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1. Summarize the physiology of the integumentary system related to skin integrity. (Ch. 31, pp. 955-957)
- a. Skin, integument, largest organ in the body
- The Integumentary System is made up of…
- 1. Skin
- a. Consists of 2 layers
- 1. Epidermis: Protective waterproof barrier
- 2. Dermis: Nerves, hair follicles, glands, and blood vessels are in this layer
- 2. Subcutaneous layer directly under the skin
- a. It is the underying layer that anchors the skin layers to the underlying tissues of the body
- 3. The appendages of the skin
- 4. Includes glands in the skin, hair, and nails
- 5. Also includes the blood vessels, nerves, and sensory organs of the skin
- b. Functions of the skin and mucous membranes
- • Skin
- a. Protection
- b. Temperature regulation
- c. Psychosocial
- d. Sensation
- e. Vitamin D production
- f. Immunolgic, absorption
- g. Elimination
- • Mucous Membranes
- a. Line body cavities that open to the outside of the body
- b. Found in digestive tract
- c. Respiratory passages
- d. Urinary and Reproductive tracts
- e. They have receptors that act as body protection
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2. Examine the relationship between tissue integrity and other concepts/systems. (Ch. 31, pp. 957-958)
- a. Healthy, unbroken skin help and mucous membranes are the first line of defense against harmful agents
- b. Resistance to injury of the skin and mucous membranes varies among people
- 1. Factors influencing resistance includes
- a. Person's age
- b. The amount underlying tissue
- c. Illness conditions
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• Therapeutic Measures
- A. Bed rest
- 1. Bed rest predisposes patients to skin breakdown
- 2. Harsh detergents on hospital laundry compound this problem
- 3. Pressure points need to be examined frequently and protected
- B. Casts
- 1. Casts easily irritate skin
- 2. Careful assessment, covering the edge of the cast, and skin care are indicated
- C. Aquathermia unit
- 1. Wet heat is beneficial but if applied too long, may macerate the skin
- 2. Follow protocol in length of application
- 3. Examine skin carefully between treatments and allow to dry
- D. Medications
- 1. May cause allergic skin reactions, such as rashes
- 2. When evaluating a patient's response to a new drug, examine the skin for redness and itching
- E. Radiation Therapy
- 1. Exposes skin cells as well as cancer cells in treatment field to effects of radiation
- a. Potential for erythema and mooist desquamation (loss of skin integrity)
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4. Differentiate common assessment procedures used to examine tissue integrity. (Ch. 31, pp. 974, Focused Assessment Guide 31-1, Ch.24, pp.638-841)
- • Assessments for Skin Integrity (YOU HAVE TO ASK QUESTIONS and BE DILIGENT IN YOUR OBSERVATIONS FOR YOUR PATIENT ASSESSMENTS)
- • Appearance of skin
- 1. Discolored areas of skin
- 2. Areas of skin warmer / colder than others
- 3. Moisture: damp, dry, mild
- 4. Thinner skin
- 5. Swelling in feet, ankles, or fingers
- 6. Skin care
- a. Bath / shower
- b. How often
- c. Oils / lotions
- b. Recent changes in skin
- 1. Developing sores
- a. How many
- b. Where are they
- c. Size change
- d. Any drainage from them
- 2. Redness of skin over the hips and backbone if you sit up or lie in one position for a long time
- a. Doesit disappear in a short time when you are up
- b. Recent tattoos / piercings
- c. Activity / Mobility
- 1. Assistance walking / moving
- 2. Confined to a bed or chair when up
- 3. Ability to change positions independently
- d. Nutrition
- 1. Recent weight gain / loss
- 2. Description of usual meals a day
- 3. Glasses / cups of liquid per day
- 4. Food supplements or vitamins
- 5. Preparation of own meals
- 6. Dentures
- a. Do you wear them
- b. How do they fit
- 7. Difficulty swallowing
- 8. Anemic by doctor's diagnosis
- e. Pain
- 1. If you have a sore, is it painful
- 2. Anything taken for pain
- a. How much
- b. How often
- c. Does it help
- f. Elimination
- 1. Any problems with bowels or urination, if so, describe
- 2. Pad or special pants use because of uncontrollable urine or stool
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5. Explain management of tissue integrity and prevention of impaired tissue integrity. (Ch.31, pp. 960, Table, Focus on the older adult, Nursing strategies…changes in skin)
- • Age-related changes (ARC)
- Subcutaneous and dermal tissue become thin
- a. Skin is more easily injured
- b. Skin has less capacity to insulate
- c. Skin wrinkles more easily
- d. Sensation of pressure and pain is reduced
- • Nursing strategies (NS)
- a. Do not apply tape to skin unless necessary
- b. Check skin frequently to observe for signs o pressure ulcer
- c. Pad bony prominences if necessary
- d. Assess pressure tolerance by checking pressure points for redness after 30 minutes
- • Age-related causes
- Activity of the sebaceuos and sweat glands decreases
- a. Skin becomes dryer
- b. Pruritis (Itching) may occur
- • Nursing strategies
- a. Clean perineal area daily but do not bathe full body on a daily basis
- b. Apply lotions as needed
- c. Encourage adequate hydration
- • Age-related causes
- Cell renewal is shorter
- a. Healing time is delayed
- • Nursing strategies
- a. Perform careful skin assessments, looking for signs of skin break down
- • Age-related causes
- Melanocytes (cells that make pigment that colors hair an skin) decline in number
- a. Hair becomes gray-white
- b. Skin may be unevenly pigmented
- • Nursing strategies
- a. Assist patient with skin check, observing for any signs of melanoma or other skin abnormalities
- • Age-related causes
- Collagen fiber is less organized
- a. Skin loses elasticity
- • Nursing strategies
- a. Check skin frequently for tears, irritation, or breakdown
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6. Compare and contrast common independent and collaborative interventions for clients with alterations in tissue integrity.
