DISC 5

Chapter_017.pptx

Chapter 17

Integumentary Function

Is to serve as barrier against harmful bacteria and other threatening agents; skin is the first line of defense for the immune system

Prevents fluid loss or dehydration

Protects the body from ultraviolet (UV) rays and other external environmental hazards

Protects underlying organs from injury

Provides thermal regulation of body temperature

Primary Function of Skin

Replacement rate of first layer of epidermis declines by 50% as person ages.

Area of contact between epidermis and dermis decreases with age.

Is thinner

Number of melanocytes decreases with age.

Age spots

Age-Related Changes in Epidermis

Decreases in thickness by approximately 20%

Number of sweat glands, blood vessels, and nerve endings decreases.

Collagen stiffens and becomes less soluble.

Decreased amount of subcutaneous tissue and a redistribution of fat to abdomen and thighs

Breast tissue becomes more granular and atrophic.

Age-Related Changes in the Dermis and Subcutaneous Fat

Fewer eccrine glands and apocrine sweat glands exist.

Sebaceous glands and pores become larger.

Hair thins, and its growth declines with progressive loss of melanin.

Changes in the patterns of hair growth and distribution

Nails grow more slowly and become thicker, brittle, dull and develop longitudinal striation with ridges.

Age-Related Changes in Dermal Appendages

Common, bright red, 1–5-mm superficial vascular lesions that increase in number with age

Cause of lesions unknown

Most commonly found on trunk, but can be located anywhere on body and vary in number

Benign growths

Cherry Angiomas

Benign, scaly growths with “stuck-on,” crumbly appearance; varies in color from tan to brown to black; elevated and range in diameter from 2 to 3 mm

Characterized by slow growth

Borders may be round and smooth or irregular and notched.

Have greasy feeling and often occur in sun-exposed areas but can appear anywhere on body

Seborrheic Keratoses

Common stalklike, benign tumors often found on neck, axilla, eyelids, and groin, although can be located anywhere on body.

Tiny, flesh-colored or brown excrescences that develop into a long, narrow stalk (up to 1 cm)

As they mature, can be easily removed with scissors, electrocautery, or liquid nitrogen

Skin Tags (Acrochordons)

Chronic inflammation of skin

Common sites: scalp, ear canals, eyebrows, eyelashes, nasolabial folds, axilla, breasts, chest, and groin area

Appears as a white or yellow scale with a plaquelike appearance

Usual pattern of distribution begins with the scalp and moves down toward the eyebrows, progressing to the chest with a bilateral, symmetric presentation

Inflammatory Dermatoses: Seborrheic Dermatitis

Results from friction of opposing skin surfaces and the irritation this causes

Usually found in armpits, inner aspects of thighs, skin folds of breasts, and abdominal folds

Area is erythematous and may itch.

Antimicrobial agent (antifungal or antibacterial), low potency topical steroid and keeping the skin clean and dry

Inflammatory Dermatoses: Intertrigo

Autoimmune condition

Associated with cardiovascular disease, metabolic syndrome, hypertension, dyslipidemia, and Crohn’s disease

Genetic component

Periods of remission and relapse with varying degrees of intensity

Well-circumscribed, pink plaques covered with silver-white, loosely adherent scales

Affects skin of elbows, knees, scalp, lumbosacral areas, intergluteal cleft, and glans penis

Inflammatory Dermatoses: Psoriasis

Recognizing inflammatory dermatitis and noting location, degree of erythema, itching, and scaling

Can you name four nursing diagnoses for inflammatory dermatoses?

Inflammatory Dermatoses Nursing Management: Assessment and Diagnosis

Reduced skin integrity, resulting from immunologic deficit (psoriasis)

Reduced skin integrity, resulting from bedbound state (seborrheic dermatitis)

Reduced skin integrity, resulting from the physiologic disease process (intertrigo)

Distorted body image, resulting from the psoriatic lesions

The patient will do the following:

Have skin lesions free from infection

Experience resolution of the inflammatory process

Verbalizing the rationale for regular and consistent skin care

Verbalizing knowledge of maintenance therapy

Verbalizing triggers to inflammatory dermatitis

Correctly demonstrating application of topical medications

Inflammatory Dermatoses Nursing Management: Planning and Expected Outcomes

Ensure proper use of medications to treat inflammatory dermatoses

Teach patient and family the correct way to apply the prescribed treatments

Explain that treatment measures and importance of follow-through will increase compliance and involvement in care

Symptom management is an area where nurses can have positive effect on older adult’s quality of life.

