integumentary problems
Download
Report
Transcript integumentary problems
MANAGEMENT OF CLIENTS WITH
INTEGUMENTARY PROBLEMS
Basal Cell Carcinoma,
Decubitus Ulcers
Hypothermia
Pruritus
Urticaria
Trauma
BRIEF REVIEW OF INTEGUMENTARY
SYSTEM
Comprised of skin,
hair and nails
First line of defense
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
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
Inspection
Observe
all areas
Systematic assessment
obvious
changes in color or vascularity
Presence of absence of moisture
Edema
Skin lesions
Skin integrity
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
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
Therapeutic baths
Antihistamines +/or topical steroids
URTICARIA
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:
Drug -- Foods -- Infections -- Autoimmune disease
Malignancies
-- Physical stimuli
-- Psychogenic reactions
Treatment aimed at removal of potential stimulus and relief of
symptoms
Antihistamines
Avoidance of overexertion, alcohol consumption, and warm
environments
SKIN TRAUMA
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
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
PRESSURE ULCERS
Mechanical
Forces
Pressure
Friction
Shear
Causes
Mechanical
Trauma
Tissue
Anoxia
PRESSURE ULCERS: PREVENTION
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
Aggressive approach to pressure relief
Must consider capillary closing pressure
Pressure relief and reduction devices
Amt. of pressure needed to occlude skin capillary blood flow
in the area at risk
Normal 12-32 mm HG
Dynamic vs. Static
Positioning
30º rule
Change positions at least every 2 hours
PRESSURE ULCERS: KEY THINGS TO
REMEMBER
Pressure relieving/reducing devices do not
take the place of observation of skin color,
integrity, and temperature at intervals to
determine capillary blood flow.
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
Appearance changes with the depth of injury
Assess for:
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
PRESSURE ULCERS: IMPAIRED SKIN
INTEGRITY
Wound care techniques will vary
Non-surgical Management
Dressings
(Table 70-5, p. 1588)
Physical therapy
Drug therapy
Diet therapy
Surgical Management
Sharp
debridement
Skin grafting
PRESSURE ULCERS: RISK FOR INFECTION
AND EXTENSION
Frequent monitoring of ulcer progress
Prevention of infection and wound extension
Be alert for classic signs of wound infection
Prevent further pressure damage
Maintaining a safe environment
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
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
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
Isolation precautions
Minimize spread of microorganisms
handwashing
Drug therapy
Antibacterial soaps or baths
Astringent compresses
Topical medications (antibacterial, antifungal)
Acyclovir for viral infections (topical or oral)
Surgical Management
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)
Cysts: firm, flesh-colored nodules that contain liquid or
semi-solid material
Seborrheic keratoses: benign epidermal neoplasm
common in elderly
Keloids: overgrowth of scar from excessive accumulation
of collagen and ground substance after skin trauma
Nevi: (mole) benign neoplasm of pigment forming cells
Warts: small tumors caused by papillomaviruses
Hemangiomas : blood vessel tumors
SKIN CANCERS
Actinic/solar keratosis
Squamous cell
Cancer of epidermis
Potentially metastatic
Basal cell
Premalignant
May progress to squamous cell
Metastasis is rare
Underlying tissue destruction
Melanoma
Originate in melanin-producing cells of epidermis
Highly metastatic
SKIN CANCERS: INTERVENTIONS
Non-surgical management
Drug therapy
Radiation therapy
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
Experimental, melanoma vaccine
SKIN CANCER: INTERVENTIONS
Surgical Management
Cryosurgery
Local
Curettage/electrodesiccation
For
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
Read up on Nursing Management of older
clients with Skin Cancers