (ringworm) affects: head (tinea capitis), body (tinea corporis), groin (tinea cruris or jock itch), feet (tinea pedis or athlete's foot), and nails (tinea unguium)
• Medical treatment involves antifungal medications.
• Prevent fungal infections by avoiding causative factors like tight shoes, moisture, perspiration, contact with bare skin, and sharing personal items.
• Frequent hand washing and eliminating the sharing of personal items are the main infection control methods.

Psoriasis

• Aggravated by infections, medications, stress, trauma, and hormonal changes
• Men and women are equally likely to develop psoriasis with a mean onset age of 28 (range 15-35 years).
• Plaque psoriasis affects 80-90% of those with the disease.
• Psoriatic arthritis affects the hand and spine joints.
• Nail involvement includes pitting, onycholysis (nail lifting), and splinter hemorrhages.
• There is no cure, but treatment exists with topical agents (corticosteroids, Vit D analogues, retinoids, tar), phototherapy, stress management and trigger avoidance.

Skin Trauma and Wound Healing

• The phases of wound healing are:
  • Homeostasis
  • Inflammatory (lasts 1-2 days)
  • Proliferative (begins 2-3 days after injury, lasts up to 2 weeks)
  • Maturation (begins several weeks after injury, lasts up to 2 years).
• Granulation is growth of new tissue.
• Eschar is brown or black, thick, leathery, devitalized tissue.
• Slough is moist, stringy, white/yellow/tan/gray.
• Macerated is white moist.
• Surgical debridement is the removal of dead or infected skin to facilitate healing.

Pressure Injuries

• Risk Factors are immobility, prolonged pressure, altered skin moisture, equipment like casts/traction/restraints, friction/shear forces, impaired sensory perception, decreased tissue perfusion, and decreased nutritional status.
• Pressure Injury Classifications:
  • Stage 1: Intact skin with non-blanchable redness over a bony prominence that is painful, warm, cool, soft, or firm,
  • Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed that may be shiny or dry, and no slough or bruising,
  • Stage III: Full thickness tissue loss, where Subcutaneous fat may be visible, slough may be present, and tunneling or undermining,
  • Stage IV: Full thickness tissue loss with exposed bone, muscle, or tendon, that includes possible slough or eschar, undermining, and tunneling,
  • Unstageable: Full thickness tissue loss where base is covered in slough or eschar making it impossible to stage until removed.
• Medical Management based on stage - Stage I: Relieve pressure, maintain nutrition and fluid, reduce friction and shear, avoid moisture on skin; Stage II: Same interventions as Stage I; cleanse wound; dressing with semipermeable occlusive, hydrocolloid wafers, or wet saline; Stage III: Same interventions as Stage I; debride wound, clean wound; apply topical treatment to promote granulation; proper dressing; Stage IV: Same interventions as Stage III; may need surgical intervention (debridement, incision and drainage, bone resection, and skin grafting)
• Nursing Diagnoses: Impaired skin integrity related to trauma, acute/chronic pain d/t skin trauma/wound infection/wound treatment, imbalanced nutrition (less than requirements) r/t hypermetabolic state 2nd to open wound, depression, risk for infection
• Nursing Assessment: Assess vitals, pain, skin, pressure areas, Braden scale, wounds, and nutrition.
• Nursing Interventions: Positioning off bony prominences, HOB <30, using draw sheets, skin and incontinence care, appropriate bed surfaces, wound care, and teaching mobility/fluid intake

Bowel Elimination, Nutrition, Metabolism CONCEPTS

• Liver functions - blood storage/filtration, bilirubin production, synthesis of clotting factors, removal of clotting factors, metabolism of carbs/fat/protein, detoxification, and storage of vitamins A/D/E/K and iron
• As an exocrine gland, the pancreas secretes 1,200 to 1,500 mL of pancreatic juice containing water, sodium bicarbonate, proenzymes, and pancreatic enzymes needed for carbohydrate (amylase), fat (lipase, phospholipase A, cholesterol esterase), DNA/RNA (deoxyribonucleases, ribonucleases) digestion.
• Small Intestine:
  • Chyme leaves the stomach to the duodenum
  • The jejunum (8ft) contains a rich blood supply and muscular wall.
  • The ileum (12 ft) connects to the large intestine at the ileocecal valve.
  • The lining contains villi containing goblet cells for secretion.
• Large Intestine:
  • Consists of the cecum (2-3 in), colon, rectum, and anus.
  • Consists of the ascending, transverse, descending, and sigmoid colon.
  • Functions in drinking.

