Transcript 12 The Integument Lecture Note PowerPoint Presentation

12
Lecture Note PowerPoint Presentation
The Integument
24/04/2011
LEARNING OUTCOME 1
Describe normal skin changes associated with aging.
2
NORMAL STRUCTURE AND FUNCTION OF
THE SKIN
24/04/2011
Skin consists of 15–20% of the total body weight
 Epidermis



Consists of five continually regenerating and
shedding layers
Dermis
3
24/04/2011
FIGURE 12-1
CORPUSCLES AND THEIR DISTRIBUTION IN THE SKIN.
4
NORMAL STRUCTURE AND FUNCTION OF
THE SKIN
24/04/2011

Subcutaneous layers
A specialized connective tissue attached to muscles
 Contains blood vessels, lymphatic channels, hair
follicles, and sweat glands

5
NORMAL STRUCTURE AND FUNCTION OF
THE SKIN
24/04/2011

Accessory structures
Hair
 Nails
 Glands

Sebaceous glands
 Apocrine sweat glands

6
NORMAL STRUCTURE AND FUNCTION OF
THE SKIN
24/04/2011

Function





Protection
Regulation of immune functions
Thermoregulation
Vitamin synthesis
Sensory receptor for CNS
7
SKIN CHANGES ASSOCIATED WITH AGING
Intrinsic factors


24/04/2011

Genetic makeup and the normal aging process
Extrinsic factors
UV lighting
 Smoking
 Environmental pollutants

8
24/04/2011
9
FIGURE 12-2
NORMAL CHANGES OF AGING IN THE INTEGUMENTARY SYSTEM.
SKIN CHANGES ASSOCIATED WITH AGING
Epidermal changes





Thinning
Reduced moisture leading to a dry, rough appearance
Mitosis slows after age 50 by 30%
Increased healing time
Increased risk of infection
24/04/2011

10
SKIN CHANGES ASSOCIATED WITH AGING
Epidermal changes
Rete ridges flatten: in the dermal layer, less collagen
is being produced. The elastin fibers also wear out.
Such factors will cause the skin to sag and wrinkle.
The rete ridges, meanwhile, will flatten out. This
will cause the skin to be fragile.
 Increased risk of skin breakdown
 Reduced melanocytes

24/04/2011

Paler complexion
 Increased risk of UV damage

11
SKIN CHANGES ASSOCIATED WITH AGING
Epidermal changes

Scattered pigmented areas
24/04/2011

Nevi (skin moles)
 Age spots
 Liver spots
 Increased number and size of freckles (clusters of
concentrated melanin)
 Age spots — also called liver spots and solar lentigines —
are flat gray, brown or black spots. They vary in size and
usually appear on the face, hands, shoulders and arms —
areas most exposed to the sun. Though age spots are very
common in adults older than age 40, they can affect younger
people as well.

12
SKIN CHANGES ASSOCIATED WITH AGING
Dermal changes
Decreased thickness and function begin in 3rd decade
of life
 Elastin decreases in quality



24/04/2011

Wrinkling and sagging
Collagen less organized

Loss of turgor
13
SKIN CHANGES ASSOCIATED WITH AGING
Dermal changes

Reduced vascularity


Paler complexion
Capillaries thin and are easily damaged


24/04/2011

Senile purpura Easy skin bruising in older people
Reduced touch and pressure sensations
14
SKIN CHANGES ASSOCIATED WITH AGING
Subcutaneous layer

Tissue thins in the face, neck, hands, and lower legs


24/04/2011

Visible veins in exposed areas
Hypertrophy of tissue in certain body areas
Increased body fat
 Increased body fat in abdomen and thighs

15
HAIR CHANGES WITH AGING
24/04/2011
Reduced number of functioning melanocytes
 Replacement of pigmented strands of hair with
nonpigmented hair
 Hormone levels decline

Loss of hair in pubic and axillary areas
 Growth of facial hair in women
 Growth of nasal and ear hair in men


Increased baldness
16
NAIL CHANGING WITH AGING
Color changes
Dull
 Yellowing or grayness


