the integument 12 lecture note powerpoint presentation

The Integument

12Lecture Note PowerPoint Presentation

LEARNING OUTCOME 1Describe normal skin changes associated with

aging.

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NORMAL STRUCTURE AND FUNCTION OF THE SKIN

Skin consists of 15–20% of the total body weight

Epidermis Consists of five continually regenerating and

shedding layers Dermis

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FIGURE 12-1CORPUSCLES AND THEIR DISTRIBUTION IN THE SKIN.

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NORMAL STRUCTURE AND FUNCTION OF THE SKIN

Subcutaneous layers A specialized connective tissue attached to

muscles Contains blood vessels, lymphatic channels, hair

follicles, and sweat glands

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NORMAL STRUCTURE AND FUNCTION OF THE SKIN

Accessory structures Hair Nails Glands

Sebaceous glands Apocrine sweat glands

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NORMAL STRUCTURE AND FUNCTION OF THE SKIN

Function Protection Regulation of immune functions Thermoregulation Vitamin synthesis Sensory receptor for CNS

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SKIN CHANGES ASSOCIATED WITH AGING

Intrinsic factors Genetic makeup and the normal aging process

Extrinsic factors UV lighting Smoking Environmental pollutants

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FIGURE 12-2NORMAL CHANGES OF AGING IN THE INTEGUMENTARY SYSTEM.

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SKIN CHANGES ASSOCIATED WITH AGING

Epidermal changes Thinning Reduced moisture leading to a dry, rough

appearance Mitosis slows after age 50 by 30% Increased healing time Increased risk of infection

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SKIN CHANGES ASSOCIATED WITH AGING

Epidermal changes Rete ridges flatten: in the dermal layer, less

collagen is being produced. The elastin fibers also wear out. Such factors will cause the skin to sag and wrinkle. The rete ridges, meanwhile, will flatten out. This will cause the skin to be fragile.

Increased risk of skin breakdown Reduced melanocytes

Paler complexion Increased risk of UV damage

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SKIN CHANGES ASSOCIATED WITH AGING

Epidermal changes Scattered pigmented areas

Nevi (skin moles) Age spots Liver spots Increased number and size of freckles (clusters of

concentrated melanin) Age spots — also called liver spots and solar lentigines

— are flat gray, brown or black spots. They vary in size and usually appear on the face, hands, shoulders and arms — areas most exposed to the sun. Though age spots are very common in adults older than age 40, they can affect younger people as well.

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SKIN CHANGES ASSOCIATED WITH AGING

Dermal changes Decreased thickness and function begin in 3rd

decade of life Elastin decreases in quality

Wrinkling and sagging Collagen less organized

Loss of turgor

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SKIN CHANGES ASSOCIATED WITH AGING

Dermal changes Reduced vascularity

Paler complexion Capillaries thin and are easily damaged

Senile purpura Easy skin bruising in older people Reduced touch and pressure sensations

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SKIN CHANGES ASSOCIATED WITH AGING

Subcutaneous layer Tissue thins in the face, neck, hands, and lower

legs Visible veins in exposed areas

Hypertrophy of tissue in certain body areas Increased body fat Increased body fat in abdomen and thighs

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HAIR CHANGES WITH AGING Reduced number of functioning melanocytes Replacement of pigmented strands of hair

with nonpigmented hair Hormone levels decline

Loss of hair in pubic and axillary areas Growth of facial hair in women Growth of nasal and ear hair in men

Increased baldness

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NAIL CHANGING WITH AGING

Color changes Dull Yellowing or grayness

Slowed growth Thicker nails prone to splitting

Longitudinal striations Related to damage at the nail matrix (the ROOT

of the nail)

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NAIL CHANGING WITH AGING

Longitudinal pigmented bands Single or multiple brown or black bands on

thumb and index finger Frequently seen in African-Americans over age

20 Increased visibility in the older adult

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GLANDULAR CHANGES WITH AGING

Eccrine or sweat glands Decreased number; decreased ability to regulate

body temperature Sebaceous glands

Increased size; decreased activity; increased water evaporation causes cracked, dry skin

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LEARNING OUTCOME 2Identify risk factors related to common skin

problems of older adults.

