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Nursing care of the integumentary System
 

Nursing care of the integumentary System

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Janette Bisbee, RN-BC, BSN, NHA

Janette Bisbee, RN-BC, BSN, NHA
Walden University
NURS 6510A-18
Synthesis Practicum

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  • We’re going to talk about the integumentary system, or skin and how you can care for your patients in this regard. Skin is a body organ, just like liver and kidneys, and, in fact, is the largest organ of the body. Your skin can go into “failure” at the end of life, just like your other body organs shut down. When that occurs, skin break down sometimes happens, which we will discuss in more detail in the next set of slides.
  • The skin is composed of two primary layers . The thickness of the skin varies from extremely thin over the eye lids (hence wrinkles) to thick over the palms of the hands and the soles of the feet. The Epidermis is the protective layer. It shields underlying tissue from water loss and injury and prevents entry of disease-producing microorganisms. The Dermis supports the epidermis and is well vascularized. It nourishes the epidermis and regulates body temperature. The subcutaneous layer is called the fatty layer. This functions as a heat insulator for the body. As long as the skin remains intact and healthy, its physiological function remains optimal.
  • Here is a cross section of the skin. You can see on the far right the epidermis, dermis and subcutaneous tissue and the structures of each. The outermost layer, the epidermis, continually generates new cells to replace dead cells. Note that the dermis is the thickest layer with the most going on. It’s where sweat glands, sebaceous glands (oil producing) and hair follicles originate and it’s rich with blood vessels. Melanocytes produce pigment, or color of the skin. Pacinian corpuscles are nerve endings. The subcutaneous level contains blood vessels, nerves, lymph and loose connective tissue filled with fat cells . The fatty tissue functions as a heat insulator for the body. The skin often reflects a change in physical condition by alterations in color, thickness, texture, turgor, temperature and hydration.
  • PROTECTION : Keratin (structural material) in the Epidermis protects from injury by corrosive materials and inhibits proliferation (to grow or multiply) of microorganisms. Dermis provides fibroblasts for healing and collagen fibers for mechanical strength. Subcutaneous layer is a shock absorber . HOMEOSTASIS: Epidermis with low permeability to water prevents systemic dehydration and electrolyte loss . Dermis has lymphatic and vascular tissues which can respond to inflammation, injury and infection . TEMPERATURE REGULATION: Epidermis has sweat glands (sudoriferous ) which allow dissipation of heat via evaporation . Dermis has vasculature which promotes or inhibits heat conduction by dilation or construction . Subcutaneous has fat cells which act as insulators and assist in retention of body heat. SENSORY ORGAN : Epidermis transmits sensations thru neuroreceptors. Dermis has an extensive network of nerve endings relaying sensation to the brain. Subcutaneous contains large pressure receptors . EXCRETION & SECRETION: In the Dermis , sebaceous glands produce sebum which lubricates skin & hair . Sweat glands promote heat loss via evaporation . VITAMIN SYNTHESIS: Epidermis converts sunlight to Vitamin D. PSYCHOSOCIAL: Body image alterations can be affected by disease, age, appearance (loss of limb, for example).
  • ( Read Slide ) Diaphoresis may be a new word for you (sweating). So, you’ll say (and document) that a patient is diaphoretic (not sweating like a pig). While it’s not always attractive, perspiration plays a very big role in homeostasis ( keeps body stable and functioning within normal range.)
  • AGE: Newborns are unable to control body temperature because temperature control mechanisms are immature . A newborn loses up to 30% of body heat thru the head (which is why they wear those cute little caps in the hospital.) Elderly : Average body temp of older adults is lower (36 C or 96.8 F). Older adults are sensitive to temperature extremes because of thinner skin, poor vasomotor control, reduced amounts of subcutaneous tissue, reduced sweat gland activity and reduced metabolism. EXERCISE: Increases metabolism because increased heat production increases body temperature . HORMONE LEVELS: Women generally experience greater fluctuations in body temperature than men. Temperature fluctuations are greatest during menstruation and menopause . (Which is why some of us of a certain age stick our heads in the freezer.) CIRCADIAN RHYTHM: Body temperature can change from 0.5 degrees to 1 degree C during a 24 hour period . Lowest temperatures are between 1:00 and 4:00 AM, and temperature rises until 6:00 PM. STRESS: Physical and emotional stress an increase body temperature. ENVIRONMENT: Extreme heat or cold can affect body temperature .
