Lecture 2B

Fluid & electrolytes (Chapter 7) Integumentary System (chapters 44-

45)

Structure & Function of the Integumentary System

• 2 regions– Epidermis– Dermis

Epidermis

• Location:– Outermost part

• Melanin– Color– Protects from UV light

• Keratin– Water repellent

Epidermis

• Function– Protect!

Dermis

• Location– Deeper layer

• Contains– Blood vessels– Nerve endings– Lymphatic vessels– Hair follicles– Sebaceous glands– Sweat glands

Skin Assessment

• History– C/O

• Onset• Duration• Characteristics• Relief factors• Exacerbation

– Changes• Skin• Meds

Skin Assessment

• Assess all skin areas– Redness– Swelling– Lesions– Pain

• Measure lesions

Common skin lesions

• Macule, patch– Flat, nonpalpable change

in skin color.– Macule < 1 cm– Patch > 1 cm – i.e. freckles, Mongolian

spots

Common skin lesions

• Papule, plaque– Elevated, solid, palpable

mass with circumscribed border.

– Papule < 0.5 cm– Plaque > 0.5 cm– i.e. moles, warts,

psoriasis

Common skin lesions

• Nodule, tumor– Elevated, solid palpable

mass extending deeper into the dermis than a papule

– Nodule• 0.5 – 2cm

– Tumor• > 2cm

Common skin lesions

• Vesicle, bulla– Elevated, fluid filled,

round/oval shaped, palpable mass with thin translucent walls

– Vesicle• < 0.5 cm

– Bulla• >0.5 cm

– i.e. herpes simplex, chicken poxs, burns

Common skin lesions

• Wheal– Elevated, often reddish,

irregular borders, caused by diffuse fluid in the tissue rather than free fluid in a cavity

– i.e. • Insect bites, hives

Common skin lesions

• Pustule– Elevated pus-filled

vesicle or bulla with circumscribed border.

– i.e. acne, impetigo, carbuncles

Older skin

• Normal changes– i Subcutaneous tissue– Dermal thinning– i Elasticity– i Turgor– i Hair and nail growth

Common diagnostic test for integumentary disorders

• Biopsy– Skin sample – To rule out malignancy

• Nrs. Responsibilityconsent form signedSuppliesApply dressingSend specimen to the

lab

Pressure ulcers

• AKA– Decubitus ulcers

• Ischemic lesions• Caused by

– External pressure– Friction– Shear

Pressure ulcer development

Pressure

i blood flow

i oxygen

ischemia

necrosis

ulceration

High Risk Areas for Pressure ulcers

• Bony prominence– Heels– Greater trochanter– Sacrum– Ischia– Shoulder

Usual pressure ulcer locations• Over Bony Prominences

1. Occiput 2. Ears 3. Scapula 4. Spinous Processes 5. Shoulder 6. Elbow 7. Iliac Crest 8. Sacrum/Coccyx 9. Ischial Tuberosity 10. Trochanter 11. Knee 12. Malleolus 13. Heel 14. Toes

Other locations…• Any skin surface subject

to excess pressure• Examples include skin

surfaces under: – Oxygen tubing – Urinary catheter drainage

tubing – Casts – Cervical collars

Pressure Ulcers from other sources of pressure

• Boots/boot straps• Heel protectors/protector straps• Oxygen tubing• Stockings• Any device that can lead to pressure induced

ischemia on the skin

High risk clients: pressure ulcers

• Immobile• Elderly• Incontinence• Nutritional deficit• Smoking

Complications

• Pain

Pain with Pressure Ulcers

• 59% report some degree of pain• Only 2% receive pain medication

within 4 hours of dressing change• 45% report pain as distressing or

horrible

Complications

• Pain• Infection

Infection COMPLICATIONS

• Sepsis

• Localized infection

• Cellulitis

• Osteomyelitis

Complications

• Pain• Infection• Quality of life• Cost• Death

Mortality• 40% die per year• 60% die within 1 year

after hospital discharge

Prevention!!!General Skin Care

• Assess• Clean & Dry• Avoid massage• i Pressure• Well balanced nutrition

Protect skin from Moisture

• Clean• Moisturize• Barriers• Bowel & Bladder

program

Pressure Reduction

• Rehabilitation h mobility• Repositioning • Pressure reduction devices• Float Heels• No sliding

nutrition and fluid Support

• Dietician• Preferences• Provide assistance & time• Snacks and fluids• Supplements• Assess lab values

