nursing care of the integumentary system

Nursing Care of the Nursing Care of the Integumentary SystemIntegumentary System

HACCHACCCentral Pennsylvania’s Community CollegeCentral Pennsylvania’s Community College

N 103 AN 103 A

Anatomy Overview of SkinAnatomy Overview of Skin

Epidermis Epidermis Outer layerOuter layer Shields underlying tissueShields underlying tissue

DermisDermis Contains collagen and elastic fibersContains collagen and elastic fibers Nerve fibers, blood vessels, sweat glands, sebaceous Nerve fibers, blood vessels, sweat glands, sebaceous

glands and hair folliclesglands and hair follicles

SubcutaneousSubcutaneous Contains blood vessels, nerves, lymph, and loose Contains blood vessels, nerves, lymph, and loose

connective tissueconnective tissue

Skin Cross-SectionSkin Cross-Section

Normal Functions of SkinNormal Functions of Skin

ProtectionProtection HomeostasisHomeostasis Temperature RegulationTemperature Regulation Sensory Organ/SensationSensory Organ/Sensation Excretion/secretionExcretion/secretion Vitamin SynthesisVitamin Synthesis PsychosocialPsychosocial

Perspiration and EvaporationPerspiration and Evaporation Evaporation is the transfer of heat energy Evaporation is the transfer of heat energy

when a liquid is changed to a gas. The body when a liquid is changed to a gas. The body continuously loses heat by evaporation. continuously loses heat by evaporation.

By regulating perspiration the body promotes By regulating perspiration the body promotes additional evaporative heat loss.additional evaporative heat loss. Exercise, emotional and mental stress causes Exercise, emotional and mental stress causes

increased metabolic rateincreased metabolic rate Diaphoresis is visible perspiration primarily Diaphoresis is visible perspiration primarily

occurring on the forehead, upper thorax, and occurring on the forehead, upper thorax, and other places on the bodyother places on the body Excessive evaporation causes skin scaling and Excessive evaporation causes skin scaling and

itchingitching

Factors Affecting Factors Affecting Temperature RegulationTemperature Regulation

AgeAge ExerciseExercise Hormone levelsHormone levels Circadian RhythmCircadian Rhythm StressStress EnvironmentEnvironment

Problems with Temperature Problems with Temperature RegulationRegulation

Hyperthermia: elevation in body Hyperthermia: elevation in body temperature over normal limitstemperature over normal limits

Hypothermia: body temperature lower than Hypothermia: body temperature lower than normalnormal

Hyperthermia/PyrexiaHyperthermia/Pyrexia

What is normal body temperature?What is normal body temperature?

Low grade elevation: 98.8-100.6Low grade elevation: 98.8-100.6

High grade elevation: >100.6High grade elevation: >100.6

Hyperthermia: over 104.9Hyperthermia: over 104.9

Hyperthermia’s CausesHyperthermia’s Causes

InflammationInflammation AllergyAllergy InfectionInfection Drug reactionDrug reaction Cerebral or Neurological injuryCerebral or Neurological injury Idiopathic (FUO)Idiopathic (FUO)

SymptomsSymptoms

ColdCold HeadacheHeadache MalaiseMalaise Skin flushingSkin flushing DiaphoresisDiaphoresis TachycardiaTachycardia TachypneaTachypnea

Nursing Interventions: FeverNursing Interventions: Fever

Promote cool environmentPromote cool environment

Encourage fluidsEncourage fluids

Antipyretic medicationsAntipyretic medications

Reassess temperature frequentlyReassess temperature frequently

Drugs Acting on Thermal Drugs Acting on Thermal RegulationRegulation

acetylsalicylic acid (Aspirin)acetylsalicylic acid (Aspirin)

acetaminophen (Tylenol)acetaminophen (Tylenol)

ibufrofen (Advil, Motrin)ibufrofen (Advil, Motrin)

HypothermiaHypothermia

Prolonged exposure to coldProlonged exposure to cold Body temp lower than normal: mild to Body temp lower than normal: mild to

profoundprofound Cell function in all body cells declinesCell function in all body cells declines

Signs of HypothermiaSigns of Hypothermia

Decrease in vital signs, shivering, chillsDecrease in vital signs, shivering, chills Waxy, pale cool skinWaxy, pale cool skin Decreased urinary outputDecreased urinary output Decreased muscle coordinationDecreased muscle coordination DisorientationDisorientation Drowsiness progressing to coma Drowsiness progressing to coma

Nursing InterventionsNursing InterventionsHypothermiaHypothermia

Warm environmentWarm environment Warm blankets, dry clothingWarm blankets, dry clothing Warm oral/intravenous fluidsWarm oral/intravenous fluids Keep limbs close to bodyKeep limbs close to body

Application of Heat and ColdApplication of Heat and Cold

Physician’s order neededPhysician’s order needed

Assessment Prior to Therapy Assessment Prior to Therapy Warm or ColdWarm or Cold

Temperature toleranceTemperature tolerance Circulatory stateCirculatory state Neurological responseNeurological response Medication decreasing sensitivityMedication decreasing sensitivity Age Age New tissue (skin)New tissue (skin)

Application of HeatApplication of Heat

HEATHEAT VASODILATION (Increasing blood flow), VASODILATION (Increasing blood flow),

MUSCLE RELAXATION, PAIN RELIEF, MUSCLE RELAXATION, PAIN RELIEF, INCREASES ROM, REDUCES JOINT INCREASES ROM, REDUCES JOINT STIFFNESSSTIFFNESS

MAY BE MOIST OR DRY FORMATMAY BE MOIST OR DRY FORMAT

Application of ColdApplication of Cold

COLD: VASOCONSTRICTION (reduces COLD: VASOCONSTRICTION (reduces blood flow)blood flow)

REDUCES PAIN, DECREASES REDUCES PAIN, DECREASES BLEEDING, LOCAL ANESTHETIC BLEEDING, LOCAL ANESTHETIC EFFECT, DECREASES INFLAMMATIONEFFECT, DECREASES INFLAMMATION

MOIST OR DRY FORMATSMOIST OR DRY FORMATS

Skin AssessmentSkin Assessment

Inspect the skin for:Inspect the skin for: ColorColor TextureTexture ThicknessThickness TurgorTurgor TemperatureTemperature HydrationHydration

Common Nursing DiagnosesCommon Nursing Diagnoses

Risk for Impaired Skin IntegrityRisk for Impaired Skin Integrity Impaired Skin IntegrityImpaired Skin Integrity Disturbed body imageDisturbed body image Risk for imbalanced Body temperatureRisk for imbalanced Body temperature HyperthermiaHyperthermia HypothermiaHypothermia Ineffective ThermoregulationIneffective Thermoregulation

Health TeachingHealth Teaching

Monitor skin dailyMonitor skin daily Report alterations/changesReport alterations/changes Keep well moisturizedKeep well moisturized Use sunscreenUse sunscreen Avoid direct sunlight between 10AM and Avoid direct sunlight between 10AM and

2PM2PM Know your family history of skin cancerKnow your family history of skin cancer

Thank You!Thank You!

Questions/comments?Questions/comments?