Inflammatory Dermatoses Nursing Management: Intervention

Accurate, comprehensive charting describing physical assessment and maintenance interventions

Response to teaching as measured by patient and family compliance with treatment

Inflammatory Dermatoses Nursing Management: Evaluation

The nurse caring for an older adult patient notices a scaly well-prescribed pink plaque covered with silver white area on the patient’s elbow. What does the nurse tell the patient?

“This area needs to be checked for basal cell carcinoma.”

“Daily application of an antiseborrheic shampoo will help.”

“Continue the treatment plan provided by your physician.”

“This skin lesion is caused by the chickenpox virus.”

Quick Quiz!

ANS: C

Answer to Quick Quiz

Term for itching so intense it causes the patient to scratch

Most common cause is dry skin.

Can be precipitated by heat, sudden temperature changes, sweating, clothing, cleaning products such as soap, fatigue, and emotional stress; can be more severe in winter

Can be related either skin disorder or systemic disease

Pruritus

Full skin assessment warranted when patient complains of pruritus

Inquire about patterns of behavior that precipitate itching and obtain information about bathing practices and kinds of soaps, detergents, and skin products used

Assess for rashes, vesicles, scaling, and erythema

Can you name four nursing diagnoses for pruritus?

Pruritus Nursing Management: Assessment and Diagnosis

Potential for reduced skin integrity, resulting from scratching

Pain, resulting from persistent burning and itching

Anxiety, resulting from role strain, family crisis, or other sources of patient’s anxiety

Potential for infection, resulting from impaired skin integrity

The patient will do the following:

Have intact skin

Experience adequate periods of rest without symptoms of scratching

Obtain adequate pain relief, as evidenced by verbalization of comfort and pain relief

Pruritus Nursing Management: Planning and Expected Outcomes

Influenced by cause of pruritus

Teach management of pruritus and need to prevent skin trauma from scratching

Explain treatment measures to increase compliance and involvement in care

Pruritus Nursing Management: Intervention

Focuses on symptom relief, prevention of secondary complications, and, when possible, identification of source of pruritus

Documentation of physical presentation, response to treatment measures, patient comprehension of teaching, and other nursing interventions

Pruritus Nursing Management: Evaluation

Inflammatory process of epidermis caused by yeastlike fungus Candida albicans

Normally occurring flora in mouth, vagina, and gut

Antibiotics, diabetes, topical and inhalant steroids, skin maceration, and immunocompromised conditions create environment that fosters development of yeast infections.

Erythematous, denuded, or raw skin usually surrounded by satellite papules or pustules

Candidiasis

Inspect skin particularly under any fat folds, where moisture will accumulate.

Conduct medication assessment to identify medications that may have precipitated fungal infection.

Conduct diet assessment if patient is diabetic to evaluate compliance and check blood sugar level.

Can you name three nursing diagnoses for candidiasis?

Candidiasis Nursing Management: Assessment and Diagnosis

Reduced skin integrity, resulting from poor control of moisture

Inadequate toileting self-care

Inadequate urinary elimination

The patient will do the following:

Have skin lesions that are healing without evidence of infection

Perform self-care practices (within limitations) for keeping the skin dry and clean

Have skin that has regained its usual appearance without evidence of candidiasis

Candidiasis Nursing Management: Planning and Expected Outcomes

Keep skin dry.

Cleanse and dry skin well, and apply a zinc-based cream to buttocks and perineal area.

Promptly delivery of care after incontinent events.

Evaluate for positive outcomes, adherence with preventive actions, and verbalized comprehension.

Document how infection responds to medical treatment and maintenance therapy of keeping skin dry and applying moisture barrier.

