chapter 043 integument

Care of the Patient with an Integumentary Disorder and Surgical Wound Care

Module BChapter 3 and Chapter 13

Overview of Anatomy and Physiology

Skin covers the outside of the bodyMain function:

HomeostasisProtection

Functions of the skinProtectionTemperature regulationVitamin D synthesis

Figure 43-1

Structures of the skin.

(From Thibodeau, G.A., Patton, K.T. [2005], The human body in health and disease. [4th ed.]. St. Louis: Mosby.)

Basic Structure of the Skin

EpidermisThe outer layer of the skinNo blood supplyComposed of stratified squamous epitheliumDivided into layers: stratum germinativum, pigment-

containing layer, stratum corneumDermis

“True skin”Contains blood vessels, nerves, oil glands, sweat

glands, and hair folliclesSubcutaneous layer

Connects the skin to the musclesComposed of adipose and loose connective tissue

Basic Structure of the Skin

Appendages of the skinSudoriferous glands—sweat glandsCeruminous glands—secrete cerumen

(earwax)Located in the external ear canal

Sebaceous glands—“oil glands”Secrete sebum

Hair Composed of modified dead epidermal tissue,

mainly keratinNails

Composed mainly of keratin

Assessment of the Skin

Inspection and palpationAsk the patient about:

Recent skin lesions or rashesWhere the lesions first appearedHow long the lesions have been present

Recent skin color changesExposure to the sun without sunscreenFamily history of skin cancer

Observe the skin colorAssess any skin lesions

Assessment of the SkinInspection and palpation (continued)

Assess for rashes, scars, lesions, or ecchymoses Assess temperature and textureInspect nails for normal development, color,

shape, and thicknessInspect hair for thickness, dryness, or dullnessInspect mucous membranes for pallor or

cyanosisAssess the ceruminous and sebaceous gland for

overactivity or underactivityAssessment of dark skin

Assess lips and mucous membranes

Chief ComplaintWhen skin lesions

foundExact locationLengthWidthGeneral

appearanceName

Make sure all information is documented

Assess Chief Complaint:Provocative/

palliativeQuality/quantityRegionSeverityTime

Psychosocial AssessmentMay affect body image and self-

esteemAssess coping abilitiesNurse’s attitude should be

nonjudgmental, warm, and acceptingProvide consistent informationInclude family in treatment planProvide positive feedback

Bacterial Disorders of the Skin

CellulitisPotentially serious infection of the skinEtiology/pathophysiology

Streptococci and Staphylococcus aureusHaemophilus influenza type B {more common in

children}Diagnostic TestsMedical Management/nursing interventions:

AntibioticsPatient teaching

Prognosis

Cellulitis

Folliculitis, furuncles, carbuncles, and felonsEtiology/pathophysiology

Folliculitis Infected hair follicle

Furuncle (boil) Infection deep in hair follicle; involves surrounding

tissueCarbuncle

Cluster of furunclesFelons

Infected soft tissue under and around an area

Folliculitis, furuncles, carbuncles, and felons (continued)Clinical manifestations/assessment

Pustule EdemaErythemaPainPruritus

Diagnostic testsPhysical examCulture of drainage

Folliculitis, furuncles, carbuncles, and felons (continued)Medical management/nursing interventions

Warm soaks 2-3 times per day (promote suppuration)

May require surgical incision and drainageTopical antibiotic cream or ointmentMedical asepsis

furuncle carbuncle

Fungal Infections of the Skin

DermatophytosesEtiology/pathophysiology

Microsporum audouinii major fungal pathogenTinea capitis

o Ringworm of the scalpTinea corporis

o Ringworm of the bodyTinea cruris

o Jock itchTinea pedis (most common)

o Athlete’s foot

Dermatophytoses (continued)Clinical manifestations/assessment

Tinea capitisErythematous around lesion with pustules around

the edges and alopecia at the siteTinea corporis

Flat lesions—clear center with red border, scaliness, and pruritus

Tinea crurisBrownish-red lesions in groin area, pruritus, skin

excoriationTinea pedis

Fissures and vesicles around and below toes

Dermatophytoses (continued)Diagnostic tests

Visual inspectionUltraviolet light for tinea capitis

Infected hair becomes fluorescent (blue-green)Medical management/nursing interventions

