Unit XIV Nursing Care of the Patient with Problems of the Integumentary System PDF

Unit XIV- Nursing Care of the Patient with Problems of the Integumentary System 1 Anatomy and Physiology Review Chapter 49, pages 1138-40 § Structure of the skin § Fat § Dermis § Epidermis § Hair § Nails § Glands 2 Functions of the Skin § § § § § § Protection Homeostasis Temperature regulation Senso...

Unit XIV- Nursing Care of the Patient with Problems of the Integumentary System 1 Anatomy and Physiology Review Chapter 49, pages 1138-40 § Structure of the skin § Fat § Dermis § Epidermis § Hair § Nails § Glands 2 Functions of the Skin § § § § § § Protection Homeostasis Temperature regulation Sensory organ Vitamin synthesis Psychosocial 3 1 Skin Assessment § Color § Lesions, primary and secondary § Assess each lesion for: § ABCD features § A= Asymmetry of shape § B= Border irregularity § C= Color variation within one lesion § D= Diameter greater than 6mm 4 Common Skin Lesios § Macules- flat lesions < 1cm in diameter § Flat moles, freckles § Patches- Macules that are > 1cm in diameter § Vitiligo § Papules- Small firm raised lesions < 1cm in diameter § Elevated moles or warts § Plaques- Elevated, plateau-like lesions >1cm in diameter and don’t extend to lower layers of skin. § Psoriasis 5 More Common Skin Lesions See Table 49.8, pages 1149-1154 § Nodules-Elevated, marble-like lesions >1cm deep/ wide § Lipoma § Cyst- Nodules that are liquid or semi-solid filled and can be expressed § Sebaceous cyst § Vesicles or Bullae- Blisters filled with clear fluid- vesicles are < 1cm in diameter and bullae are >1cm in dia. § 2nd degree burns § Pustules- Vesicles filled cloudy or purulent fluid § Acne § Wheals- Elevated, irregularly shaped transient areas of dermal edema § Urticaria or bug bites 6 2 Inspect Skin § Look for signs of: § Edema § Moisture § Vascular markings § Petechiae § Ecchymoses § Integrity § Cleanliness 7 Integrity of Skin § Skin tears result from of flattening of the dermal-epidermal junction and are a common finding with aging. § Look for skin tears where constrictive clothing rubs the skin, on the upper extremities where the skin is grasped when assisting a client to move, and the areas where adhesive tapes or dressings have been used. 8 Palpation § Palpation confirms the size of the lesions and determines whether they are flat or slightly raised § Macular: flat rash § Papular: raised rash § Skin temperature: assessed with the back of the hand § Turgor: the amount of skin elasticity 9 3 Hair Assessment § Inspect and palpate the hair for cleanliness, distribution, quantity, and quality. § Dandruff is an accumulation of patchy or diffuse white or gray scales that appear on the surface of the scalp. § Hirsutism is excessive growth of body hair, which is one manifestation of hormonal imbalances. 10 Nail Assessment § Dystrophic nails may occur with a serious systemic illness or local skin disease involving the epidermal keratinocytes § Evaluate fingernails and toenails for color, shape, thickness, texture, and presence of lesions § Minor associations w/ the aging process include gradual thickening of nail plate, presence of longitudinal ridges, and yellowish-gray discoloration 11 Skin Assessment techniques for Clients with Darker Skin § Assess for: § Pallor § Cyanosis § Inflammation § Jaundice 12 4 Age-Related Changes § 5 basic functions of the skin (protection, temperature regulation, vitamin D metabolism, sensation, and excretion) becomes less efficient § Skin increasingly more fragile § Longer healing times § Dermatoporosis= term for declining function of the skin § Common Age-Related Skin Conditions: § Xerosis § Eczema § Psoriasis § Herpes zoster (shingles) 13 Diagnostic Assessment § Cultures for: § Fungal infections § Bacterial infections § Viral infections § Skin biopsies § Punch biopsy § Shave biopsy § Excisional biopsy 14 Diagnostic Assessment § Wood’s light examination: exposes some skin infections, produces a specific color such as blue-green or red in a darkened room. No discomfort with this exam. 15 5 Xerosis (Dryness) § § § § A common problem among older clients. Fine flaking of the stratum corneum Generalized pruritus Scratching a result of secondary skin lesions, excoriations, lichenification, and infection 16 Xerosis 17 Collaborative Management § Nursing interventions aim to rehydrate the skin and relieve itching. § Bathing with moisturizing soaps, oils, and lotions may reduce dryness. § Water softens the outer skin layers; creams and lotions seal in the moisture provided by water. 18 6 Pruritus § Pruritus is caused by stimulation of itchspecific nerve fibers at the dermalepidermal junction. § Itching is a subjective symptom similar to pain. § Cool sleeping environment is helpful. § Fingernails should be trimmed short. (Continued) 19 Pruritus (continued) § Balneotherapy is a therapeutic bath using colloidal oatmeal. § Therapy: § Antihistamines § Topical steroids 20 Sunburn § § § § First-degree, superficial burn Cool baths Soothing lotions Antibiotic ointments for blistering and infected skin § Topical corticosteroids for pain 21 7 Sunburn 22 Sunburn (one too many times) 23 Urticaria § Urticaria: presence of white or red edematous papules or plaques of varying sizes § Removal of triggering substances § Antihistamines helpful § Avoidance of overexertion, alcohol consumption, and warm environments, which can worsen symptoms 24 8 Urticaria 25 Trauma § Phases of wound healing § Inflammatory phase § Fibroblastic, or connected tissue repair phase § Maturation or remodeling phase 26 Process of Wound Healing § First intention resulting in a thin scar § Second intention (granulation) and contraction—a deeper tissue injury or wound § Third intention (delayed closure)—high risk for infection with a resultant scar 27 9 Process of Wound Healing 28 Partial-Thickness Wounds § Involve damage to the epidermis and upper layers of the dermis § Heal by re-epithelialization within 5 to 7 days § Skin injury immediately followed by local inflammation 29 Full-Thickness Wounds § Damage extends into the lower layers of the dermis and underlying subcutaneous tissue. § Removal of the damaged tissue results in a defect that must be filled with granulation tissue in order to heal. § Contraction develops in healing process. 