Stomatitis/Oral Mucositis

• Risk factors include viral/bacterial/Fungal (Candida albicans) infections, irritants, radiation therapies, allergy, vitamin deficiency, and systemic disease
• It presents a painful inflammation and ulceration of the lining of the mouth that include the lips, pharynx, tongue, gingiva, and esophagus.
• Complications include Vincent's (trench mouth), from germs (fusiform bacteria and spirochetes).

Hiatal Hernia

• 96% of patients with Barrett's esophagitis have a hiatal hernia that is 2cm+
• Type 1 (sliding) hernias are caused by disruptions to the GEJ from muscle weakness, obesity, pregnancy, and ascites.
• Type 2 (rolling) hernias are due to anatomical defect causing improper anchoring of the stomach below the diaphragm.
• Can be asymptomatic or result in regurgitation, heartburn, and dysphagia.
• Surgical methods such as Nissen fundoplication used to wrap portion of gastric fundus around the sphincter area of the esophagus.
• Post-op care includes not driving, soft diet, and no air swallowing.

Gastroesophageal Reflux Disease (GERD)

• Caused by excessive reflux of hydrochloric acid in the esophagus.
• It can result from an incompetent lower esophageal sphincter, pyloric stenosis, or motility disorder.
• Manifestations include pyrosis, heartburn, dyspepsia/indigestion, regurgitation, and dysphagia.
• Barrett's Esophagus includes altered lining that can accelerate gastric emptying or lead to cancer easier.

Irritable Bowel Syndrome (IBS)

• Twice as often in women, where symptoms often worsen with a woman's menstrual cycle.
• Involves a change in motility by a neuroendocrine dysregulation, infection, irritation, or vascular disturbance.
• Symptoms include spastic colon, abdominal pain with tenderness, altered bowel habits, and mimic detectable diseases.

Diverticulosis

• Often in the left colon and is related to the lack of fiber, obesity, and low physical activity.
• Diverticulum is a sac-like herniation of the bowel lining through a muscle layer defect.
• Diverticulosis: Multiple diverticula are present without inflammation.
• Caused by stress, muscular fiber weakening, and fiber deficiencies.
• Manifestations include difficulty swallowing, fullness, belching, coughing, and regurgitation.
• Monitor labs.

Appendicitis

• When appendicitis occurs in older adults, it ruptures easier. Mortality is higher among the elderly. There are no particular risk factors or preventive measures.
• The appendix has no known function.
• Clinical manifestations include abdominal pain, nausea, temperature, and signs of peritonitis.

Cirrhosis

• Can cause 35,000 deaths annually in the U.S.
• It is a chronic disease that causes cell destruction and fibrosis or scarring of hepatic tissues.
• Portal hypertension causes an increase of blood pressure.

Urinary Elimination CONCEPTS

• Excrete waste product (urine)
• Regulatory function includes removing waste and fluid balance
• Nephrons remove the end products.

Renal and Urinary Assessment

• Includes health history and consideration of multiple parameters such as voiding changes, symptoms, kidney, bladder, and lower extremities.
• Common complaints include fatigue, and pain
• Includes GI symptoms and Family/Social History
• CVA tenderness and Palpation of the Prostate and lower extremities are methods of assessment.

Age-Related Changes

• Renal and urinary systems change with increasing age
• Kidneys decrease in mass by 10% each decade from age 50
• Number of glomeruli begin a decline near age 50
• Blood flow and Glomeruli decrease
• Bladder Capacity lowers for both sexes

Urinary Tract Infection (UTI)

• 50% of females will have at least one UTI in their lifetime
• UTIs can be caused by short urethra and proximity of rectum and vagina, resulting in a hematogenous.
• Symptoms include painful urination, frequency, incontinence, cloudy urine, and pelvic pain
• Surgical Management may be needed
• Nursing care includes education and prevent the spread of infection

Urolithiasis/Kidney Stones

• The majority of stones are calcium, and remaining are cystine, uric acid, and xanthine.
• Pain is typically colicky, with nausea, vomiting, and hematuria
• Management options include alpha blockers, x-ray, and ultrasound.

Incontinence

• Incontinence is more common when aging.
• Can be caused by injuries, nerve damage, strong urges to void, or overdistention of the bladder.
• Symptoms include overdistention of the bladder, involuntary loss of urine, and cognitive impairment
• Diagnose the source of incontinence to better treat it