Transcript Alteration

Nursing:
A Concept-Based Approach to Learning
VOLUME ONE | SECOND EDITION
MODULE
21
Tissue Integrity
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Definition
• A nurse’s most important responsibilities
include assessing and monitoring skin
integrity; identifying problems; and
planning, implementing, and evaluating
interventions to maintain skin integrity.
2
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
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The Concept of Tissue Integrity
• Integumentary system includes:
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Skin
Hair
Nails
Sebaceous, sweat, and mammary glands
• Important nursing functions
 Maintain skin integrity
 Promote wound healing
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Normal Presentation of the Skin
• Functions of the skin
 Protect underlying tissues
 Nerves, skin enable perception
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•
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Touch
Pain
Pressure
Heat
 Body temperature regulation
 Synthesize vitamin D
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Physiology Review
• Epidermis
 Outermost layer: stratum corneum
• keratin
 Stratum granulosum
 Stratum spinosum
 Stratum basale
• Melanin
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
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Physiology Review,
continued
• Dermis
 Second, deeper layer of skin
 Papillary layer
 Reticular layer
• Subcutaneous tissue
 Loose connective tissue
 Stores half of body's fat cells
 Cushions, insulates
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Genetic and Lifespan
Considerations
• Changes normal in the aging process
 Occur slowly
 Skin's thickness and collagen content
decrease with age which causes skin to
become thinner and less elastic over time
 Epidermal cell turnover slows
 Subcutaneous fat decreases and is
redistributed
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Genetic and Lifespan
Considerations, continued
• Epidermis of older individual
 Atrophic
 Stratum corneum replacement slows
 Skin takes on a rough, dry appearance
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Genetic and Lifespan
Considerations, continued
• Epidermis of older individual
 Reduced cell turnover has a negative effect
on skin's barrier function and healing
processes
 Decreased exchange of nutrients between
the layers
 Melanocyte activity, function and
distribution decreases
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Genetic and Lifespan
Considerations, continued
• Dermis
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Becomes thinner with aging
Fibroblasts decrease in number
Collagen decreases
Elastin quality declines, quantity increases
 wrinkling, sagging
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Genetic and Lifespan
Considerations, continued
• Subcutaneous tissue
 Distribution of remaining fat changes
 Tissue loses fat during the aging process
 Thins  prone to fractures and pressure
sores over bony areas
 Problems with thermoregulation
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
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All Rights Reserved
Alterations and Manifestations
• Skin disorders
 Infectious
 Inflammatory
 Neoplastic
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
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Alterations and Manifestations,
continued
• Skin lesions
 Vary in shape, color, and texture
characteristics
 Examples: Table 21-2 and Table 21-3
Nursing: A Concept-Based Approach to Learning
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Alterations and Manifestations,
continued
• Wounds
 Intentional (Table 21-4)
• Occur during therapy
 Unintentional (Table 21-4)
• Accidental
 Degree of contamination
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•
•
•
Clean wounds
Clean contaminated wounds
Contaminated wounds
Dirty, infected wounds
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Wounds-Drainage…what does it
mean?