Griseofulvin—oralAntifungal soaps and shampoosTinactin or DesenexKeep area clean and dryBurrow's solution (tinea pedis)

Figure 43-7

Tinea capitis. (From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)

Tinea corporis

Tinea cruris

Tinea pedis

Inflammatory Disorders of the Skin

Contact dermatitisEtiology/pathophysiology

Direct contact with agents of hypersensitivityDetergents, soaps, industrial chemicals, plants

Clinical manifestations/assessmentBurningPainPruritusEdemaPapules and vesicles

Contact dermatitisDiagnostic tests

Health historyIntradermal skin testingElimination diets

Medical management/nursing interventionsRemove causeBurrow's solutionCorticosteroids to lesionsCold compressesAntihistamines (Benadryl)

Dermatitis venenata, exfoliative dermatitis, anddermatitis medicamentosaEtiology/pathophysiology

Dermatitis venenata: Contact with certain plants Exfoliative dermatitis: Infestation of heavy metals,

antibiotics, aspirin, codeine, gold, or iodineDermatitis medicamentosa: Hypersensitivity to a

medication Clinical manifestations/assessment

Mild to severe erythema and pruritusVesiclesRespiratory distress (especially with medicamentosa)

Dermatitis venenata, exfoliative dermatitis, anddermatitis medicamentosa (continued)Medical management/nursing interventions

All dermatitisColloid solution, lotions, and ointmentsCordicosteroids

Dermatitis venenataThoroughly wash affected areaCool, wet compressesCalamine lotion

Dermatitis medicamentosaDiscontinue use of drug

UrticariaEtiology/pathophysiology

Allergic reaction (release of histamine in an antigen-antibody reaction)

Drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold

Clinical manifestations/assessmentPruritusBurning painWheals

Urticaria (continued)Diagnostic tests

Health historyAllergy skin test

Medical management/nursing interventionsIdentify and alleviate causeAntihistamine (Benadryl)Therapeutic bathEpinephrineTeach patient possible causes and prevention

AngioedemaEtiology/pathophysiology

Form of urticariaOccurs only in subcutaneous tissueSame offenders as urticariaCommon sites: eyelids, hands, feet, tongue, larynx, GI,

genitalia, or lips

Angioedema (continued)Clinical manifestations/assessment

Burning and pruritusAcute pain (GI tract)Respiratory distress (larynx)Edema of an entire area (eyelid, feet, lips, etc.)

Medical management/nursing interventionsCold compressesAntihistamines, epinephrine, corticosteroids

Eczema (atopic dermatitis)Etiology/pathophysiology

Allergen causes histamine to be released and an antigen-antibody reaction occurs

Primarily occurs in infantsClinical manifestations/assessment

Papules and vesicles on scalp, forehead, cheeks, neck, and extremities

Erythema and dryness of areaPruritus

Eczema (atopic dermatitis) (continued)Diagnostic tests

Health history (heredity)Diet eliminationSkin testing

Medical management/nursing interventionsReduce exposure to allergenHydration of skinTopical steroidsLotions—Eucerin, Alpha-Keri, Lubriderm, or Curel 3-4

times/day

Acne vulgarisEtiology/pathophysiology

Occluded oil glandsAndrogens increase the size of the oil gland

Influencing factorsDietStressHeredityOveractive hormones

Acne vulgaris (continued)Clinical manifestations/assessment

Tenderness and edema Oily, shiny skinPustulesComedones (blackheads)Scarring from traumatized lesions

Diagnostic testsInspection of lesionBlood samples for androgen level

Acne vulgaris (continued)Medical management/nursing interventions

Keep skin cleanKeep hands and hair away from areaWash hair dailyWater-based makeupTopical therapy

Benzoyl peroxide, vitamin A acids, antibiotics, sulfur-zinc lotions

Systemic therapyTetracycline, isotretinoin (Accutane)

PsoriasisEtiology/pathophysiology

NoninfectiousSkin cells divide more rapidly than normal

Clinical manifestations/assessmentRaised, erythematous, circumscribed, silvery, scaling

plaquesLocated on scalp, elbows, knees, chin, and trunk

Psoriasis (continued)Medical management/nursing interventions

Topical steroidsKeratolytic agents

Tar preparationsSalicylic acidReduces shedding of the outer layer of skin

PhotochemotherapyPUVA

o Oral psoraleno Ultraviolet light

Figure 43-10

Psoriasis.

(Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)

MalignanciesThree most common:

MelanomaBasal cell carcinomaSquamous cell carcinoma

Mnemonic:ASYMMETRYBORDERSCOLORDIAMETERELEVATEDFEELING

Tumors of the SkinBasal cell carcinoma

Skin cancerCaused by frequent contact with chemicals,

overexposure to the sun, radiation treatmentMost common on face and upper truckFavorable outcome with early detection and

removalSquamous cell carcinoma

Firm, nodular lesion; ulceration and indurated margins

Rapid invasion with metastasis via lymphatic system

Sun-exposed areas; sites of chronic irritationEarly detection and treatment are important

Tumors of the SkinMalignant melanoma

Cancerous neoplasmMelanocytes invade the epidermis, dermis, and

subcutaneous tissueGreatest risk

Fair complexion, blue eyes, red or blond hair, and freckles

TreatmentSurgical excisionChemotherapy

Cisplatin, methotrexate, dacarbazine

Figure 43-16

Basal cell carcinoma.

(From Belcher, A. E. [1992]. Cancer nursing. St. Louis: Mosby.)

Figure 43-17

Squamous cell carcinoma.

(Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)

Figure 43-18

The ABCDs of melanoma.

(From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)

Stage I

Stage II

Stage III

Stage IV

Chapter 13

Surgical Wound Care

Wound ClassificationWounds Classified According to

CauseIncision or puncture

Severity of InjuryAmount of Contamination

Clean, clean-contaminated, contaminated, and dirty or infected

Skin Integrity

Wound HealingPhases of Wound Healing

HemostasisTermination of bleedingBegins as soon as the injury occurs

Inflammatory PhaseAn initial increase in blood elements and water flow

out of the blood vessel into the vascular spaceCauses cardinal signs and symptoms of

inflammation: erythema, heat, edema, pain, and tissue dysfunction

Reconstruction PhaseCollagen formation occursa glue-like protein

substance that adds tensile strength to the wound and tissue.

Appearance changes to an irregular, raised, purplish, immature scar.

Wound dehiscence most frequently occurs during this phase.

Maturation PhaseFibroblasts begin to exit the wound.The wound continues to gain strength, although

healed wounds rarely return to the strength the tissue had before surgery.

Keloids may form during this phase.

Wound HealingProcess of Wound Healing

Primary IntentionWound is made surgically with little tissue loss.Skin edges are close together.Minimal scarring results.It begins during the inflammatory phase of healing.

Wound HealingProcess of Wound Healing

Secondary IntentionHealing occurs when skin edges are not close

together or when pus has formed.If wound has purulent exudates, the surgeon

provides a means for its release via drainage system or by packing the wound.

The necrotized tissue decomposes and escapes.The cavity begins to fill with granulation tissue.The amount of granulation tissue required depends

on the size of the wound; scarring is greater in a larger wound.

Wound HealingTertiary Intention

Occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together.

Occurs when a contaminated wound is left open and sutured closed after the infection is controlled or a primary wound becomes infected, is opened, allowed to granulate, and then sutured.

Figure 13-1

Types of wound healing. A, Primary intention.

B, Secondary intention. C, Tertiary intention.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.)

Wound HealingFactors that Affect Healing

Nutritional NeedsIf the patient cannot tolerate food or fluids, total

parenteral nutrition or nasogastric feedings can be provided.

Because patients may not be able to tolerate large meals or solid foods, dietary services can provide small frequent feedings.

FluidsOffer hourly; encourage 2000 to 2400 ml in 24

hours.

Wound HealingFactors that Affect Healing

Rest and ActivityThe nurse assists the patient to achieve a balance

between time to rest to facilitate healing and activity to decrease venous stasis.

When the patient is confined to bed, moving one body section at a time should be encouraged.

Surgical WoundSelection of the site for the surgical wound is

based onTissue or organ involvedNature of injury or disease processProcess of inflammation or infectionStrength of the siteIf a drainage system is required, the position of

the drain may also influence the placement of the incision.

Surgical WoundThe surgeon’s goal is to enter the cavity

involved, repair the injured or diseased area, and minimize trauma as quickly as possible.

Many options are available to the surgeon for closing the surgical incision.Sutures, staples, Steri-Strips, butterfly strips,

and transparent sprays and filmsBinder or bandage used to support the incision

of secure dressings without the use of adhesive materials

Figure 13-5

Wound closure with staples.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

Figure 13-6

Steri-Strips placed over incision for closure.