Candidiasis Nursing Management: Intervention and Evaluation

Caused by reactivation of latent varicella zoster virus

Main reason for recurrence is immune system deficiency caused by advanced age, stress or emotional upset, fatigue, or radiotherapy, immunocompromised state caused by disease or drugs

May spread through direct contact with open sores

Often has prodromal symptoms of tingling, hyperesthesia, tenderness, and burning or itching pain along affected dermatome

Herpes Zoster (Shingles)

Prodromal symptoms followed by vesicles with erythematous base occurring within 3–5 days

Unilateral, bandlike, erythematous, maculopapular rash first occurs along involved dermatome and rarely crosses midline of body.

Rash develops into clustered vesicles that become purulent, rupture, and crust.

Affects thoracic region 50%, cranial dermatomes 15%, and cervical and lumbar regions 10%

Major complication: postherpetic neuralgia

Shingles Clinical Manifestation

Interview patient to identify prodromal symptoms

Obtain pertinent health history

Identify at risk persons whom the patient has had close physical contact who have not had chickenpox or the chickenpox vaccine

On basis of lesions and prescribed treatments, must determine effect on patient’s mobility and capacity for activities of daily living (ADLs)

Can you name five nursing diagnoses for shingles?

Shingles Nursing Management: Assessment and Diagnosis

Reduced skin integrity, resulting from immunologic deficit

Potential for infection, resulting from impaired skin integrity

Disrupted sleep pattern, resulting from impaired skin integrity or pain

Pain, resulting from inadequate pain relief from analgesia

Need for health teaching, resulting from lack of previous exposure to disease process and treatment

The patient will do the following:

Have skin lesions will remain free from necrotic tissue and infection

Experience adequate periods of restful sleep

Obtain adequate pain relief

Demonstrate increased knowledge of his or her condition

Shingles Nursing Management: Planning and Expected Outcomes

Follow through with medical and nursing management

Monitor closely for development of secondary bacterial infections

Teach cause of shingles so anxiety and misconceptions can be alleviated, and explain treatment measures to increase compliance and involvement in care

Promptly administer pain medications

Use antidepressants as adjuncts to analgesics if postherpetic neuralgia occurs

Shingles Nursing Management: Intervention

Focuses on pain control, with documented results of analgesics and adjunct therapies, and on prevention of secondary infection by frequent monitoring of site

Documentation of assessment, response to treatment measures, patient comprehension of teaching, and other nursing interventions demonstrate nursing accountability.

Shingles Nursing Management: Evaluation

Premalignant lesion of epidermis caused by long-term exposure to UV rays

Most common on dorsum of hands, scalp, outer ears, face, and lower arms

Begins as reddish macule or papule that has rough, yellowish brown scale that may itch or cause discomfort

Induration, inflammation, or oozing may indicate malignancy and merit prompt referral.

Actinic Keratosis

Interview to determine risk factors

Inspect skin for any rough lesions or erythematous macule or papule

Explain value of treating skin cancer early

Can you name three nursing diagnoses for actinic keratosis?

Actinic Keratosis Nursing Management: Assessment and Diagnosis

Reduced skin integrity, resulting from removal of a lesion

Potential for infection, resulting from a break in skin integrity

Distorted body image, resulting from disfigurement and scarring resulting from removal of lesion

The patient will do the following:

Have healing on the site of lesion removal without evidence of secondary infection

Demonstrate no changes in body image perception

Demonstrate behavior change through adoption of preventive skin care practices

Actinic Keratosis Nursing Management: Planning and Expected Outcomes

Reinforce treatment regimen with patient and family

Monitor treated site to prevent secondary infection, providing support, and teaching preventive strategies

Lower patient’s anxiety and assist with body image changes by explaining treatment

Encourage sunscreen with a sun protection factor (SPF) of at least 15

Actinic Keratosis Nursing Management: Intervention

Documentation addressing treatment progress, including physical description, patient comprehension of educational information, and identification of and coping with body image disturbances

Actinic Keratosis Nursing Management: Evaluation

Most common skin cancer more prevalent in fair-skinned, blond, or red-headed individuals with extensive previous sun exposure

Most commonly found on face and scalp

Usually does not metastasize, but if left untreated, may metastasize to bone, lungs, and brain

Pearly papule with depression in center, giving lesion a doughnut-shaped appearance with telangiectasia on or around lesion

Basal Cell Carcinoma

Cancer arising from epidermis and found most often on scalp, outer ears, lower lip, and dorsum of hands

Can also develop in chronic leg ulcers or open fractures and has 20% incidence of metastasis

Etiologic factors can be UV rays, chemical carcinogens, and x-rays.

