Transcript The Integumentary System

The Integumentary System
Sasha Alexis Rarang, RN, MSN
NURS 120
Instructor
The integument as an organ:
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Alternative name for skin.
The integumentary system includes the skin
and the skin derivatives hair, nails, and
glands.
The integument is the body’s largest organ
and accounts for 15% of body weight.
The skin
Functions of the
skin:
 Thermoregulation
 Vitamin D
production
 Protection
 Absorption &
secretion
 Wound healing
The skin
The Two Layers of
Skin:
 Epidermis – The
Epidermis is the
thinner more
superficial layer of
the skin.
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Dermis: is the
deeper, thicker layer
composed of
connective tissue,
blood vessels,
nerves, glands and
hair follicles.
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Stratum corneum: the outermost layer. replaced.
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Stratum lucidum: Only found in the fingertips, palms of
hands, & soles of feet. This layer is made up of 3-5 layers
of flat dead keratinocytes.
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Stratum granulosum: made up of 3-5 layers of
keratinocytes, site of keratin formation,
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Stratum spinosum: appears covered in thornlike spikes,
provide strength & flexibility to the skin.
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Stratum basale: The deepest layer, made up of a single
layer of cuboidal or columnar cells. Cells produced here are
constantly divide & move up to apical surface.
Five distinct sub-layers of the
Epidermis:
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There are two main divisions of the dermal
layer:
◦ Papillary region - The superficial layer of the
dermis, made up of loose areolar connective tissue
with elastic fibers.
◦ Dermal papillae - Fingerlike structures invade the
epidermis, contain capillaries or Meissner
corpuscles which respond to touch.
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Reticular region of the Dermis – Made up
of dense irregular connective & adipose
tissue, contains sweat lands, sebaceous (oil)
glands, & blood vessels.
The Dermis
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The outer layer is called the epidermis; it is a tough protective
layer that contains melanin (which protects against the rays of
the sun and gives the skin its color).
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Dermal melanin is produced by melanocytes. which are found in
the stratum basale of the epidermis.
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Some individual animals and humans have very little or no
melanin in their bodies, a condition known as albinism.
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Because melanin is an aggregate of smaller component
molecules, there are a number of different types of melanin with
differing proportions and bonding patterns of these component
molecules.
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Both pheomelanin and eumelanin are found in human skin and
hair, but eumelanin is the most abundant melanin in humans, as
well as the form most likely to be deficient in albinism.
Factors that influence Color
Assessing Clients with Integumentary Disorders
Functional Health
Use the following health history questions and
leading statements, categorized by functional
health patterns, with a family member, friend,
or client.
 Identify areas for focused physical assessment
based on findings from the health history.
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Assessing the Integumentary System
Techniques of assessing the integumentary system.
1. Health Perception-Health Management
 Have pt. describe any skin problems or injuries,
nail problems, and/or scalp problems you have
had.
 How was pt. problem treated?
 Ask pt. to describe current problem.
 Ask pt. if taking any medications for this
problem? If so, what does he or she takes, and
how often?
 Did pt. recently had any insect bites? Explain.
 Have pt. describe any food, drug, plant, or
animal allergies she/he have.
 Ask pt. to describe how he/she care for her skin.
Techniques of assessing the
Integumentary system.
2. Nutritional-Metabolic
 Ask pt. to describe usual intake of fluids and
food over a 24-hour period.
 Ask pt. if pt. made any changes in her diet or
have recently introduced new foods into diet?
What are they? When did he/she eat them?
 How well do skin cuts or scratches heal? Has
there been a recent change in the way pt.
heal?
3. Elimination
 Is pt.’s skin and/or scalp dry or oily?
 Does the pt. perspire heavily?
Techniques of assessing the
Integumentary system.
4. Activity-Exercise
 Ask pt. to describe her/his usual activities in a 24-hour
period.
 How much sun exposure does pt. get? Does she or he use
sunscreen or sun-block products?
 Does he/she bruise easily? Ask pt. to explain.
5. Sleep-Rest
 How many hours of sleep does the pt. get each night?
 Does itching or sweating wake the pt. at night?
 Is pt. unable to rest because of a skin problem?
6. Cognitive-Perceptual
 Does the pt. have any skin pain, including itching, burning,
stinging, tingling, achiness, tenderness, or numbness? Ask
pt. to explain.
Techniques of assessing the Integumentary
system.
