Let’s Get Skintimate:
Integumentary System
PROFESSOR HILL, RN, MN, MSG
NURSING 102
At the End of This Lecture, the Learner Will Be Able to:
• Discuss the physiology & function of the skin
• Perform an integumentary assessment
• Discuss pressure ulcers
Integumentary System
Assessment Includes:
SKIN
HAIR
SCALP
NAILS
•Epidermis
•Dermis
•Subcutaneous tissue
•Sebaceous glands
•Sweat glands
Epidermis
Dermis •Collagen (connective tissue)
•Resilient elastic tissue
•Contains nerves Sensory receptors, Blood vessels
•Hair follicles
•Sebaceous glands
•Sweat glands Eccrine sweat gland
Apocrine sweat glands
Subcutaneous
Tissue
Insulating layer of fat
Contains blood vessels, nerves and remaining portions of sweat glands & hair follicles
Eccrine sweat gland
Sweat glands
Eccrine glands Open directly onto skin Odorless,colorless fluid Over all skin surface
Apocrine glands Released into hair follicle Thick, milky secretions In axillae, anogenital region
Sebaceous glands
Assoc w/hair root Oil glands Produce sebum Lubricate skin & hair Located everywhere but palms & soles
Major functions of the Skin
Protection Temperature regulation Sensation Vitamin D production Immunity Absorption & Excretion Psychosocial
Function
Waterproof Sebum
Barrier to bacteria and other pathogens
Protects underlying tissue from injury Thermal Mechanical Chemical
Thermoregulation Vitamin synthesis
Vitamin D Sensory organ
Heat Cold Pain Touch Pressure
Excretion Secretion
Now, We Know About the Integumentary System, what’s next?
Every day is Christmas!
Visual Skin Assessment
Look at your patient…what do you see? General color Areas of breakdown What risks are in front of you?
Tactile Assessment
When you touch your patient, how do they feel? Temperature Turgor/Elasticity Moisture Texture
Integumentary Assessment
• Mucus Membranes– Color– Moisture
• Hair– Texture– Lubrication– Thick or Thin
Integumentary Assessment
Nails– Color
– Shape and
Thickness
– Texture
– Capillary Fill Time – (CFT)
Integumentary Alterations
Mucus Membranes
Stomatitis
Glossitis
Gingivitis
Parotitis
Cheilosis
Integumentary Alterations
HAIRHAIR
TERMINAL - LONG, COARSETERMINAL - LONG, COARSEVELLUS - SMALL, SOFTVELLUS - SMALL, SOFT
HIRSUTISMHIRSUTISMALOPECIAALOPECIA
ASSESS – ASSESS – DISTRIBUTION, TEXTURE,DISTRIBUTION, TEXTURE,LUBRICATION, THICKNESS ORLUBRICATION, THICKNESS ORTHINNESSTHINNESS
Skin Changes in the Older Adult
Subcutaneous & dermal tissue thin
Sebaceous & sweat glands decrease
Cell renewal is shorter
Melanocytes decline in number
Collagen fiber decreases
NORMAL CHANGES WITH AGINGNORMAL CHANGES WITH AGING
Integumentary Alterations
• Skin Color
Changes
– Pallor
– Cyanosis
– Jaundice (icterus)
– Erythema
SKIN COLORSKIN COLOR
PALLOR (DECREASE IN COLORPALLOR (DECREASE IN COLOR))
CYANOSIS (BLUISH TINGE)CYANOSIS (BLUISH TINGE)
ERYTHEMA (REDNESS)ERYTHEMA (REDNESS)
JAUNDICE (YELLOW)JAUNDICE (YELLOW)
SKIN LESIONSSKIN LESIONS
INSPECT FORINSPECT FOR PALPATE FORPALPATE FOR
COLORCOLOR MOBILITYMOBILITYLOCATIONLOCATION CONTOURCONTOURSIZESIZE CONSISTENCYCONSISTENCYGROUPINGGROUPINGDISTRIBUTIONDISTRIBUTION
IF MOIST OR DRAINING, NOTE:IF MOIST OR DRAINING, NOTE:COLOR, CONSISTENCY, ODOR, AMOUNTCOLOR, CONSISTENCY, ODOR, AMOUNT
Integumentary Alterations
Skin Lesions
Primary
Vesicles
Bullae
Pustules
Nodules
Tumors
Skin Lesions
Primary
Papules
Wheals
Plaques
Macules
Patches
Integumentary Alterations
Integumentary Alterations
Integumentary Alterations
Hirsutism and Alopecia
EDEMAS/SCAUSEINSPECT FOR: LOCATION,
COLOR, SHAPEDEPENDENT EDEMA/
PITTING EDEMA
ANKLES, SACRUMFEET
PRINCIPILES r/t MAINTAINING SKIN INTEGRITY
Healthy & unbroken skin- first line of defense
Skin’s resistance to injury
Adequately nourished & hydrated cells
Adequate circulation to cells
What Skin Alteration remains the biggest challenge facing practitioners today?