Squamous Cell Carcinoma

Usually presents as a firm, elevated lump

It may have a thick, adherent scale with a center that is often ulcerated or crusted

May even look like a wart

The base may be inflamed and red and usually bleeds easily.

Squamous Cell Carcinoma Clinical Manifestations

Malignant neoplasm of pigment-forming cells capable of metastasizing to any organ of body, even before lesion is noted

If detected and treated before spreading to the lymph nodes, there is a 99% five-year survival rate.

Ninety-five percent of melanomas can be attributed to UV exposure.

Genetic predisposition—10% of patients have parent or sibling with history of melanoma

Fair skinned, red or blond hair, have multiple nevi, and have a tendency to freckle.

Melanoma

Clinical hallmark: irregularly shaped nevus, papule, or plaque that has undergone a change, particularly in color

Characteristic signs of majority of malignant melanomas referred to as the ABCDs:

Asymmetry, border irregularity, color variation (red, white, blue), diameter greater than 6 mm

Some clinicians now include E: evolution, elevation

Melanoma Clinical Manifestations

Lentigo maligna occurs most often in the elderly, is a brown-tan macular lesion with varied pigmentation and highly irregular borders

Acral lentiginous melanoma usually occurs on the palms of hands and soles of feet, as well as under finger/toe, most common melanoma found in blacks and Asians.

Melanoma

Determine how long lesion has been present

Identify risk factors such as chronic sun exposure and family history

Inspect and palpate suspicious lesion, surrounding tissue, and lymph nodes

Explain that early treatment lessens the extent of scarring and possibly metastasis

Discuss patient’s feelings and fears about cancer

Can you name four nursing diagnoses for skin cancer?

Melanoma Nursing Management: Assessment and Diagnosis

Reduced skin integrity, resulting from removal of a cancerous lesion

Fear of cancer, pain, or death, resulting from having a cancerous skin lesion

Potential for infection, resulting from a break in skin integrity and a surgical wound

Distorted body image, resulting from disfigurement and scarring resulting from removal of a cancerous lesion

The patient will do the following:

Experience healing at site of excision will heal without evidence of infection

Verbalize fears related to the diagnosis and actively seek information and clarification

Identify community resources for support and additional information

Verbalize understanding of the treatment plan

Demonstrate increased knowledge of condition, as evidenced by adoption of preventive strategies

Melanoma Nursing Management: Planning and Expected Outcomes

Reinforce treatment regimen by monitoring wound for secondary infection

Reinforcement caring component by discussing patient’s and family’s feelings related to cancer

Teach patient or family dressing care and signs of infection

Focus on comfort, education, and emotional support

Melanoma Nursing Management: Intervention

Focuses on monitoring for infection, effectiveness of pain control measures, comprehension of patient education, and discussions related to body image changes and fears about cancer

Documentation of assessment, response to treatment measures, patient comprehension of teaching, and other nursing interventions demonstrate nursing accountability.

Melanoma Nursing Management: Evaluation

Common problem in older adults - from three causes: arterial insufficiency, venous hypertension, and diabetic neuropathy

Arterial or ischemic ulcers result from arterial insufficiency.

Referred to as peripheral vascular disease (PVD)

Risk factors, including obesity, diabetes, hyperlipoproteinemia, and hypertension

Arterial Ulcers

Pain with exercise, at night, or while resting

Cramping, burning, or aching

As disease advances, extremity develops cyanotic hue and becomes cool.

Skin becomes thin, shiny, and dry with loss of hair and thickened nails.

Arterial ulcers are usually located on the outer ankle, feet, and toes.