Pressure Ulcer Monitoring and Treatment

Description of Ulcers

• Stage Ulcer• Location• Size• Wound bed • Granulation tissue

• Necrotic tissue• Wound edges• Drainage• Infection• Pain

STAGING OF PRESSURE ULCERS

Stage I: Persistent nonblanchable erythema of intact skin.

STAGING OF PRESSURE ULCERS

• Stage II: Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial and presents as an abrasion, blister, or shallow crater.

STAGING OF PRESSURE ULCERS

Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

STAGING OF PRESSURE ULCERS

• Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts may also be present.

Used with permission LWW

STAGING OF PRESSURE ULCERS

• Unstageable: Full thickness tissue loss in which slough (yellow, tan, gray, green or brown), eschar (tan, brown or black), or both in the wound bed cover the base of the ulcer.

Granulation tissue

• Intermediate step in healing

• Very fragile • Appearance: Shiny

red & grainy • When inadequate blood

flow exists, granulation tissue may pale in color.

Slough

• non-viable tissue and requires debridement

• Appearance – stringy mass

• Color– white, yellow/tan, brown

• Becomes thicker and harder to remove

• Easily confused with normal tissues (tendons)

Eschar• Dead tissue, • Color:

– Tan, brown, black • Leathery, dry hard• Soft, with purulent

discharge– Slimy.

Prevention

• Reposition – at least every 2 hours (may use pillows, foam wedges)

• Keep head of bed at lowest elevation possible

• Use lifting devices to decrease friction and shear

• Remind patients in chairs to shift weight every 15 min

“Doughnut” seat cushions are contraindicated,may cause pressure ulcers

• Pay special attention to heels (heel ulcers account for 20% of all pressure ulcers)

PREVENTING HEEL ULCERS

• Assess heels of high-risk patients every day

• Use moisturizer on heels (no massage) twice a day

• Apply dressings to heels:

PREVENTING HEEL ULCERS

• Have patients wear: Socks to prevent friction (remove at bedtime) Properly fitting sneakers or shoes when in wheelchair

• Place pillow under legs to support heels off bed

• Place heel cushions to prevent pressure

• Turn patients every 2 hours, repositioning heels

PRESSURE-REDUCINGSUPPORT SURFACES

**Use for all older persons at risk for ulcers**

Nrs. Dx: Impaired tissue integrity

• Document• Track progress• Do not “reverse stage”

Ulcers do not replace lost muscle, subcutaneous fat, or dermis before re-epithelializing

E.g. Stage IV cannot become stage III

Dressing

• Keep wound bed moist • Keep surrounding tissue clean & dry• Do not use antiseptic agents

Types of Dressings

• Gauze• Transparent films• Hydrocolloid• Hydrogel

• Alginates• Foam• Composite

Nrs. Dx: risk for infection

• Wound cleansing and dressing– frequency when purulent or foul-smelling drainage is first

observed– Avoid topical antiseptics because of their tissue toxicity

• topical antibiotics • Cultures

Bacterial Infection

• Clinically Infected– redness– purulent drainage– foul odor– edema

Nrs. Dx: Alt. nutrition, less than body requirements

• nutritional assessment• q day wts• h Protein• Lab

– Albumin

MANAGEMENT:SURGICAL REPAIR

• used for stage III and IV• Risks to benefits • All wounds with necrotic tissue should be

debrided

SUMMARY

• Older adults are at high risk for development of pressure ulcers

• Pressure ulcers may result in serious complications

• Techniques that reduce pressure, moisture, friction, and shear can prevent pressure ulcers

• Pressure ulcers should be treated with proper cleansing, dressings, debridement, or surgery as indicated