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“THE SUN NEVER FORGETS”

Ultraviolet radiation (UVR) Ultraviolet A (UVA)

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“THE SUN NEVER FORGETS” Responsible for premature aging and

decreased immune function Ultraviolet B (UVB): The elderly have reduced

capacity to synthesize vitamin D in skin when exposed to UVB radiation. Intense, intermittent exposures

Basal cell carcinoma Malignant melanoma

Chronic sun exposure Squamous cell carcinoma

Photoaging: refers to the damage that is done to the skin from prolonged exposure, over a person's lifetime, to UV radiation

Actinic keratosis: is a premalignant condition of thick, scaly, or crusty patches of skin

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SKIN TEARS

Traumatic separation of the epidermis from the dermis

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PRESSURE ULCERS

Impact between 1 and 3 million people annually in the United States

Localized injury to the skin and underlying tissue Usually over a bony prominence Results from pressure or pressure and shear

force and/or friction

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PRESSURE ULCERS

High-risk populations Hospitalized patients Individuals over age 65

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CELLULITIS

Acute bacterial infection of the skin and subcutaneous tissue

Risk factors Skin breaks Chronic illness Age-related skin changes

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CONDITIONS OF THE FINGER AND TOE NAILS

Risk factors Trauma Age-related changes Systemic diseases

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LEARNING OUTCOME 3Delineate skin changes associated with benign and

malignant skin types.

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SKIN CANCER IS THE LEADING CANCER IN THE UNITED STATES

Malignancies are associated with the time spent in the sun

Older and light-skinned persons are at an increased risk

Darker-skinned persons may be at risk

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ACTINIC KERATOSIS

Most common precancerous lesion; it is seen more in men than women 1:1,000 will progress to skin cancer

Also known as solar keratosis or senile keratosis

Sore, rough, scaly, erythematous papules or plaques

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BASAL CELL CARCINOMA

Most common skin cancer for Caucasians Metastasis rare Originates in lowest layer epidermis Manifests as small, fleshy bumps

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SQUAMOUS CELL CARCINOMA

Second most common skin cancer for Caucasians

Most common skin cancer for persons with dark skin

Originates in upper levels of epidermis Manifests as flesh-colored erythematous,

scaly plaques, papules or nodules Metastasis can occur

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MELANOMA

Most dangerous skin cancer; responsible for more than three quarters of all skin cancer deaths

Originates in the melanocytes Lesions may be brown, black, or

multicolored; develop nodules or; plaques (a broad papule ) and have a black, irregular spreading outline

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SKIN TEARS

Caused by friction or shearing forces Payne-Martin classification for skin tears

Category 1 Linear or flap tear without tissue loss

Category 2 Tears with partial tissue loss

Category 3 Tears with full thickness complete tissue loss

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PRESSURE ULCERS

The majority occur in persons over age 70 Stages

Stage I: Nonblanchable erythema of intact skin Stage II: Partial-thickness skin loss involving

dermis and/or epidermis Stage III: Full-thickness skin loss involving

damage or necrosis of subcutaneous tissue that may extend to underlying fascia

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PRESSURE ULCERS

Stages Stage IV: Full-thickness skin loss with extensive

destruction, tissue necrosis, or damage to muscle, bone, or supportive structures

Types of pressure ulcers Necrosis of epidermis and dermis Deep or malignant pressure ulcers Full-thickness wounds

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PRESSURE ULCERS

Mechanisms of Tissue Breakdown Occlusion of blood flow to the skin Damage to the lining of the arterioles and

smaller vessels Direct occlusion of blood vessels by long periods

of pressure

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WOUND HEALING

Phases Inflammation and destruction Proliferation Maturation

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DELAYED WOUND HEALING

A wound that does not heal within 6 weeks is termed chronic

Signs Wound size is increasing Exudate, slough, or eschar is present Tunnels, fistula, or undermining has developed Epithelial edge is not smooth and continuous and

does not move toward wound

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DELAYED WOUND HEALING

Causes Aging Inadequate nutrition Inadequate blood supply Immunocompetence Damage to wound

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CELLULITIS

Acute bacterial infection of skin Characterized with inflammation, intense

pain, heat, redness, and swelling

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NAIL PROBLEMS

Fungal infection Inflammation of the nail matrix Hypertrophy of the nail plate

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LEARNING OUTCOME 4List nursing diagnoses related to common skin

problems.

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THREE MAJOR NURSING DIAGNOSES FOR INTEGUMENT PROBLEMS

Risk for Impaired Skin Integrity Impaired Tissue Integrity

Damage to integument, cornea, or mucous membranes

Impaired Skin Integrity Damage to epidermal or dermal tissue

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NURSING DIAGNOSES FOR INTEGUMENT PROBLEMS

Impaired Skin Integrity related to lesions and inflammatory response

Risk for Impaired Skin Integrity related to physical immobility

Risk for Impaired Skin Integrity related to decrease skin turgor

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NURSING DIAGNOSES FOR INTEGUMENT PROBLEMS

Risk for Impaired Skin Integrity related to the effects of pressure, friction, or shear

Risk for Impaired Tissue Integrity related to decreased circulation

Risk for Infection related to pressure ulcer

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LEARNING OUTCOME 5Discuss the nursing responsibilities related to

pharmacological and nonpharmalogical treatment of common skin problems.