• Serous
• Purulent
• Serosanguineous
• Sanguineous
15
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Alterations and Manifestations,
continued
• Untreated wounds
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Control severe bleeding
Prevent infection
Control swelling, pain
Assess for signs of shock
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Wounds-Repair
• Partial-Thickness:
 Example: Surgical wounds
 Involve dermis and epidermis
 Heal by primary intention (page 1507)
• Full-Thickness:
 Example: Pressure ulcers
 Involve dermis, epidermis, subcutaneous,
muscle and bone
 Heal by secondary intention (page 1507)
17
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Primary and Secondary
Intention
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
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Alterations and Manifestations,
continued
• Treated wounds
 Observe wound or dressing
 Presence of pain
 Exemplar 21.4
Nursing: A Concept-Based Approach to Learning
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Concepts Related to Tissue
Integrity (Page 1449)
• Immunity
 Immune system assessment
• Infection
 Chain of infection
 Standard precautions
 Infection assessment
• Mobility
 Mobility assessment
 Independent interventions and therapies
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Risk Factors
• Age: circulation slows; clotting process changes;
inflammatory response becomes impaired; fibroblastic
activity and collagen synthesis decrease
• Obesity: adipose tissue provides a weak defense against
microbial invasion; impairs delivery of nutrients to the
wound; risk for wound dehiscence and infection
• Smoking: vasoconstriction, decreased hemoglobin levels,
and impaired oxygenation; hypercoagulability
• Medications: drugs affecting the immune response,
anticoagulants, aspirin, nonsteroidal anti-inflammatory
drugs, steroids
• Stress: triggers release of catecholamines and
vasoconstriction
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Screenings
• Regular self-examinations
 Identify problems as they occur
 Develop familiarity with skin
• Professional examinations
 Common for identifying skin disorders
 Dermatologist
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Assessment
• Be alerted to skin abnormalities even
when providing routine care
• Remove medical, assistive devices to
assess skin condition underneath
• Detect variations in skin color using good
lighting
Nursing: A Concept-Based Approach to Learning
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Nursing Assessment
• Review of systems
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Skin diseases
Previous bruising
General skin condition
Skin lesions
Usual healing
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Assessment Interview
• Page 1456
• When did you first notice your current skin
problem?
• Are lesions slow to heal on your skin?
• Have you noticed any drainage from your
skin lesions?
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Nursing Assessment
• General
Assessment
• Color,odors
• Impaired Skin
Assessment
• Lesions
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Turgor
Edema
Hair
Scalp
Nails
• Temperature
• Texture
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Assessment
Skin Cancer Focused
• Health questionnaire
 Changes in mole, wart, birthmark, scar
 Sunburn history
 Tanning
• Skin assessment:
 Head to toe order
 Inspect, palpate skin
 Measure and record all skin lesions
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Diagnostic Tests
• Skin biopsy
• Cultures
• Infection: Immunofluorescent studies,Wood
lamp, Tzanck test,Potassium hydroxide
• Allergy: Patch tests
• Laboratory Data
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Leukocyte count
Hemoglobin
Blood coagulation
Albumin level
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Wound Culturette Tube
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Nursing Diagnosis
Risk for infection
Impaired tissue
integrity
Imbalanced nutrition: less than
body requirements
Impaired
physical mobility
Ineffective
peripheral tissue
perfusion
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Acute or chronic
pain
Impaired skin
integrity
Risk for impaired
skin integrity
Copyright © 2015, 2011 by Pearson Education, Inc.
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Planning
• Goals:
 Control severity
 Prevent infection
 Promote healing
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Planning
• Expected outcome
 Patient’s skin will show evidence of
healing within 3 days, as evidenced by a
decrease in redness, a decrease in
drainage, an increase in pink, clean
tissue.
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Independent
•
•
•
•
•
Home remedies
Good hygiene
Teach infection prevention measures
Exercise
Nutrition
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Independent
• Topical skin care and incontinence
management
• Protect bony prominences, skin barriers for
incontinence.
• Positioning
• Turn every 1 to 2 hours as indicated.
• Support surfaces
• Decrease the amount of pressure exerted
over bony prominences.
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
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Collaborative
• Treatment in some cases requires
pharmacologic therapy
 Over-the-counter
• Lice, minor sunburn
 Extensive or long-term prescription therapy
• Eczema, dermatitis
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Collaborative
• Corticosteroids
• Hydrocortisone
• Antibiotics
• Antifungals
• Clotrimazole (Lotrisone)
• Creams
• Curel
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Evaluation
• Was the etiology of the skin impairment
addressed? Were the pressure, friction, shear,
and moisture components identified; and did
the plan of care decrease the contribution of
each of these components?
• Were issues such as nutrition assessed and a
plan of care developed that provided the
patient with the calories to support healing?
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved
Alterations and Therapies
Tissue Integrity (Page 1453-4)
Alteration
Manifestations and Treatment
• Impaired Skin
Integrity
• Pain
• Inflammation
• Infection
• Pruritus
• Eschar
• Edema
• Exudate
• Bruising
Nursing: A Concept-Based Approach to Learning
Volume One, Second Edition
Copyright © 2015, 2011 by Pearson Education, Inc.
All Rights Reserved