Treatment is usually surgical intervention with revascularization, amputation if advanced disease

Arterial Ulcer Clinical Manifestations

Also known as stasis ulcers, thought to arise secondary to chronic venous insufficiency

Venous hypertension is primary cause of venous ulcers.

Valvular incompetence of the deep or perforating veins of the lower leg is present.

The accumulation of erythrocytes in the tissue produces a brownish skin discoloration caused by the release of hemoglobin.

Discoloration and thickening of the skin (lipodermatosclerosis) is the first indication of venous hypertension.

Venous Ulcers

Usually on medial aspect of lower leg, with flat or shallow craters and irregular borders, accompanied by varicosities, liposclerosis, and itching

Generate large amount of exudate and usually surrounded by erythema and edema

Venous ulcers heal with prolonged elevation of affected extremity; however, compliance is difficult.

Venous Ulcer Clinical Manifestations

Risk factors for developing a diabetic foot lesions are peripheral neuropathy, foot deformity, peripheral arterial disease, and history of previous foot lesions.

Risk factor for lower extremity amputation is neuropathy, implicated in approximately 90% of diabetic foot ulcers.

Pain and temperature usually first sensations affected by neuropathy

Diabetic Foot Lesions

Lesions tend to be bilateral, symmetric, and located on the plantar surface of the foot.

Complain of pain and paresthesias, they also have diminished or absent vibratory and temperature sensation of the affected extremities.

Pain relieved by walking is one diagnostic sign of neuropathy.

Patient education to minimize the risk of chemical, thermal, and mechanical trauma is the first line of defense against diabetic foot lesions.

Diabetic Foot Lesions Clinical Manifestations

Determine wound dimensions, depth, and amount of exudate

Palpate popliteal pulses

Pain assessment

Nutritional assessment

Can you name two nursing diagnoses for lower leg ulcers and lesions?

Lower Leg Lesions Nursing Management: Assessment and Diagnosis

Reduced skin integrity, resulting from altered circulation

Potential for infection, resulting from open, chronic wounds

The patient will do the following:

Have skin lesions free from necrotic tissue and infection

Have edema in lower extremities that is controlled

Have skin lesions that will heal with minimum scarring

Be able to maintain a healed state for at least 6 months

Lower Leg Lesions Nursing Management: Planning and Expected Outcomes

Keep the legs elevated.

Implement compression therapy.

Administer wound care.

Educate the patient about the causes of a lower extremity ulcers and lesions; the strategy of compression therapy, and specific wound care.

Stress the need to maintain compression therapy to facilitate healing of venous ulcers and avoid further breakdown.

Lower Leg Lesions Nursing Management: Intervention

Focuses on prevention of further wound deterioration and infection, as well as the effectiveness of patient education

A return demonstration of compression therapy application and wound care is a concrete evaluation and ensures patient comprehension.

Lower Leg Lesions Nursing Management: Evaluation

Pressure injury is a more appropriate term than pressure ulcer or decubitus.

Pressure on soft tissue over bony prominences or other hard surfaces is primary causative factor.

Common bony prominences susceptible are sacrum, ischial tuberosity, lateral malleolus, trochanter, and heels.

Intensity of pressure leading to capillary closure, compounded by duration of pressure and tissue tolerance, results in tissue anoxia, ischemia, edema, and eventually tissue necrosis.

Pressure Injuries

Is major contributing factor in the development of a pressure injury

Defined as the ability of the skin and supporting structures to endure the effects of pressure

Extrinsic factors: moisture, friction, and shearing

Intrinsic factors: poor nutrition, advanced age, hypotension, emotional stress, smoking, and skin temperature

Pressure Injuries Tissue Tolerance

Shearing forces can decrease blood supply, leading to tissue ischemia and necrosis.

Friction primarily affects epidermal and dermal layers, causing a superficial abrasion.

Moisture from incontinence or profuse sweating can decrease tensile strength, alter skin resiliency to external forces, and exacerbate friction and shearing forces.

Protein deficiency weakens tissue tolerance, making soft tissue more susceptible to breakdown when pressure intensity is prolonged.