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DIAGNOSTIC TESTS FOR INTEGUMENTARY DISORDERS

Total body photography: is established techniques for detecting and monitoring dysplastic and atypical nevi for early detection of malignant cutaneous melanomas

Skin biopsy Wound cultures Laboratory tests

Serum albumin Serum transferrin Lymphocyte count

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PHARMACOLOGIC TREATMENT OPTIONS

Topical antifungal agents Topical antibiotics Systemic antibiotics Selected antimicrobials Aminoglycosides Prescription creams

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NONPHARMACOLOGICAL INTERVENTIONS

Patient education Awareness and reporting of skin cancer Characteristics of darker skin

Prevention Guidelines on sun exposure Wearing protective clothing

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NONPHARMACOLOGICAL INTERVENTIONS Treatment

Basal cell carcinoma and squamous cell carcinoma

Malignant melanoma Excisional biopsy for diagnosis Wide excision for cure Adjuvant therapy

Chemotherapy Chemoimmunotherapy Regional radiation therapy Biotherapy

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NONPHARMACOLOGICAL INTERVENTIONS

Preventing skin tears Avoid pulling or sliding Pad surfaces Keep environment free of obstacles Maintain safe environmental lighting Keep skin moist Use tape cautiously Encourage long sleeves and pants

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NONPHARMACOLOGICAL INTERVENTIONS Managing skin tears

Clean with normal saline or other nontoxic cleaner

Pat or air dry Gently place torn skin in its approximate normal

position Apply dressings and change per protocol or

product requirements Photograph if permitted Document all findings

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NONPHARMACOLOGICAL INTERVENTIONS

Managing cellulitis Treat acute infection Immobilization Elevate limb Pain relief Possible anticoagulant therapy Prevent further complications

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NONPHARMACOLOGICAL INTERVENTIONS

Management of Fingernail and Toenail Problems Onychomycosis: means fungal infection of the nail

. It is the most common disease of the nails and constitutes about a half of all nail abnormalities. Pain management Patient education Oral antifungal agents

Chronic paronychia: Paronychia is one of the most common infections of the hand. Clinically, paronychia presents as an acute or a chronic condition. It is a localized, superficial infection or abscess of the paronychial tissues of the hands or, less commonly, the feet Keep affected nails dry Antibiotics

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OnychomycosisChronic paronychia

NONPHARMACOLOGICAL INTERVENTIONS

Management of Fingernail and Toenail Problems Onychogryphosis:is a hypertrophy that may

produce nails resembling claws or a ram's horn, possibly caused by trauma Keep nails short Podiatry consultation: is a branch of medicine devoted

to the study, diagnosis and treatment of disorders of the foot, ankle and lower leg.

Surgical intervention

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LEARNING OUTCOME 6Explain the nursing management principles related

to the care of pressure ulcers.

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THE BRADEN SCALE

Used to assess pressure ulcer risk Assesses mobility, activity, sensory

perception, skin moisture, friction, shear, and nutritional status

Used as an adjunct tool to nursing assessment and clinical judgment

Can be found at this link http://www.bradenscale.com/images/bradenscale.pdf

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MOBILITY AND ACTIVITY CONSIDERATIONS

Repositioning q2h Ensure proper positioning Avoid prolonged sitting Increase activity Choose a mattress surface based on the

assessment and diagnosis * a low air loss bed is indicated for all

pressure ulcers in any stage * a water mattress for stage 1, 2 and 3 * an alternating pressure mattress for stage 1

and 2.

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SKIN CARE FOR OLDER PERSONS

Correct bathing procedures Keep skin clean and dry Lubricate with non–alcohol-containing

moisturizer Prevent injury Evaluate and manage incontinence Provide dietary support

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NURSING CARE OF PRESSURE ULCERS

Assess and stage the wound Debride necrotic tissue Cleanse

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TREATMENT

Avoid contamination Colonization: presence and proliferation of

organism in the wound with no signs of infection.

Infection: presence and proliferation of organism in the wound with signs of infection

Topical antibiotics Systemic antibiotics

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NURSING CARE AND DOCUMENTATION OF SKIN PROBLEMS

Assess risk factors Provide nursing interventions to minimize

skin breakdown Document care Evaluate patient status

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KNOWLEDGE-BASED DECISION MAKING

Current literature Share with colleagues, patients, and their

significant others

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HELPFUL QUESTIONS WHEN ASSESSING WOUND CARE PRODUCTS

What is the stage, drainage, moisture, or eschar?

What are the wound needs? What products are available to manage the

wound?

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ONGOING EVALUATION OF NURSING CARE

Family situation Available resources Patient needs and requests Patient and family understanding of the

teaching and plan of care

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