Transcript integumentary problems

MANAGEMENT OF CLIENTS WITH
INTEGUMENTARY PROBLEMS
Basal Cell Carcinoma,
Decubitus Ulcers
Hypothermia
Pruritus
Urticaria
Trauma
BRIEF REVIEW OF INTEGUMENTARY
SYSTEM
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Comprised of skin,
hair and nails
First line of defense
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Barrier between
internal and
external
environment
Largest organ of
the body
BRIEF REVIEW OF INTEGUMENTARY
SYSTEM
Physiologic Functions:
 Protection
 Water balance
 Temperature regulation
 Sensory organ
 Vitamin synthesis
Psychologic Function:
 Psychosocial
INTEGUMENTARY ASSESSMENT: HISTORY
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An accurate history is needed before physical
examination
 Demographic
 Many
data
integumentary changes are a result of aging
 Personal
and family history
 Medication history
 Diet history
 Socioeconomic background
 Current health problems
INTEGUMENTARY ASSESSMENT: EXAM
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Inspection
 Observe
all areas
 Systematic assessment
 obvious
changes in color or vascularity
 Presence of absence of moisture
 Edema
 Skin lesions
 Skin integrity
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Palpation
INTEGUMENTARY ASSESSMENT:
PSYCHOSOCIAL AND LABORATORY
Psychosocial:
 Assess for altered perceptions in body image or
disturbances in self concept
 Assess for social isolation
Laboratory Tests:
 Microscopic examination
 Cultures
 Biopsies
PRURITIS
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Itching caused by stimulation of itch-specific nerve
fibers at the dermal-epidermal junction
Scratching brings relief, but causes the “itch-scratch
cycle”
Associated with local (skin lesions) or systemic (liver,
venous) disorders
Care goal: promote comfort and prevent alterations in
skin integrity
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Therapeutic baths
Antihistamines +/or topical steroids
URTICARIA
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White or red edematous papules or plaques of varying sizes
Usually caused by exposure to a specific noxious stimulus
which causes release of histamines
Exact cause not always identified, possible factors:
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Drug -- Foods -- Infections -- Autoimmune disease
Malignancies
-- Physical stimuli
-- Psychogenic reactions
Treatment aimed at removal of potential stimulus and relief of
symptoms
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Antihistamines
Avoidance of overexertion, alcohol consumption, and warm
environments
SKIN TRAUMA
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Varies from neat, aseptic surgical incision to grossly
infected, draining wound
Stimulates a series of events for repair and reestablishment of the skin as a barrier
Phases of wound healing
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Inflammatory
Fibroblastic
Maturation
Length of each phase dependent upon type of
injury and whether wound heals by first, second or
third intention
PRESSURE ULCERS
Lesion from unrelieved pressure causing
damage of underlying tissue or a localized
area of cellular necrosis resulting from
vascular insufficiency in tissues under
pressure
 Occurs with limited mobility
 Once formed, pressure ulcers are slow to
heal
 Result from mechanical forces
 Occurs most often over bony prominences
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PRESSURE ULCERS
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Mechanical
Forces
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Pressure
Friction
Shear
Causes
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Mechanical
Trauma
Tissue
Anoxia
PRESSURE ULCERS: PREVENTION
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Recognize high risk clients
 Risk
assessment scale (Braden or Norton)
 Mental status
 Active
vs. Passive participant
 Activity/mobility
 Level
status
or mobility a direct factor
 Nutritional
 Positive
status
nitrogen balance is essential
 Incontinence
 Urine/feces
are irritants to skin
PRESSURE ULCERS: PREVENTION
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Aggressive approach to pressure relief
Must consider capillary closing pressure
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Pressure relief and reduction devices
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Amt. of pressure needed to occlude skin capillary blood flow
in the area at risk
Normal 12-32 mm HG
Dynamic vs. Static
Positioning
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30º rule
Change positions at least every 2 hours
PRESSURE ULCERS: KEY THINGS TO
REMEMBER
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Pressure relieving/reducing devices do not
take the place of observation of skin color,
integrity, and temperature at intervals to
determine capillary blood flow.