(From Potter, P.A., Perry, A.G. [2003]. Basic nursing: Essentials for practice. [5th ed.]. St. Louis: Mosby.)

Figure 13-4

Sutures. A, Interrupted, or separate. B, Continuous. C, Blanket. D, Retention.

Surgical WoundThe nurse should inspect dressings every 2

to 4 hours for the first 24 hours.On the day of surgery, most wounds will have

sanguineous or serosanguineous exudates.As the exudate subsides, it becomes serous. Because pressure to the surgical wound

retards bleeding, wounds are usually covered by a gauze dressing.

The nurse should inspect both the dressing or incisional area and the area under the patient; exudate follows the flow of gravity.

Care of the IncisionSurgical wounds, because they are

aseptically created, generally heal well and quickly.

Incision CoveringsGauze

Permits air to reach the woundSemiocclusive

Permits oxygen but not air impurities to passOcclusive

Permits neither air nor oxygen to pass

Figure 13-2

Types of dressings.

Care of the IncisionRemoving Dressings

Care is taken to avoid accidental removal or displacement of underlying drains.

An analgesic may need to be given at least 30 minutes before exposing a wound.

Sutured, clean wounds may not be dressed after surgery or dressing may be removed within 24 hours postoperatively to allow air circulation.

Sterile technique is followed whenever the wound or dressing is handled.

A gown, mask, and protective goggles are worn if soiling or splashing of wound exudate is expected.

Care of the IncisionDry Dressings

May be chosen for management of a wound with little exudate/drainage

Protects the wound from injury, prevents introduction of bacteria, reduces discomfort, and speeds healing

Most commonly used for abrasions and nondraining postoperative incisions

Care of the IncisionWet-to-Dry Dressing

Primary purpose is to mechanically debride a wound.

The moistened contact layer of the dressing increases the absorptive ability of the dressing to collect exudate and wound debris.

As the dressing dries, it adheres to the wound and debrides it when the dressing is removed.

Commonly used wetting agents are normal saline and lactated Ringer’s solution, acetic acid, sodium hypochlorite solution, povidone-iodine, and antibiotic solutions.

Care of the IncisionTransparent Dressings

Self-adhesive transparent film is a synthetic permeable membrane that acts as a temporary secondary skin.

AdvantagesAdheres to undamaged skin to contain exudates and

minimize wound contaminationServes as a barrier to external fluids and bacteria

yet still allows the wound to breathePromotes a moist environment that speeds

epithelial cell growthPermits visualization of the wound

Care of the IncisionIrrigations

Wound cleansing and irrigation is accomplished using sterile or clean technique.

Cleansing solution is introduced directly into the wound with a syringe, syringe and catheter, shower, or whirlpool.

Fluid retention is avoided by positioning the patient on his or her side to encourage the flow of the irrigant away from the wound.

Promote wound healing through removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar.

Care of the IncisionIrrigations

Solutions used for irrigations include warm water, saline, or mild detergents.

Principles of Basic Wound IrrigationCleanse in a direction from the least contaminated

area to the most contaminated area.When irrigating, all of the solution flows from the

least contaminated area to the most contaminated area.

Complications of Wound HealingImpaired wound healing requires accurate

observation and ongoing interventions.Situation can be life-threatening.Recognizing the seriousness of signs and

symptoms is vital throughout the patient’s recovery phase.

Wound bleedingBleeding may indicate a slipped suture,

dislodged clot, coagulation problem, or trauma to blood vessels or tissue.

If internal hemorrhage occurs, the dressing may be dry while the abdominal cavity collects blood.

Complications of Wound HealingDehiscence

Wound layers separate.Patient may say that something has given way.It may result after periods of sneezing, coughing,

or vomiting.It may be preceded by serosanguineous drainage.Patient should remain in bed and receive nothing

by mouth, be told not to cough, and be reassured.

The nurse should place a warm, moist sterile dressing over the area until the physician evaluates the site.

Complications of Wound HealingEvisceration

Abdominal organs protrude through an opened incision.

Patient is to remain in bed, and the wound and contents should be covered with warm, sterile saline dressings.

The surgeon is notified immediately.This is a medial emergency, and the wound

requires surgical repair.