  • Hyperthermia is related to the inability of the body to promote heat loss or reduce heat production. Advanced hyperthermia related to environmental factors are called Heat Stroke or Heat Exhaustion , both of which can be deadly. Heat Stroke is defined as a body temperature of 40 C or 104 F and the very young or the very old are most at risk. Signs and symptoms include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps with an increased HR and lowered BP. You know the victim is in serious trouble when they no longer sweat and have hot, dry skin and this is a medical emergency. In Heat Exhaustion, profuse diaphoresis occurs and results in excess water and electrolyte loss. This, again, is caused by environmental heat exposure. Hypothermia can be caused accidently by prolonged exposure to severe cold or intentionally such as during surgery in order to reduce metabolic demand. Accidental hypothermia usually occurs gradually. When skin temperature falls below 35 C or 94 F the patient exhibits uncontrolled shivering, loss of memory, depression and poor judgment. HR, respiratory rate and BP all fall. The skin becomes cyanotic (blue). Hypothermia can be classified as mild (34-36 C, 93.2-96.8) moderate (30-34 C, 86-93.2 F) or severe (less than 30 C or less than 86 F). Frostbite occurs when the body is exposed to subnormal temperatures to the point that ice crystals form inside the cell and permanent circulatory and tissue damage occurs . What are areas particularly susceptible to frostbite ? (ears, nose, toes, fingers).
  • Pyrexia is another word for fever. NORMAL adult BODY TEMP IS a range from 96.8 TO 98.6 (it’s important to establish a baseline upon admission, as everyone is different.) My norm is your high. ( Read Slide ) Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate.
  • When inflammation becomes systemic (throughout the body), fever can occur . Allergies can cause fever and often have corresponding rashes . Causes of infection need to be identified and that can be done via cultures (UTI, Surgical or traumatic wound, Respiratory tract, bloodstream). Drug reactions can cause fevers . Fever in the patient with Cerebral or Traumatic Brain Injury may lead to poor outcomes. Idiopathic fever is FUO (what does that mean?) Fever of unknown origin is a fever with no apparent source.
  • Symptoms of Fever (read slide ). Malaise? (General discomfort, lack of well being). What is tachycardia (accelerated heart rate over 100 beats/minute). Tachypnea (accelerated breathing over 20 breaths/minute) DELIRIUM IN EXTREME CASES
  • TAKE EXCESS BLANKETS OFF PATIENT/fan/keep bedding dry, but don’t chill the patient/keep environment cool but not cold . Very important to stay hydrated so encourage fluids due to fluid loss through sweating . REDUCE ACTIVITY to minimize heat production. Promote comfort (cool wash cloth, oral care because mouth dries out) Assess temperature frequently. Administer antipyretic medications as ordered
  • ASPIRIN CLASSIFIED AS ANTYPYRETIC, ANTI-INFLAMMATORY, ANALGESIC SIDE EFFECTS : TINNITUS, DIZZINESS, N/V/, GI BLEED, H/A, DROWSINESS, MAY BE GIVEN ORAL, RECTAL, DOSE DEPENDS ON AGE, USUALLY 325-650 MG PO FOR ADULTS GIVE WITH FOOD , CHECK TEMP TYLENOL-ACETAMINOPHEN, ANTIPYRETIC, ANALGESIC FOR MILD PAIN AND FEVER SIDES :LIVER FAILURE, RENAL FAILURE, RASH, GIVEN PO OR RECTAL, 325-650MG FOR ADUTLTS, NEVER EXCEED RECOMMENDED DOSE AND DO NOT TAKE FOR LONG PERIODS OF TIME, GIVE WITH FULL GLASS OF WATER Ibuprofen-Motrin, Advil. Analgesic, antipyretic, anti-inflammatory . Side effects : Anxiety, constipation, stomach pain, hives, difficulty breathing Dose: 200-400 mg q 4-6 hours for adults. Take with food or milk to avoid upset stomach.
  • Now change our focus to hypothermia or low body tempuerature . Due to: EXCESSIVE HEAT LOSS, INADEQUATE HEAT PRODUCTION TO COUNTERACT LOSS, IMPAIRED HYPOTHALAMIC THERMOREGULATION Vital Signs : DECREASED HR (SLOW, WEAK PULSE), DECREASED RESP. RATE, DECREASED BP
  • ( Read slide ). In severe cases, these are the folks who are seemingly unconcerned about their condition and just want to sleep .