7. Self-Perception-Self-Concept
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Describe the appearance of pt. skin, hair, and nails.
Does the pt. have a rash or open area on her/his skin? If so,
where is it located? What size and shape is it? Is it flat or raised?
Does it have any drainage from it?
How long pt. had the rash or open area? What precipitates or
relieves it?
Ask pt. to describe any changes she/he have recently noticed in
the appearance of a mole (such as changes in color and size,
bleeding, or pain).
Had pt. recently lost any hair? From where, and how much?
Had pt.’s nails changed in color or shape? Have they become
more brittle?
Has a problem with pt. skin, scalp, or nails affected how the pt.
feel about her/himself?
Has a problem with skin, scalp, or nails affected how he/she feel
about his/her normal life?
Techniques of assessing the Integumentary
system.
8. Role-Relationship
Is there a history of allergic disorders or skin problems in
pt’s family? Ask pt. to describe.
 Is pt’s problem with her/his skin affected her relationships
with others in her/his family? At work? In social activities?
Ask pt. to explain.
 Is a problem with pt.’s skin or scalp affected her/his ability
to work? Explain.
9. Sexuality-Reproductive
 Has a health problem with pt. skin or scalp interfered with
or changed her/his usual sexual activities? Ask pt. to
explain.
 Describe how problems with pt.’s skin, scalp, or nails have
made her/him feel about her/himself as a man or woman.
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Techniques of assessing the Integumentary
system.
10. Coping-Stress
 Does pt’s skin problem seems to become
worse when he/she experience increased
stress? Explain.
 Are health problems with pt. skin created
stress for him/her? Explain.
 Describe what pt. do to cope with stress.
 Who or what will be able to help pt. cope
with stress from this skin problem?
11. Value-Belief
 How will this health problem affect pt. future?
Techniques of assessing the Integumentary
system.
Pressure Ulcers
- Tissue necrosis commonly occurring
adjacent to bony prominences caused by
unrelieved pressure blocking blood flow to
the region.
- Most common sites
 Sacrum
 Heels
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Integumentary Problems
Pressure Ulcer – heel
Pressure Ulcer- sacrum
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Skin changes related to aging
Immobility
Incontinence or excessive moisture
Skin friction and shearing
Vascular Disorders
Obesity
Risk Factors
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Inadequate nutrition and/or hydration.
Anemia
Fever
Impaired circulation
Edema
Sensory deficits
Low diastolic blood pressure
Impaired cognitive functioning
Neurological disorders
Chronic Diseases – e.g. Diabetes Millitus,
Chronic Renal Failure, CHDs, CLD
Contributing Factors
Wound Culture and Sensitivity
 CBC with Differential
 Blood Cultures
 Serum albumin and Pre-albumin
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Diagnostic Procedures
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Monitor for s/s – assess stage of the
wound
Wound Stages ( pressure ulcer)
Some ulcers cannot be staged
Assess/monitor
Alteration in skin integrity
Skin Moisture status
Incontinence
Nutritional status
See Braden Scale assessment tool.
Assessment
Nonblanchable erythema of intact skin the
heralding lesion of skin ulceration. In
individuals with darker skin, discoloration,
warmth, edema, induration, or hardness
may be indicators.
 Intact skin with some observable damage
such as redness or a boggy feel.
 Does not blanch
 Recersible if pressure is relieved.
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Stage I
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Relieve pressure
Frequent turning repositioning
Use pressure relieving devices such as air
fluidized bed.
Utilize pressure reduction surfaces ( air
mattress, foam mattress)
Keep the client dry, clean, and wellnourished and hydrated.
Nursing Intervention
Partial thickness skin loss involving
epidermis, dermis, or both. The lesion is
superficial and presents clinically as an
abrasion, blister, or shallow center.
 Lesion present as an abrasion, shallow
crater, or blister
 May appear swollen and painful
 Takes several weeks to heal after pressure
is relieve.
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Stage II
Maintain a moist healing environment.
(saline or occlusive dressing)
 Promote naturalhealing whilepreventing
formation of scar tissue.
 Provide nutritional supplement as needed
Protein supplement PROSTAT,(vitamins
and mineral e.g. zinc sulfate, Vitamin C)
 Administer analgesics as needed.
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Nursing Interventions
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Full thickness skin loss involving damage or
necrosis of subcutaneous tissue that may extend
down to, but not through, underlying fascia. The
sore presents clinically as a deep crater with or
without undermining of adjacent tissue.