Slowed growth


24/04/2011

Thicker nails prone to splitting
Longitudinal striations

Related to damage at the nail matrix (the ROOT of
the nail)
17
NAIL CHANGING WITH AGING
Longitudinal pigmented bands
Single or multiple brown or black bands on thumb
and index finger
 Frequently seen in African-Americans over age 20
 Increased visibility in the older adult

24/04/2011

18
GLANDULAR CHANGES WITH AGING
Eccrine or sweat glands


Decreased number; decreased ability to regulate body
temperature
24/04/2011

Sebaceous glands

Increased size; decreased activity; increased water
evaporation causes cracked, dry skin
19
24/04/2011
LEARNING OUTCOME 2
Identify risk factors related to common skin problems of
older adults.
20
“THE SUN NEVER FORGETS”
Ultraviolet radiation (UVR)

Ultraviolet A (UVA)
24/04/2011

21
“THE SUN NEVER FORGETS”
Responsible for premature aging and decreased
immune function

24/04/2011

Ultraviolet B (UVB): The elderly have reduced
capacity to synthesize vitamin D in skin when
exposed to UVB radiation.
Intense, intermittent exposures
 Basal cell carcinoma
 Malignant melanoma
 Chronic sun exposure
 Squamous cell carcinoma

Photoaging: refers to the damage that is done to the
skin from prolonged exposure, over a person's
lifetime, to UV radiation
 Actinic keratosis: is a premalignant condition of
thick, scaly, or crusty patches of skin

22
SKIN TEARS
Traumatic separation of the epidermis from the
dermis
24/04/2011

23
PRESSURE ULCERS
24/04/2011
Impact between 1 and 3 million people annually
in the United States
 Localized injury to the skin and underlying tissue

Usually over a bony prominence
 Results from pressure or pressure and shear force
and/or friction

24
PRESSURE ULCERS
High-risk populations
Hospitalized patients
 Individuals over age 65

24/04/2011

25
CELLULITIS
24/04/2011
Acute bacterial infection of the skin and
subcutaneous tissue
 Risk factors

Skin breaks
 Chronic illness
 Age-related skin changes

26
CONDITIONS OF THE FINGER AND TOE
NAILS
Risk factors
Trauma
 Age-related changes
 Systemic diseases

24/04/2011

27
24/04/2011
LEARNING OUTCOME 3
Delineate skin changes associated with benign and
malignant skin types.
28
SKIN CANCER IS THE LEADING CANCER IN
THE UNITED STATES
24/04/2011
Malignancies are associated with the time spent
in the sun
 Older and light-skinned persons are at an
increased risk
 Darker-skinned persons may be at risk

29
ACTINIC KERATOSIS
Most common precancerous lesion; it is seen
more in men than women

24/04/2011

1:1,000 will progress to skin cancer
Also known as solar keratosis or senile keratosis
 Sore, rough, scaly, erythematous papules or
plaques

30
24/04/2011
Actinic Keratosis
31
BASAL CELL CARCINOMA
24/04/2011
Most common skin cancer for Caucasians
 Metastasis rare
 Originates in lowest layer epidermis
 Manifests as small, fleshy bumps

32
SQUAMOUS CELL CARCINOMA
24/04/2011
Second most common skin cancer for Caucasians
 Most common skin cancer for persons with dark
skin
 Originates in upper levels of epidermis
 Manifests as flesh-colored erythematous, scaly
plaques, papules or nodules
 Metastasis can occur

33
MELANOMA
24/04/2011
Most dangerous skin cancer; responsible for more
than three quarters of all skin cancer deaths
 Originates in the melanocytes
 Lesions may be brown, black, or multicolored;
develop nodules or; plaques (a broad papule ) and
have a black, irregular spreading outline

34
SKIN TEARS

Category 1


Linear or flap tear without tissue loss
Category 2


24/04/2011
Caused by friction or shearing forces
 Payne-Martin classification for skin tears

Tears with partial tissue loss
Category 3

Tears with full thickness complete tissue loss
35
PRESSURE ULCERS
24/04/2011
The majority occur in persons over age 70
 Stages