  • The primary treatment is to prevent further decrease in body temperature . Replace wet clothes with dry ones, wrap patient in blankets. Conscious patient can benefit from drinking warm fluids . Place heating pads or blankets next to areas of the body that lose heat the quickest. COVER PTS’S HEAD
  • Order should include body site to be treated and the type, frequency, and duration of application.
  • Before applying heat or cold therapies, assess the patient’s physical condition for signs of potential intolerance to heat and cold . Observe the area to be treated . Look for open areas to the skin . Include in your assessment the neurological system to determine if the patient can sense extremes to heat or cold . Is the patient taking any medication which makes them sensitive to temperature fluxuations ? Consider the patient’s age (elderly have thin skin ) and their cognitive status (can they cooperate with intervention ?) Consider presence of malignancy, renal function, size/depth of wounds, edema, abdominal pain, oral pain . Ensure the condition of the equipment that you’re going to use and that you’ve been adequately trained to use it safely.
  • WHEN TO USE HEAT : ARTHRITIS, DJD, MUSCLE STRAINS WHEN NOT TO USE : FIRST 24HRS AFTER TRAUMATIC INJURY, ACTIVE HEMORRHAGE, LOCALIZED TUMOR, SKIN DISORDER CAUSING REDNESS OR BLISTERS MOIST HEAT :AQUA KA PAD, HOTPACKS, WATER BOTTLE, SOAKS, BATHS SUCH AS WHIRLPOOL OR SITZ DRY HEAT : HYPERTHERMIA BLANKETS, RADIANT HEAT WARMERS, ULTRAVIOLET LIGHTS, HEATING PADS, CHEMICAL PACKS, HEAT LAMPS-NO LONGER THAN 20 MINUTES AND CHECK FREQUENTLY CONTINUOUS HEAT DAMAGES EPITHELIAL CELLS, CAUSING REDNESS, LOCALIZED TENDERNESS AND EVEN BLISTERING to be careful of burns. Moist heat reduces drying of skin and penetrates into tissue layers, however prolonged use can macerate (make too moist) skin and has greater risk of burns because moisture conducts heat. Dry heat has less risk of burns and does not cause skin maceration. Dry heat increases sweating (body fluid loss) and does not penetrate into deep into tissues. Be extremely cautious not to cause burns. Stay with pt. who is unable to sense temperature change or to move away from temperature source or who has cognitive issues . Use equipment only as it is meant to be used. Keep call light in reach . Teach patient to report discomfort immediately .
  • ( Read slide .) COLD USED FOR TRAUMA AS IN SPRAINS, FRACTURES, MUSCLE SPASMS (RICE) BURNS, JOINT TRAUMA, SUPERFICIAL LACERATIONS AND PUNCTURES DON’T USE : OPEN WOUNDS, IMPAIRED CIRCULATION, ALLERGY OR HYPERSENSITIVITY TO COLD BE ALERT TO : NEUROSENSORY IMPAIRMENT, IMPAIRED MENTAL STATE, IMPAIRED CIRCULATION, OPEN WOUNDS MOIST COLD -cold COMPRESSES-CRYOCUFF, TEPID BATHS DRY COLD : COOLING OR HYPOTHERMIA BLANKETS, ICE PACKS, CHEMICAL PACKS Observe for adverse reactions such as burning or numbness, mottling (purplish or blotchy color), redness, extreme paleness, bluish skin discoloration. Safety precautions are the same for use of heat. Know what you’re doing, use equipment as it is intended to be used, stay with someone who can’t remove the cold application, keep call bell in place, educate.
  • Skin colo r varies from person to person and from body part to body part. Note if the skin is unusually pale or dark (look for pallor or cyanosis, erythema (redness), bruises, any variation from normal. Texture : refers to the character of the surface of the skin and how the deeper layers feel. Should be smooth, soft, even and flexible . Thickness : thicker over palms of hands and soles of feet. Thinner and wrinkled in elderly because of decreases in collagen, subcutaneous fat and sweat glands. Turgor refers to the elasticity of the skin. Skin loses elasticity with age. Edema or dehydration affect turgor. How to assess turgor ? Grasp a fold on back of forearm or sternal area, skin should lift easily and immediately fall back into original position. When turgor is poor tenting occurs and it stays pinched . Temperature : Should be warm (not hot) and dry. Compare symmetrica l body parts. Increase in temperature often accompanies erythema (redness) and decrease accompanies pallor (pale ). Hydration noted via check on skin turgor, look at mucous membranes (should be moist), lips should not be cracked, skin should be flexible, not dry).