Complications of Wound HealingWound Infection

Surgical wound becomes contaminated.CDC labels a wound “infected” when it

contains purulent (pus) drainage.A patient with an infected wound displays a

fever, tenderness, and pain at the wound; edema; and an elevated WBC count.

Purulent drainage has an odor and is brown, yellow, or green, depending on the pathogen.

Exudate/DrainageExudate

Fluid, cells, or other substances that have slowly exuded from cells or blood vessels through small pores or breaks in the cell membrane

DrainageRemoval of fluids from a body cavity, wound,

or other source of discharge through one or more method

Exudate/DrainageSerous

Clear, watery fluid that has been separated from its solid elements

SanguineousFluid that contains blood

SerosanguineousThin and red; composed both of serum and

bloodIf the tissue is infected, exudate/drainage may

be brown-green purulent.Exudate/drainage from organs has its own

particular color. (Bile from the liver and gallbladder is green-brown.)

D. Sanguineous: • Bright red:

indicates active bleeding

B. Purulent: • Thick, yellow, green,

tan, or brownC. Serosanguineous:

• Pale, red, watery: mixture of serous and sanguineous

A. Serous: • Clear, watery plasma

Exudate/DrainageThe type and amount produced depend on

the tissue and organs involved.More than 300 ml in the first 24 hours

should be treated as abnormal.When patients first ambulate, a slight

increase may occur.Assess

Color, amount, consistency, and odorIt may be contained either in a drainage

system or on a dressing.

Maintaining Oxygenation

Oxygen TherapyGoal:

Prevent or relieve hypoxiaPatient with impaired tissue oxygenation can

benefit from controlled oxygen therapyConsidered a drug:

Need an order to administerColorless, odorless, tasteless gas that does

not burn/explodeIf combined with other factors can support

combustion and igniteInitiated by respiratory therapist

Oxygen Delivery SystemRoom air: 21%

Nasal Cannula: 22 – 45% (1-6 L)Effective for low oxygen concentration

Simple Mask:25 – 60% (6 – 10 L)Delivers oxygen concentrations up to 60%

Partial Non-Rebreather:35 – 60% (8 – 12 L)Flaps stays open; valves allows expired carbon dioxide to leave

the maskNon-rebreather:

80 – 95% (10 – 15 L)Delivers highest possible oxygen concentration without

intubation

OxygenBest position for respiratory distress:

FowlersSemi-fowlers

Assess for signs of hypoxia/respiratory distress:Apprehension, anxiety, restlessnessDecreased level of consciousness, decrease

ability to concentratePallor, cyanosis, dyspneaMay require humidification due to drying out

effects of oxygen

Pulse OximetryNoninvasive method to determine oxygen

saturationDetect within 6 secondsOxygen saturation: 90 – 100%

Needed to adequately replenish oxygen in plasma

<90% need oxygen<70% life threatening

If questionable, the physician will order an arterial blood gas (ABG)

Pulse OximetryDon’t use:

On an extremity with a blood cuff or arterial catheter in place

Place probe over a pulsating vascular bedProtect from direct sunlightAvoid excessive movementHypothermia, Hypotension, vasoconstriction

Clearing the AirwayGather your equipmentAssess need for suctioning

Gurgling respirationsRestlessnessVomitus in mouthDrooling

Explain procedureCoughing, sneezing, or gagging

Position:Conscious: Semi-fowlers with head dto one side

Promotes drainage

Clearing the AirwayPosition:

Conscious: Semi-fowlers with head to one sidePromotes drainage of secretionsFacilitates insertion of suction catheter

Unconscious:Side-lying facing nurse

Common vacuum settings for wall suction units:110-150 mm Hg

Common catheter settings:12-16 French

Oropharygneal SuctioningYankauer:

Clean glovesEncourage to cough

NasopharyngealSterileLength of insertion: 10 cm

Nasotracheal Suction:Length of insertion: 20-24 cm

Limit suction to 10-15 secondsAllow 1-2 minutes of rest betweenAdminister oxygen if neededProvide mouth care after suctioning

Collection of SpecimenNasal:

Ask patient to blow nose to clear nasal passages of mucus that contains resident bacteria

Throat:Obtain before starting antibioticsIf antibiotics already started, notify labCollect before mealtime or one hour after

eating

Emergency Procedures

AirwayBreathingCirculation

chapter 043 integument

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