Stage I: Nonblanchable erythema of intact skin
 Stage II: Partial-thickness skin loss involving dermis
and/or epidermis
 Stage III: Full-thickness skin loss involving damage
or necrosis of subcutaneous tissue that may extend to
underlying fascia

36
PRESSURE ULCERS
Stages


Stage IV: Full-thickness skin loss with extensive
destruction, tissue necrosis, or damage to muscle,
bone, or supportive structures
24/04/2011

Types of pressure ulcers



Necrosis of epidermis and dermis
Deep or malignant pressure ulcers
Full-thickness wounds
37
PRESSURE ULCERS
Mechanisms of Tissue Breakdown
Occlusion of blood flow to the skin
 Damage to the lining of the arterioles and smaller
vessels
 Direct occlusion of blood vessels by long periods of
pressure

24/04/2011

38
WOUND HEALING
Phases
Inflammation and destruction
 Proliferation
 Maturation

24/04/2011

39
DELAYED WOUND HEALING
24/04/2011
A wound that does not heal within 6 weeks is
termed chronic
 Signs

Wound size is increasing
 Exudate, slough, or eschar is present
 Tunnels, fistula, or undermining has developed
 Epithelial edge is not smooth and continuous and
does not move toward wound

40
DELAYED WOUND HEALING
Causes





Aging
Inadequate nutrition
Inadequate blood supply
Immunocompetence
Damage to wound
24/04/2011

41
CELLULITIS
24/04/2011
Acute bacterial infection of skin
 Characterized with inflammation, intense pain,
heat, redness, and swelling

42
NAIL PROBLEMS
24/04/2011
Fungal infection
 Inflammation of the nail matrix
 Hypertrophy of the nail plate

43
24/04/2011
LEARNING OUTCOME 4
List nursing diagnoses related to common skin problems.
44
THREE MAJOR NURSING DIAGNOSES FOR
INTEGUMENT PROBLEMS


24/04/2011
Risk for Impaired Skin Integrity
 Impaired Tissue Integrity

Damage to integument, cornea, or mucous
membranes
Impaired Skin Integrity

Damage to epidermal or dermal tissue
45
NURSING DIAGNOSES FOR INTEGUMENT
PROBLEMS
24/04/2011
Impaired Skin Integrity related to lesions and
inflammatory response
 Risk for Impaired Skin Integrity related to
physical immobility
 Risk for Impaired Skin Integrity related to
decrease skin turgor

46
NURSING DIAGNOSES FOR INTEGUMENT
PROBLEMS
24/04/2011
Risk for Impaired Skin Integrity related to the
effects of pressure, friction, or shear
 Risk for Impaired Tissue Integrity related to
decreased circulation
 Risk for Infection related to pressure ulcer

47
24/04/2011
LEARNING OUTCOME 5
Discuss the nursing responsibilities related to
pharmacological and nonpharmalogical treatment of
common skin problems.
48
DIAGNOSTIC TESTS FOR INTEGUMENTARY
DISORDERS
24/04/2011
Total body photography: is established
techniques for detecting and monitoring
dysplastic and atypical nevi for early detection of
malignant cutaneous melanomas
 Skin biopsy
 Wound cultures
 Laboratory tests

Serum albumin
 Serum transferrin
 Lymphocyte count

49
PHARMACOLOGIC TREATMENT OPTIONS
24/04/2011
Topical antifungal agents
 Topical antibiotics
 Systemic antibiotics
 Selected antimicrobials
 Aminoglycosides
 Prescription creams

50
NONPHARMACOLOGICAL INTERVENTIONS
Patient education
Awareness and reporting of skin cancer
 Characteristics of darker skin


24/04/2011

Prevention
Guidelines on sun exposure
 Wearing protective clothing

51
NONPHARMACOLOGICAL INTERVENTIONS
Treatment


Basal cell carcinoma and squamous cell carcinoma
Malignant melanoma
24/04/2011

Excisional biopsy for diagnosis
 Wide excision for cure
 Adjuvant therapy
 Chemotherapy
 Chemoimmunotherapy
 Regional radiation therapy
 Biotherapy