  • ( Read slide ).
  • ( Read slide ) “Check your birthday suit on your birthday!”

Nursing care of the integumentary System Nursing care of the integumentary System Presentation Transcript

  • Nursing Care of theIntegumentary System HACC Central Pennsylvania’s Community College N 103 A
  • Anatomy Overview of Skin Epidermis  Outer layer  Shields underlying tissue Dermis  Contains collagen and elastic fibers  Nerve fibers, blood vessels, sweat glands, sebaceous glands and hair follicles Subcutaneous  Contains blood vessels, nerves, lymph, and loose connective tissue
  • Skin Cross-Section
  • Normal Functions of Skin Protection Homeostasis Temperature Regulation Sensory Organ/Sensation Excretion/secretion Vitamin Synthesis Psychosocial
  • Perspiration and Evaporation Evaporation is the transfer of heat energy when a liquid is changed to a gas. The body continuously loses heat by evaporation. By regulating perspiration the body promotes additional evaporative heat loss.  Exercise, emotional and mental stress causes increased metabolic rate Diaphoresis is visible perspiration primarily occurring on the forehead, upper thorax, and other places on the body  Excessive evaporation causes skin scaling and itching
  • Factors Affecting Temperature Regulation Age Exercise Hormone levels Circadian Rhythm Stress Environment
  • Problems with Temperature Regulation Hyperthermia: elevation in body temperature over normal limits Hypothermia: body temperature lower than normal
  • Hyperthermia/Pyrexia What is normal body temperature? Low grade elevation: 98.8-100.6 High grade elevation: >100.6 Hyperthermia: over 104.9
  • Hyperthermia’s Causes Inflammation Allergy Infection Drug reaction Cerebral or Neurological injury Idiopathic (FUO)
  • Symptoms Cold Headache Malaise Skin flushing Diaphoresis Tachycardia Tachypnea
  • Nursing Interventions: Fever Promote cool environment Encourage fluids Antipyretic medications Reassess temperature frequently
  • Drugs Acting on Thermal Regulation acetylsalicylic acid (Aspirin) acetaminophen (Tylenol) ibufrofen (Advil, Motrin)
  • Hypothermia Prolonged exposure to cold Body temp lower than normal: mild to profound Cell function in all body cells declines
  • Signs of Hypothermia Decrease in vital signs, shivering, chills Waxy, pale cool skin Decreased urinary output Decreased muscle coordination Disorientation Drowsiness progressing to coma
  • Nursing Interventions Hypothermia Warm environment Warm blankets, dry clothing Warm oral/intravenous fluids Keep limbs close to body
  • Application of Heat and Cold Physician’s order needed
  • Assessment Prior to Therapy Warm or Cold Temperature tolerance Circulatory state Neurological response Medication decreasing sensitivity Age New tissue (skin)
  • Application of Heat HEAT  VASODILATION (Increasing blood flow), MUSCLE RELAXATION, PAIN RELIEF, INCREASES ROM, REDUCES JOINT STIFFNESS  MAY BE MOIST OR DRY FORMAT
  • Application of Cold COLD: VASOCONSTRICTION (reduces blood flow) REDUCES PAIN, DECREASES BLEEDING, LOCAL ANESTHETIC EFFECT, DECREASES INFLAMMATION MOIST OR DRY FORMATS
  • Skin Assessment Inspect the skin for:  Color  Texture  Thickness  Turgor  Temperature  Hydration
  • Common Nursing Diagnoses Risk for Impaired Skin Integrity Impaired Skin Integrity Disturbed body image Risk for imbalanced Body temperature Hyperthermia Hypothermia Ineffective Thermoregulation
  • Health Teaching Monitor skin daily Report alterations/changes Keep well moisturized Use sunscreen Avoid direct sunlight between 10AM and 2PM Know your family history of skin cancer
  • Thank You! Questions/comments?