30 10 Pressure Ulcer § Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period. § Mechanical forces that create ulcers: § Pressure § Friction § Shear 31 Identification of High-Risk Clients § Mental status/decreased sensory perception—client at risk for pressure ulcers § Activity/mobility § Nutritional status § Incontinence 32 Pressure-Relieving Techniques § Adequate pressure relief key to prevention of pressure ulcers § Capillary closing pressure § Pressure relief products and devices § Positioning away from mattresses and pillows 33 11 Wound Assessment § Pressure ulcers and their features are classified and assessed in 4 stages: § § § § Stage I Stage II Stage III Stage IV 34 Pressure Ulcers- Stage 1 35 Pressure Ulcer- Stage 2 36 12 Pressure Ulcers- Stage 3 37 Pressure Ulcer- Stage 4 38 Impaired Skin Integrity § Interventions include: § Individual client needs § Nonsurgical management: dressings, physical therapy, drug therapy, diet therapy, new technologies, electrical stimulation, vacuum-assisted wound closure, and hyperbaric oxygen therapy 39 13 Surgical Management § Preoperative care § Dressing changes and prevention of infection § Operative procedures § Debridement § Possible closure/ skin grafts § Pedicle flaps § Postoperative care § § § § § Do not disturb dressing. Ensure complete rest of grafted area. Ensure care of pedicle flap. Provide postoperative care of donor sites. Ensure correct client positioning. 40 Skin Grafts/ Pedicle Flaps 41 Risk for Infection and Wound Extension § Interventions: § Monitor the ulcer’s progress. § Provide timely treatment with topical and systemic antibiotics. § Take steps to reduce introduction of pathogenic organisms to the ulcer through direct contact. 42 14 Prevention of Infection and Wound Extension § Interventions: § Report the following to the primary health care provider: § Sudden deterioration of the ulcer, increase in size or depth of the lesion § Changes in color or texture of the granulation tissue (Continued) 43 Prevention of Infection and Wound Extension (Continued) § Changes in the quantity, color, or odor of the exudate § Classic signs of wound infection 44 Bacterial Infections § Folliculitis: superficial infection involving only the upper portion of the follicle § Furuncles: much deeper infection in the follicle § Carbuncles: A group of infected hair follicles § Cellulitis: generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue 45 15 Folliculitis 46 Furuncles/ Carbuncles 47 Cellulitis 48 16 Viral Infections § Warts: Lesions causes by HPV (human papillomavirus) (genital or non genital) § More about genital HPV in Chp 67 (STIs) § Herpes Simplex viruses § HSV-1 Majority are above waist found on lips, waist, mouth (cold sore/ fever blister) § HSV-2 Classified as sexually transmitted by physical contact, oral sex, or kissing § Will study later (Chp 67) § Herpes Zoster: Shingles 49 Warts (HPV) 50 Herpes Simplex Viruses 51 17 Herpes Zoster- Shingles 52 Fungal Infections § Dermatophyte infections can differ in lesion appearance, anatomic location, and species of the infecting organism. § The term tinea describes dermatophytoses. § Tinea capitis § Tinea corporis § Tinea pedis § Candidiasis infections caused by Candida albicans (yeastlike fungus) 53 Fungal Infections 54 18 Assessment § Because most skin infections are contagious, take precautions to prevent the spread of infection. § Culture purulent material; obtain blood cultures. § A number of diagnostic tests can be run on skin: Diagnostic Tests of the Integumentary System (page 1161-1164) 55 Skin Care § Bathe daily with an antimicrobial soap. § Remove any pustules or crusts gently. § Apply warm compress twice a day to furuncles or areas of cellulitis. § Apply appropriate ointments (antibiotic, antifungals, antivirals) § Other treatments may be appropriate (cryosurgery, antipyretics, etc) § Avoid excessive moisture. § Ensure optimal client positioning. 56 Drug Therapy for Skin Disorders § Drugs can be given topically or systemically, depending on need: § § § § Antibacterial drugs Antifungal drugs Antiviral drugs Anti-inflammatory drugs 57 19 Pediculosis § Pediculosis—infestation by human lice § Head lice: Pediculosis capitis § Body lice: Pediculosis corporis § Pubic or crab lice: Pediculosis pubis § Pruritus most common symptom § Drugs such as Bio-Well, Kwell, Kwellada, Ovide, Prioderm lotion, NIX § Laundering of clothing and bed linen 58 Pediculosis 59 Scabies § Scabies is a contagious skin disease caused by mite infestations. § Transmitted by close and prolonged contact or infested bedding. § Examine skin between fingers and on the palms. § Infestation is confirmed by an examination of a scraping of a lesion under a microscope. § Scabicides include Kwell, Kwellada, or topical sulfur preparations. § Launder clothes and personal items. 60 20 Scabies 61 21