Shallow or deep.
May have deep crater with or without
undermining of adjacent tissue and maybe foul
smelling purulent drainage if locally infected.
Yellow slough/and or necrotic tissue in wound
bed
May require several months to heal after
pressure is relieved.
Staqe III
 Clean and/or debride –
1.
wet to dry dressing
2.
surgical intervention
3.
Proteolytic enzymes – e.g. accuzyme.
 Provide nutritional supplement prn.
 Administer analgesics prn
 Administer antimicrobials ( topical or
systemic)
Nursing Interventions
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Full thickness skin loss with extensive
destruction, tissue necrosis, or damage to
muscle, tendon, bone, or supporting
structures.
Deep.
Lesion may appear small in the surface but
can have extensive tunneling out of sight
beneath superficial tissues and usually
includes a foul smelling discharge.
Local infection can easily spread causing
sepsis
May take months or several years to heal.
Stage IV
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Perform non-adherent dressing chage q
12 hours
May require skin grafts.
Provide nutritional supplement as needed.
Administer analgesics as needed.
Administer antimicrobials ( topical or
systemic)
Nursing Interventions
Maintain clean, dry skin and wrinkle free
linens.
 Repositions clients in bed at least every 2
hours and every 1 hour if sitting in chair.
 Provide adequate hydration (2000 to 3000
ml/day) and meet protein and calorie
needs
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Prevention of Pressure Ulcers
Deterioration
Systemic Infections
Nursing Considerations
 When planning interventions to promote
wound healing, the nurse understands that
elevated blood glucose will impact on
multiple factors.
 Full thickness wounds heal by secondary
intention and much of the skin and skeletal
muscle will be replaced by connective tissue,
some scar tissue will form.
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Complications and Nursing
considerations
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Applying of antimicrobials ointment is not
included in wet-to-dry dressing.
Client should get pain medication prior to
starting dressing change.
Wet-to-dry dressing is used when there is
minimal eschar to be removed.
A full thickness wound filled with eschar will
require interventions such as surgical
debridement to remove necrotic tissues.
In full thickness skin destruction, the area is
painless because of the associated nerve
destruction.
Chronic corticosteroid use will interfere with
wound healing.
Nursing considerations
Vacuum-Assisted Wound Closure
 Hyperbaric oxygen Therapy
 Surgical debridement and/or wound
grafting.
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Therapeutic Procedures
Burns are 6th leading cause of accidental
death in the U.S.
 Causes – thermal, chemical, electrical,
radioactive agents.
 Results to loss of temperature regulation.
 Loss of sensory function.
 Evaluating extent of damage: need to
know;
1. Type of burning agent
2. Duration of contact
3. Site of injury
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Care of Clients with Burn
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Eyelids
Ears
Nose
Genitalia
And the tops of the hands and feets (
including fingers and toes).
Areas most vulnerable to burns
Superficial
Partial
Thickness
Deep
Partial
Thickness
Full
Thickness
Deep Full
Thickness
Tissue
layer
damage
Epedermis
Entire
epedermis to
some of
dermis
Extend to
deeper layer
of the
dermis
Ertire
Dermis
Entire
dermis and
subq skin
Can not heal
on its own.
Color
Pink to red
Pink to red
Red to white
Black,
brown,
yellow
Black
Blister
No
yes
rare
No
No
Edema
Mild
Mild to
moderate
Moderate
Severe
Absent
Pain
Yes
Yes
yes
Yes and No
Absent
Eschar
No
No
No Yes, soft
and dry
Yes, hard
and inelastic
Yes, hard
and elastic
Tx
No
emergency
care needed
No
emergency
care needed
Depending
on the area,
a local ED
ER at the
scene and
transfer to
burn center
Care and
nearest ED
and transfer
to burn
center
Healing
3-5 days
2 weeks
2-6 weeks
Weeks to
months
Weeks to
months
Classifications
Age more than 60 years
 Burn involves > 40 % total body surface
 Inhalation Injury
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Risk for Death from Burns
Lab values:
CBC, serum electrolyes, BUN, arterial
blood gas (ABGs) fasting blood glucose,
liver enzymes, urinalysis, and clotting
studies.
Initial fluid shift ( first 24 hours after injury
Fluid mobilization ( 48-72 hours after injury
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Diagnostic Procedures
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Assess/monitor:
Head to toe assessment
Airway patency ( esp. burn in the face and in
close door spaces.