Factors Influencing Tissue Tolerance

A risk assessment should be conducted on all individuals who are bed bound, chair bound, incontinent, frail, disabled, or nutritionally compromised or who have demonstrated altered mental status.

Norton risk assessment tools

Simple to use, with five assessment categories

Those with a score of 16 or lower considered to be at risk

The Braden Scale

Assesses sensory perception

Scoring below 18 considered to be at high risk

Risk Assessment Tools

Prevention is first line of defense.

At-risk individuals identified through use of risk assessment tool should have daily skin inspection with close attention to bony prominences.

Incontinent patient—use mild, nonirritating cleanser, warm water, and emollient lotions or topical barriers immediately after cleaning

Skin should not be rubbed or massaged over bony prominences.

Pressure Injuries: Preventive Strategies (1 of 2)

Proper turning and placement at a 30-degree oblique angle

Pillow or pillows under calves to lift feet and heels off bed

Use pressure-reducing support surfaces, such as mattress overlays, chair cushions or overlays, and specialized beds

Presence of skin moisture should be minimized.

Nutritional status must be closely monitored.

Pressure Injuries: Preventive Strategies (2 of 2)

Inflammatory stage: characterized by redness, heat, pain, and swelling, initiates healing process; lasts approximately 4–5 days

Proliferative, or granulation, stage begins 24 hours after injury and continues for up to 22 days; three significant events occur: epithelialization, granulation, and collagen synthesis

Physiology of Wound Healing (1 of 2)

Maturation stage, the final stage; does not begin until 21 days after injury and can take years to complete; maximum tensile strength is generated through collagen deposits that make the wound thicker and more compact.

Physiology of Wound Healing (2 of 2)

Eliminate or minimize precipitating factors such as pressure, friction, shearing, and poor nutrition.

Provide nutritional support and monitor nutritional status.

Create and maintain a clean, moist wound environment with adequate circulation and oxygenation.

Necrotic tissue must be removed and any infectious process (as evidenced by erythema, induration, and tenderness in the peri wound skin; pus; or a pale wound bed) resolved to implement a dressing strategy that fosters rapid healing.

Basic Principles of Pressure Injury Management

Inappropriate antibiotic use is decreased when wounds are cultured appropriately.

All wounds are contaminated, all cultures grow surface bacteria, and the true pathogen may not be identified.

Culture only when cellulitis or a wound infection exists.

Cellulitis—erythema, induration, and tenderness

Wound infection—pale wound bed, pus, increased tenderness, persistent exudate, or no new growth

An accurate culture includes both anaerobic and aerobic species.

When to Culture a Wound

Necrotic tissue provides ideal environment for bacteria growth, can cause inflammation, and impair body’s ability to fight infection.

Necrotic tissue must be débrided as soon as possible.

Presence of eschar slows migration of epithelial cells and delays healing.

Methods of débridement: mechanical, autolytic, enzymatic, conservative sharp, and surgical sharp

Débridement of Pressure Injuries

Goal is to create environment that supports healing.

No improvement evident in weekly measurements after 2–4 weeks, consideration should be given to changing dressing strategy.

With each dressing change, open wounds should be gently irrigated with approximately 20–50 mL of normal saline.

Wound Care Principles

Gauze dressings

Nonadherent dressings

Foam dressings

Transparent films

Hydrocolloids

Hydrogels

Alginates

Wound Care Dressing Types

Energy forms in management of pressure ulcers

Acoustic (ultrasound), mechanical, and kinetic energy

Ultraviolet light

Negative pressure wound therapy

Hydrotherapy

Biophysical Agents in Pressure Injury Management

The graduate nurse conducts an assessment on a newly admitted patient with a wound infection. The assessment reveals a shallow ulcer on the medial aspect of the lower leg, with an irregular border. The surrounding skin is brown and itches. The wound is emitting a moderate amount of purulent drainage. The assessment describes which of the following?

Stage II pressure on the leg

An arterial ulcer

A diabetic neuropathic ulcer

A venous ulcer

Quick Quiz!

ANS: D

Answer to Quick Quiz