52
NONPHARMACOLOGICAL INTERVENTIONS
Preventing skin tears







Avoid pulling or sliding
Pad surfaces
Keep environment free of obstacles
Maintain safe environmental lighting
Keep skin moist
Use tape cautiously
Encourage long sleeves and pants
24/04/2011

53
NONPHARMACOLOGICAL INTERVENTIONS
Managing skin tears






Clean with normal saline or other nontoxic cleaner
Pat or air dry
Gently place torn skin in its approximate normal
position
Apply dressings and change per protocol or product
requirements
Photograph if permitted
Document all findings
24/04/2011

54
NONPHARMACOLOGICAL INTERVENTIONS
Managing cellulitis






Treat acute infection
Immobilization
Elevate limb
Pain relief
Possible anticoagulant therapy
Prevent further complications
24/04/2011

55
NONPHARMACOLOGICAL INTERVENTIONS
Management of Fingernail and Toenail Problems

Onychomycosis: means fungal infection of the nail. It
is the most common disease of the nails and
constitutes about a half of all nail abnormalities.
24/04/2011

Pain management
 Patient education
 Oral antifungal agents


Chronic paronychia: Paronychia is one of the most
common infections of the hand. Clinically, paronychia
presents as an acute or a chronic condition. It is a
localized, superficial infection or abscess of the
paronychial tissues of the hands or, less commonly,
the feet
Keep affected nails dry
 Antibiotics

56
24/04/2011
Chronic paronychia
Onychomycosis
57
NONPHARMACOLOGICAL INTERVENTIONS
Management of Fingernail and Toenail Problems

Onychogryphosis:is a hypertrophy that may produce
nails resembling claws or a ram's horn, possibly
caused by trauma
24/04/2011

Keep nails short
 Podiatry consultation: is a branch of medicine devoted to
the study, diagnosis and treatment of disorders of the foot,
ankle and lower leg.
 Surgical intervention

58
24/04/2011
LEARNING OUTCOME 6
Explain the nursing management principles related to
the care of pressure ulcers.
59
THE BRADEN SCALE

24/04/2011
Used to assess pressure ulcer risk
 Assesses mobility, activity, sensory perception,
skin moisture, friction, shear, and nutritional
status
 Used as an adjunct tool to nursing assessment
and clinical judgment

Can be found at this link
http://www.bradenscale.com/images/bradenscale.
pdf
60
MOBILITY AND ACTIVITY CONSIDERATIONS
24/04/2011
Repositioning q2h
 Ensure proper positioning
 Avoid prolonged sitting
 Increase activity
 Choose a mattress surface based on the
assessment and diagnosis
 * a low air loss bed is indicated for all pressure
ulcers in any stage
 * a water mattress for stage 1, 2 and 3
 * an alternating pressure mattress for stage 1
and 2.

61
SKIN CARE FOR OLDER PERSONS
24/04/2011
Correct bathing procedures
 Keep skin clean and dry
 Lubricate with non–alcohol-containing
moisturizer
 Prevent injury
 Evaluate and manage incontinence
 Provide dietary support

62
NURSING CARE OF PRESSURE ULCERS
24/04/2011
Assess and stage the wound
 Debride necrotic tissue
 Cleanse

63
TREATMENT
24/04/2011
Avoid contamination
 Colonization: presence and proliferation of
organism in the wound with no signs of infection.
 Infection: presence and proliferation of organism
in the wound with signs of infection
 Topical antibiotics
 Systemic antibiotics

64
NURSING CARE AND DOCUMENTATION OF
SKIN PROBLEMS
24/04/2011
Assess risk factors
 Provide nursing interventions to minimize skin
breakdown
 Document care
 Evaluate patient status

65
KNOWLEDGE-BASED DECISION MAKING
24/04/2011
Current literature
 Share with colleagues, patients, and their
significant others

66
HELPFUL QUESTIONS WHEN ASSESSING
WOUND CARE PRODUCTS
24/04/2011
What is the stage, drainage, moisture, or eschar?
 What are the wound needs?
 What products are available to manage the
wound?

67
ONGOING EVALUATION OF NURSING CARE
24/04/2011
Family situation
 Available resources
 Patient needs and requests
 Patient and family understanding of the teaching
and plan of care

68