Transcript Lecture 2B
Lecture 2B Fluid & electrolytes (Chapter 7) Integumentary System (chapters 4445) 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. Responsibility consent form signed Supplies Apply dressing Send specimen to the lab Pressure ulcers • AKA – Decubitus ulcers • Ischemic lesions • Caused by – External pressure – Friction – Shear Pressure ulcer development Pressure ulceration i blood flow necrosis i oxygen ischemia 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-REDUCING SUPPORT 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