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In some clients pressure can occur in less
than 2 hours– the actual
turning/repositioning schedule should be
individualized based upon assessment data
PRESSURE ULCERS: WOUND ASSESSMENT
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Appearance changes with the depth of injury
Assess for:
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Location, size, color
Extend of tissue involvement
Condition of surrounding tissue
Presence of foreign bodies
Cellulits
Eschar
Undermining
STAGES OF PRESSURE ULCERS
Stage I
Stage II
STAGES OF PRESSURE ULCERS
Stage III
Stage IV
PRESSURE ULCERS: NURSING DIAGNOSIS
Impaired skin integrity
 Pain
 Disturbed body image
 Ineffective coping
 Imbalanced nutrition: less than body
requirements
 Deficient knowledge
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PRESSURE ULCERS: IMPAIRED SKIN
INTEGRITY
Wound care techniques will vary
 Non-surgical Management
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 Dressings
(Table 70-5, p. 1588)
 Physical therapy
 Drug therapy
 Diet therapy
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Surgical Management
 Sharp
debridement
 Skin grafting
PRESSURE ULCERS: RISK FOR INFECTION
AND EXTENSION
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Frequent monitoring of ulcer progress
Prevention of infection and wound extension
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Be alert for classic signs of wound infection
Prevent further pressure damage
Maintaining a safe environment
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Meticulous local wound care
Minimize cross-contamination with pathogens
Standard precautions
Thorough handwashing before and after dressing
changes
SKIN INFECTIONS
Bacterial Infections
 Usually start at the hair follicle
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Folliculitis: superficial infection of upper portion of follicle
caused by staph
Furuncles: infection caused by staph is deeper in hair follicle
(boil)
Cellulitis is a generalized non-follicular infection of the
deeper tissues caused by either staph or strep
Can spread infection to other parts by scratching
VIRAL SKIN INFECTIONS
Herpes Simplex
 Type
I : cold sore
 Type II: genital lesions
After primary infection virus remains dormant
in the nerve ganglia
 Physical or psychological stressors can
reactivate the infection
 Time between episodes and the severity of
individual attacks will vary
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VIRAL SKIN INFECTIONS
Herpes Zoster
 Reactivation of latent varicella zoster virus
 Resides in dorsal root ganglia of the sensory cranial
and spinal nerves
 Multiple lesions, segmentally distributed on skin area
innervated by infected nerve
 Discomfort is experienced before eruptions and can
persist after lesions are healed (postherpetic
neuralgia)
 Herpes Zoster is contagious to those who have never
had chickenpox
SKIN INFECTIONS: ASSESSMENT
History: clinical manifestations provide direction
for data collection
Physical exam: many skin lesions are contagious,
precautions to prevent spread must be taken
Lab: swab culture, blood culture, viral culture
SKIN INFECTIONS: INTERVENTIONS
Non-surgical
 Meticulous skin care
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Isolation precautions
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Minimize spread of microorganisms
handwashing
Drug therapy
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Antibacterial soaps or baths
Astringent compresses
Topical medications (antibacterial, antifungal)
Acyclovir for viral infections (topical or oral)
Surgical Management
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Not indicated except for I&D of furuncles or when lesion progresses
to full-thickness in immunocompromised person
PARASITIC DISORDERS
Pediculosis
 Lice infestation
 Transmitted by contact or
sharing of combs, hats,
etc.
 Pruritis- most prominent
symptom
 Can result in secondary
infection
 Lindane
 Wash clothing and linens
 Environment clean-up
Scabies
 Contagious mite
infestation which causes a
hypersensitivity reaction
 Transmitted by close and
prolonged contact
 Epidermal ridges: skin
between fingers, palms
and volmar aspect of
wrists
 Confirmed by skin scraping
 Lindane/topical sulfur
 Launder clothes and bed
linens
SKIN TUMORS (BENIGN)
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Cysts: firm, flesh-colored nodules that contain liquid or
semi-solid material
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Seborrheic keratoses: benign epidermal neoplasm
common in elderly
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Keloids: overgrowth of scar from excessive accumulation
of collagen and ground substance after skin trauma
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Nevi: (mole) benign neoplasm of pigment forming cells
Warts: small tumors caused by papillomaviruses
Hemangiomas : blood vessel tumors
SKIN CANCERS
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Actinic/solar keratosis
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Squamous cell
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Cancer of epidermis
Potentially metastatic
Basal cell
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Premalignant
May progress to squamous cell
Metastasis is rare
Underlying tissue destruction
Melanoma
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Originate in melanin-producing cells of epidermis
Highly metastatic
SKIN CANCERS: INTERVENTIONS
Non-surgical management
 Drug therapy
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Radiation therapy
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Topical chemotherapy
Systemic chemotherapy
Interferon after OR for melanoma
Limited to older clients with large, deeply invasive basal cell
tumors or poor surgical risks
Immunotherapy
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Experimental, melanoma vaccine
SKIN CANCER: INTERVENTIONS
Surgical Management
 Cryosurgery
 Local
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Curettage/electrodesiccation
 For
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application of liquid nitrogen
small lesions with well defined borders
Excision
 For
large of poorly defined skin cancers, recurrent
tumors and deeply invasive cancers
ACTIVITY
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Read up on Nursing Management of older
clients with Skin Cancers