Signed hair in the nostrils – inhalation injury
Oxygenation status
V/S, heart rhythm esp. electrical burns
Fluid status
Circulatory status – hypovolemia
Size and depth of burns (BSA) rule of nine,
lund browder.
Assessment
Estimation of Surface Area
 Use a Burn diagram (LUNDBROWDER) to accurately calculate the
area burnt, however do not count skin
with isolated erythema (no blistering)
 As a rough measure, the child's palm
represents about 1% of total body
surface.
 Rule of Nine
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Calculcation of Burned BSA
Size and depth of burns
 Renal function – urine output decreased
first 24 hours.
 Bowel sound – commonly reduced/absent.
 Stool and emesis for evidence of bleeding
(ulcer risk)
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Assessment
Ensure airway patency – intubation , trach
provide O2 if prn
 Maintain thermodynamics ( warm room,
cover with blanket)
 Monitor V/s pulses, cap refill ( check for
evidence of shock.
 Administer fluid ionotropic agents ,
osmotic diureticsas needed to maintain
adequate cardiac output and tissue
perfusion.
 Begin IV and electrolyte replacement .
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Nursing Interventions
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Parkland Formula for Treating Burn Victims.
For burn victims, fluid resuscitation is critical within the
first 24 hours. The amount of fluid resuscitation can be
determined from the percentage of body surface area
(%BSA) involved. "Rule of 9's" can estimate the %BSA.
The Parkland Formula is as follows.
Fluid for first 24 hours (ml) = 4 * Patient's weight in kg *
%BSA
Afterwards, the first half of this amount is delivered in the
first 8 hours, and the remaining half is delivered in the
remaining 16 hours.
The "Rule of 9's" is as follows.
Head and each arm = 9%
Back and chest each = 18%
Each leg = 18%
Perineum = 1%
Burn resuscitation Formula
Keep the client NPO. Administer H2 Antagonists.
Elevate client’s extremities
Encourage client to cough and deep breathe and to utilize
incentive spirometry.
 Administer tetanus prophylaxis per hospital protocol.
 Implement infection control measures. Apply topical
antimicrobials such as Silver Sulfadiazine ( Silvadene
Creame).
 Wound care and dressing changes to prevent scarring and
edema.
 Monitor and assess for pain.
 Provide nutrition support as ordered. Dietician consult is
important for proper caloric and protein needs.
( High protein intake is needed for wound healing)
 Encourage ROM – to prevent immobility and use of splints
to correct positioning.
 Collaborative care.
 Initiate referrals as appropriate.
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Nursing Interventions
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Airway Injury – progressive hoarseness of
voice, brassy cough, drooling and expiratory
sounds that include audible wheeze, crowing
and stridor. Rapid obstruction in short time.
Carbon Monoxide poisoning
Thermal heat injuries such as steam
inhalation.
Chemical Inhalation.
Inadequate Tissue Perfusion – circumferential
burns ( extremities, thorax).
Escharotomy and or fasciotomy to relieve
compartment pressure and/or to facilitate
breathing.
Complications
With chemical burrns, the initial action is
to remove the chemical from contact with
the skin as quick as possible.
 Electrical burns should be considered at
risk for cervical spinal injury and
assessment of extremity movement will
provide baseline data.
 Urine output during emergent phase
should be at least 30-50 ml/hr, when the
client is at greater risk for hypovolemic
shock.
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Care of Client with Burn
See parklands formula:
 Blood pressure of a burn patient during
the emergent phase should be > 90 SBP
and the pulse should be < 120.
 Hydrotherapy leads to loss of sodium from
open burns into the bath water, which is
hypotonic.
 Clients with large burn surface requires a
room temperature of 85 degrees
Fahrenheit during dressing.
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Care of Client with Burn
At the end of emergent phase, capillary
permeability normalizes and the client
begins to diures large amount of urine
with low specific gravity.
 Burn patients ( upper body) should be
placed in fowler’s position to make
ventilation easier.
 No pillows under the head with neck
burns.
 Arms and hands should be extended to
avoid flexure contractures.
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Care of Client with Burns
Systemic antibiotics are not well absorbed
into deep burns because of lack of
circulation.
 Enteral feeding can usually be initiated
during emergent phase at low rate and
increase over 24 to 48 hours to goal rate.
 Parenteral nutrition increases the infection
risk, does not help preserve GI function,
and is not routinely used in burn patients.
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Care of Client with Burns