THE FINAL ANSWER IS:
PRESSURE ULCERS
What is a Pressure Ulcer?
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
National Pressure Ulcer Advisory Panel (NPUAP) Feb 2007National Pressure Ulcer Advisory Panel (NPUAP) Feb 2007
2.5 million patients treated yearly for PU
60,000 patients die yearly from complications
$11 billion yearly
How do Pressure Ulcers occur?
Pressure is Major Cause
Prolonged pressure at levels greater than capillary closing pressure will ultimately result in tissue necrosis.
Small amount of pressure over long period is just as damaging as large amount over short period.
Tissue tolerance
Friction-Visible on skin surface; two surfaces move against each other
Shear-Injury beneath skin surface; patient’s skin moves one way, bed sheets move opposite when moving patient
Not visible
Where are Pressure Ulcers located?
Area over any bony prominence is vulnerable! Sacrum Coccyx Heels Hips
In children, back of the head (occiput)
What Other Risk Factors Contribute to Pressure Ulcer
Development? Immobility Incontinence Inactivity Improper nutrition Impaired sensorium
MemoryJogger
Five I’s!
Pressure Ulcer Staging- Stage I
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Stage I Pressure Ulcer
NEW VOCABULARY!
Tissue Ischemia Hyperemia Blanching (pale & white) Blanching hyperemia Reactive hyperemia Non-blanching erythema Abnormal reactive hyperemia
Stage II Pressure Ulcer
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured serum-filled blister.
Stage II Pressure Ulcer
Stage III Pressure Ulcer
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Stage III Pressure Ulcer
Stage IV Pressure Ulcer
Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar may be present on some parts of the wound bed.
Often include undermining and tunneling.
Stage IV Pressure Ulcer
Suspected Deep Tissue Injury
Purple or burgundy localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Suspected Deep Tissue Injury
Unstageable Pressure Ulcer
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Unstageable pressure ulcer
Reverse Staging
Stage III or IV pressure ulcers will not regenerate muscle, fat or dermis
During healing full thickness ulcers are filled with granulation tissue/ scar tissue
Staging Pressure Ulcers
As Registered Nurses, we must..
1. Conduct a pressure ulcer assessment on all patients upon admission
2. Inspect skin daily3. Manage moisture4. Optimize nutrition and hydration5. Minimize pressure
1. Conduct a Pressure Ulcer Admission Assessment
Assess for existing ulcers
Assess for risk factors
Use a validated risk assessment tool, such as the Braden scale or Norton Scale
Risk Assessment Scales
Braden Scale-Most widely used; focuses on intensity/duration of pressure & tissue tolerance for pressure; www.bradenscale.com
Norton Scale-Developed in United Kingdom; also used, but not as often
2. Inspect Skin Daily
When assisting to a chair or during bathing, for example
Pay attention to sacrum, back, buttocks, heels, and elbows
Check skin beneath tubes and devices Check areas such as the breasts, abdomen,
and knees in obese patients
3. Manage Moisture Clean the skin at routine intervals and
whenever the patient is incontinent Watch for excessive moisture due to
incontinence, perspiration, or wound drainage
Use appropriate cleaning agents Keep supplies at the bedside Clean soiled skin promptly Use moisture barriers as needed Use moisturizers for dry skin
4. Optimize Nutrition and Hydration
Unintentional weight loss may indicate risk Document intake Use supplements as needed Increase caloric intake by using an isotonic
nutritional supplement when administering medications
Respect dietary preferences Monitor hydration and offer water
5. Minimize Pressure Turn or reposition patients every 2 hours,
or more frequently for those with fragile skin or little subcutaneous tissue
Use alerts and cues as reminders for turning
Use lift devices or draw sheets Use heel and elbow protectors, or sleeves
and stockings Never drag the patient Keep the HOB at 30° or less Use pillows and cushions Use specialty pressure-relieving support
surfaces when appropriate Use bariatric beds when indicated
Remember..“Rule of 30”
ALTERNATIVES
Bariatric No Slip Wedge
Alternating Pressure Mattresses & Overlays
Location of pressure ulcer Size (length & width) Stage (indicates
depth/damage) Presence of sinus tracts Amount/color/consistency/ odor of exudate (drainage) Condition of periwound Any PU related pain/ per
patient
Documentation
Pressure Ulcer Treatment
Cleansing the wound bed
Maintain a moist wound bed, free from infection & necrotic tissue
Keep surrounding tissue dry
Last Words…
Dressings should be individualized!
Pain should be assessed & adequately managed!
Don’t massage bony prominences, Don’t use doughnut-type devices, or allow skin to become dried out!
YES, We can conquer
Pressure ulcers!
Nursing Responsibilities/Interventions
for Hygiene care
Practice of caring & patient comfort
Assessment of patient’s ability to perform basic hygiene care
Delegation considerations Types of baths Patients with special needs Maintaining patient’s environment