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Lecture 2B

Lecture 2B. Fluid & electrolytes (Chapter 7) Integumentary System (chapters 44-45). 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

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Lecture 2B

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  1. Lecture 2B Fluid & electrolytes (Chapter 7) Integumentary System (chapters 44-45)

  2. Structure & Function of the Integumentary System • 2 regions • Epidermis • Dermis

  3. Epidermis • Location: • Outermost part • Melanin • Color • Protects from UV light • Keratin • Water repellent

  4. Epidermis • Function • Protect!

  5. Dermis • Location • Deeper layer • Contains • Blood vessels • Nerve endings • Lymphatic vessels • Hair follicles • Sebaceous glands • Sweat glands

  6. Skin Assessment • History • C/O • Onset • Duration • Characteristics • Relief factors • Exacerbation • Changes • Skin • Meds

  7. Skin Assessment • Assess all skin areas • Redness • Swelling • Lesions • Pain • Measure lesions

  8. Common skin lesions • Macule, patch • Flat, nonpalpable change in skin color. • Macule < 1 cm • Patch > 1 cm • i.e. freckles, Mongolian spots

  9. 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

  10. Common skin lesions • Nodule, tumor • Elevated, solid palpable mass extending deeper into the dermis than a papule • Nodule • 0.5 – 2cm • Tumor • > 2cm

  11. 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

  12. 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

  13. Common skin lesions • Pustule • Elevated pus-filled vesicle or bulla with circumscribed border. • i.e. acne, impetigo, carbuncles

  14. Older skin • Normal changes • iSubcutaneous tissue • Dermal thinning • iElasticity • iTurgor • iHair and nail growth

  15. 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

  16. Pressure ulcers • AKA • Decubitus ulcers • Ischemic lesions • Caused by • External pressure • Friction • Shear

  17. Pressure ulcer development

  18. High Risk Areas for Pressure ulcers • Bony prominence • Heels • Greater trochanter • Sacrum • Ischia • Shoulder

  19. Usual pressure ulcer locations • Over Bony Prominences • Occiput • Ears • Scapula • Spinous Processes • Shoulder • Elbow • Iliac Crest • Sacrum/Coccyx • IschialTuberosity • Trochanter • Knee • Malleolus • Heel • Toes

  20. Other locations… • Any skin surface subject to excess pressure • Examples include skin surfaces under: • Oxygen tubing • Urinary catheter drainage tubing • Casts • Cervical collars

  21. 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

  22. High risk clients: pressure ulcers • Immobile • Elderly • Incontinence • Nutritional deficit • Smoking

  23. Complications • Pain

  24. 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

  25. Complications • Pain • Infection

  26. Infection COMPLICATIONS • Sepsis • Localized infection • Cellulitis • Osteomyelitis

  27. Complications • Pain • Infection • Quality of life • Cost • Death

  28. Mortality • 40% die per year • 60% die within 1 year after hospital discharge

  29. Prevention!!!General Skin Care • Assess • Clean & Dry • Avoid massage • i Pressure • Well balanced nutrition

  30. Protect skin from Moisture • Clean • Moisturize • Barriers • Bowel & Bladder program

  31. Pressure Reduction • Rehabilitation  h mobility • Repositioning • Pressure reduction devices • Float Heels • No sliding

  32. nutrition and fluid Support • Dietician • Preferences • Provide assistance & time • Snacks and fluids • Supplements • Assess lab values

  33. Pressure Ulcer Monitoring and Treatment

  34. Description of Ulcers • Stage Ulcer • Location • Size • Wound bed • Granulation tissue • Necrotic tissue • Wound edges • Drainage • Infection • Pain

  35. STAGING OF PRESSURE ULCERS Stage I: Persistent nonblanchableerythema of intact skin.

  36. 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.

  37. 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.

  38. 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

  39. 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.

  40. Granulation tissue • Intermediate step in healing • Very fragile • Appearance: Shiny red & grainy • When inadequate blood flow exists, granulation tissue may pale in color.

  41. 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)

  42. Eschar • Dead tissue, • Color: • Tan, brown, black • Leathery, dry hard • Soft, with purulent discharge • Slimy.

  43. 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)

  44. PREVENTING HEEL ULCERS • Assess heels of high-risk patients every day • Use moisturizer on heels (no massage) twice a day • Apply dressings to heels:

  45. 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

  46. PRESSURE-REDUCINGSUPPORT SURFACES **Use for all older persons at risk for ulcers**

  47. 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

  48. Dressing • Keep wound bed moist • Keep surrounding tissue clean & dry • Do not use antiseptic agents

  49. Types of Dressings • Gauze • Transparent films • Hydrocolloid • Hydrogel • Alginates • Foam • Composite

  50. 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

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