- 7. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of pressure ulcers. (Ch. Pp 966-967)
- Pressure Ulcers (Bed sores): A wound with a localized area of injury to the skin and/or underlying tissue
- A. Pathophysiology
- 1. Results from blood vessel collapse caused by pressure, usually from body weight
- 2. Two mechanisms contribute to pressure ulcer development
- 1. External pressure that compresses blood vessels
- 2. Friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin
- B. Etiology (Causes)
- 1. Caused by pressure
- a. Soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue is undergoes pressure in combination with shear and/or friction
- b. External pressure
- 1. Ischemia (deficiency of blood in a particular area)
- 2. Hypoxia (inadequate amount of oxygen available to cells)
- 3. Edema
- 4. Inflammation
- 5. Necrosis
- 6. Ulcer formation
- c. Pressure ulcers can form in 1 to 2 hours if circulation of blood flow is stimulated
- d. Friction and shear
- 1. Occurs when two surfaces rub against each other
- 2. Friction burns common on elbows, heels, and back
- 3. Shear
- a. When one layer of tissue slides over the another layer
- 1. Small blood vessels and capillaries in the area are stretched and possibly tear
- a. Causes decreased circulation
- b. Can happen if patients are pulled and not lifted
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8. Identify risk factors and prevention measures associated with pressure ulcers. (Ch. 31, pp. 966-968)
- A. Immobility
- 1. Patients who spend long periods of time in bed or are unable to shift body weight properly
- a. Surgery
- b. Use of tranquilizers and sedatives
- B. Nutrition and hydration
- 1. Protein-calorie malnutrtion
- 2. Dehydration
- 3. Edema (excess of watery fluid collecting in the cavities or tissues of the body)
- C. Skin moisture
- 1. Perspiration
- 2. Urine
- 3. Feces
- 4. Drainage from wounds
- D. Mental status
- 1. The more alert a person is, the more likely they are to protect their skin by maintaining adequate hygiene
- 2. Apathy, confusion or comatose state can diminish self -care abilities
- E. Age
- 1. Older adults are at greater risk
- 2. Chronic diseases and debilitating diseases can affect circulation and oxygenation of dermal structure
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9. Formulate priority nursing diagnoses appropriate for an individual with pressure ulcers. (Ch. 31, pp. 976-978)
- A. Risk assessment
- 1. Norton Scale
- a. Physical condition
- b. Mental condition
- c. Activity
- d. Mobility
- e. Incontinence
- 2. Braden Scale
- a. Mental status
- b. Continence
- c. Mobility
- d. Activity
- e. Nutrition
- B. Mobility
- 1. Evaluating a patient's ability to…
- a. Move
- b. Turn
- c. Reposition the body
- 2. This evaluation is done upon admission to the facility or during the initial home care interview
- C. Nutritional Status
- 1. Adequate nutrition is needed especially in older adults
- a. Advocates for optimal health and healing
- D. Appearance of existing pressure ulcers
- 1. Location of any lesion or ulcer
- 2. Identification of stage
- 3. Color and type of wound tissue
- 4. Presence of abnormal pathways
- a. Sinus tract or tunneling
- 5. Visible necrotic tissue
- 6. Presence of an exudate or drainage (amount and type)
- 7. Odor
- 8. Presence or absence of granulation tissue
- 9. Visible evidence of epithelialization
- 10. Periwound skin condition
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1. An abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another
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