premed. functional review protector and barrier between internal organs and external environment...
TRANSCRIPT
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PREMED
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Functional ReviewProtector and barrier between internal
organs and external environmentBarrier against foreign body intrusions
against invading bacteria and foreign matter
Transmits sensation – nerve receptorsallows for feelings of temperature, pain,
light touch and pressure
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Skin Functions
Regulates body temperatureregulates heat loss
Helps regulate fluid balance absorbs water prevents excessive water & electrolyte loss. Slow loss up to 600 ml daily by evaporation
Immune Response Functioninflammatory process
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Skin Functions Vitamin production
exposure to UV light allows for the conversion of substances necessary for synthesizing vitamin D
Necessary to prevent osteoporosis, rickets
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Skin Assessment Visual inspectionPalpation Olfactory sensesAdequate lightingRemove necessary clothing while
providing respect and privacyAppropriate client positions
p.568
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Visual inspectionSkin color:PalorCyanosis JaundiceErythemaHyperpigmentationHypopigmentation – vitiligo
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Visible changes if the SkinChanges in skin color texture
Eczema, infectionsAssess the vascularity & hydration of skinEdema – swelling, pitting edema
1+ 2 mm 3+ 6 mm 2+ 4 mm 4+ 8 mm p.579
Nails – configuration, consistency, color p.579
Hair – color and distribution, aloplecia, location
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Gerontology Considerations
Watch for significant changes in aging:Decrease immunity functionsSusceptibility to infectionsPoor nutritionDecrease collagen production – loss of
subcutaneousThinning of epidermal skin layersIncrease skin problems
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Gerontology ConsiderationsTaking more medicationsExcessive environmental exposureDryness, wrinklingUneven pigmentationVarious proliferative lesions
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Description Light skin Dark skin
Cyanosis - bluish Bluish tinge Ashen gray
Pallor - paleness Loss of rosy glow Ashen gray (drk skin)
Yellowish brown (brown skin)
Erythema - redness Visible redness Diffused; rely on palpation of warmth or edema
Petechiae – small size pinpoint ecchyumosis
Purplish pinpoints
Usually invisible; check oral
Mucosa, conjunctiva, eyelids, conjunctiva covering eyeballs.
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Description Light skin Dark skin
Jaundice - yellow Yellow sclera, skin, fingernails, soles, palms, oral mucosa
Reliable on sclera, hard palate, palms and soles.
Ecchymosis – large diffused bluish black
Purplish to yellow-green
Difficult to see, check mouth or conjunctiva
Brown-Tan – cortisol deficiency, increased melanin production
Bronze; Tan to light brown
Easily masked.
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Assessing LesionsVary in size, shape and causePrimary vs. Secondary Erruptions: cysts, wheals, bullous,
pustules, psoriasis, eczyma, vesicles, bullae, nodules, papules
Discoloration: macules (café-au-lait),
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Skin Lesions Etiology
Infections –herpes, impetigo, HIV, melanoma
Toxic chemicals: skin irritationPhysical trauma: burns, lacerationsHereditary factorsExternal factors: allergens, contact
dermitisSystemic diseases: measles, lupus,
nutritional deficiency
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Skin LesionsNursing Process Care:
Assessment: descriptions; pt. history, causative factors
Evaluation of skin – identify problemNursing Diagnosis Interventions for skin care to promote
healing and prevent further injuryPain management & comfortInfection controlNursing evaluation & reassessment
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Systemic Skin Diseases: Skin Disorders in Diabetes
Diabetes Dermapathy – shin spots, caused by break- down of small vessels that supply the skin.
Stasis Dermatitis – compromises circulation to the distal extremities due to damage of larger vessels.
Problem: Injuries heal slow; increase risk for ulcerations; risk for skin infections
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Fungal infections of the SkinTinea Pedis (athlete’s foot)Tinea Corporis (ringworm of the body)Tinea Capitis (scalp ringworm)Tinea Cruris (ringworm of the groin)
Jock itch jock, common in diabetes.Tinea Unguium (ringworm of the nails)
onychomycosis
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Parasitic InfectionsPediculosis capitis - licePediculosis corporis/pubisSarcoptes scabiei – scabies
Raised burrows found between fingers, wrists, elbows, nipples, feet, groin, gluteal folds, penis, scrotum
Poor hygienic living conditionsIncrease; contagiousSecondary lesions: vesicles, papules, crust,
excoriations
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Parasitic InfectionsAppear 4 wks after exposure Elderly patients from long term facilitiesLindane, crotamiton (Eurax), permethrin
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Nursing DiagnosisSkin Impairment r/t:GOAL:
Protect the skinPrevent secondary infectionsPromote healing
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Skin Care
Review of wound dressings
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Wound DressingsOcclusive – airtight cover applied to skin
lesionsWet –(obsolete) wet compresses applied on
acute weeping, inflamed lesionsMoisture-retentive –more efficient wet
drsg for removing excudate: impregnated with saline, petrolatum, zinc-saline, hydrogel, antimicrobial agents. Avoids maceration , less infections, scarring & reduces pain.
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Wound DressingsHydrogels – polymers with 90% water
content
superficial wounds, abrasions, skin graft sites, draining venous ulcers
Hydrocolloids –impermeable to water, O2
Remain intact during bathing.Produce foul-smelling yellowish covering
May leave on wound for 7 daysPromote debridment & granulation tissue
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Wound DressingsFoam – hydrophilic absorption and
hydrophobic backing to prevent leaking of exudateNonadherent; require secondary dressing
Used over bony areas and weeping wounds
Calcium alginates – absorbent fiber packing made from seaweed.Absorbes exudate, best for macerated wounds, packing deep wounds, sinus tracking, heavy drainage - nonadherent
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Muchas Gracias Al final..