NPTE Final Frontier Integumentary System

integ system

skin is the largest body organ: 15-20% of BW

primary function of skin

Protection, insulation, holding organs together, sensory, fluid balance, temperature control, absorbing UV radiation, metabolizing vitamin D, and synthesizing epidermal lipids

Epidermis

superficial

keratinocytes, melanocytes, langerhans cells, Basal cells

dermis

Deep

collagen, reticulum, fibroblasts, macrophages, lymphatic glands, blood vessels, nerve fibers

Meissner corpuscles

touch and vibration

Krause end bulbs

Cold

golgi tendon organs

contraction

ruffini endings

hot sensation

pacinian corpuscles

pressure

venous insufficiency

refers to inadequate drainage of venous blood from a body part, usually resulting in edema and/or skin abnormalities and ulcerations

arterial insufficiency

refers to a lack of adequate blood flow to a region of the body

clinical presentation: venous insufficiency

- proximal to the medial malleolus

- irregular, shallow appearance

- flaking, brownish discoloration- hemosiderin staining

- mild to moderate pain

- elevation decreases pain

clinical presentation: arterial insufficiency

- Lower 1/3 of leg, toe and lateral malleolus

- Smooth edges, well defined, tend to be deep

- Thin and shiny, hair loss, yellow nails

- Severe pain

- Elevation increases pain

"painful cramping"

claudication >> struggling to get blood >> arterial

pressure ulcers

located over bony areas and are staged related to the depth of the wound bed

pressure ulcers: stage 1

reddened area that does not go away

pressure ulcers: stage 2

first 2 layers of skin, superficial in nature

pressure ulcers: stage 3

subcutaneous fat may be visible

FAT: 3 letters

pressure ulcers: stage 4

down to the bone and including the bone

BONE: 4 letters

pressure ulcers: unstageable

related to not visualizing the wound base because of necrotic tissue

do pressure ulcers change stages after initial naming?

NO THEY DO NOT

even if they progress/heal they will always be referred to the initial stage name

diabetic ulcers

generally located on the weight-bearing surface of the foot

venous insufficiency ulcers

frequently are proximal to the medial malleolus; they are edematous

arterial ulcers

generally located on the lateral malleolus, distal toes, or areas of trauma

pressure ulcers

result of unrelieved external pressure on an area

Herpes zoster

"SHINGLES"

dermatomes

- herpes zoster (shingles) has initial symptoms of pain and paresthesia localized to the affected dermatome

integumentary

- presents as a rash

- mostly unilateral

- raised to palpation (<2mm height)

- pink w silvery white appearance

- CN 3 and 5

- NO HEAT

precautions: contact and airborne

herpes simplex virus type 1

located above the waist

cold sores

herpes simplex virus type 2

located below the waist

wheals

hives

pustules

pus filled

vesicles

fluid filled, dome

wound healing basics

- too much moisture will delay healing

- too moist, the periwound becomes macerated

- macerated wounds can be white, friable, over hydrated, and sometimes wrinkled skin

- maceration may be caused by uncontrolled wound drainage, perspiration, or incontinence

dressing: very mild exudate

transparent film

dressing: minimal exudate

hydrogel, hydrocolloid

dressing: moderate exudate

foams

dressing: heavy exudate

calcium alginates, hydrofiber

Dressings: Nonadherent

films > hydrogel > hydrocolloids > foam > calcium alginates, hydrofibers

dressing: antimicrobials

films > hydrogel > hydrocolloids > foam > calcium alginates, hydrofibers

debridement: selective

removal of ONLY non viable tissues from a wound

dead tissue < alive tissue

types of selective debridement

sharp: use of scalpel, scissors, forceps

enzymatic: use of topical application

autolytic: body's own mechanism

Debridement: nonselective

removal of both nonviable and viable tissues from a wound, >50% necrotic

types of nonselective debridement

wet to dry: application of moist gauze over area of necrotic tissues to be completely dried and removed

wound irrigation: move necrotic tissue from wound bed using pressurized fluid

hydrotherapy: using a whirlpool w agitation directed toward a wound requiring debridement

Red-Yellow-Black System

- red: pink granulation tissue, protect wound, maintain moist environment

- yellow: moist yellow slough, remove exudate and debris, absorb drainage

- black: black thick eschar firmly adhered, debride necrotic tissue

Povidone -iodine solution

infection- surgical site

zinc oxide cream

dental

nitrofurazone solution

burns

Burns: superficial

epidermis

dry, red skin, w/o open areas

heals in 5 days w/o scarring

burns: superficial partial thickness

epidermis and some dermis

weeping blisters, blanches to pressure with quick capillary refill, extremely painful

heals within 10-14 days

minimal scarring

burns: deep partial thickness

epidermis and dermis

mottled red and white areas, blanches to pressure w/ slow capillary refill, decreased pinprick sensation

can take up to 3 weeks

large wounds can be managed surgically

burns: full thickness

epidermis, dermis, some subcutaneous tissues

dry, rigid, leathery eschar, lack of pain, pressure, temp sensation

requires > 3 weeks; will require surgical closure, may have contractures

burns: subdermal

epidermis, dermis, subcutaneous tissues

charred, dry and exposed deep tissue

requires surgical interventions, amputation and paralysis possible

epidermal

no scar and have intact skin

superficial partial thickness

painful to touch, temp, have brisk capillary refill, produces minimal scarring

deep partial thickness

waxy white, have pain of deep pressure, delayed capillary refill, result in excessive scarring and development of hypertrophic and keloid scars

subdermal

charred, dry and exposed to deep tissue and often require amputation

Rule of 9s adults

head = 9% (front 4.5, back 4.5)

each arm = 9% (front 4.5, back 4.5)

trunk = 18% front, 18% back

each leg = 18% (9 front, 9 back)

genitals = 1

Upper body: 63%

Genitals: 1 %

Lower body: 36%

Rule of 9s children

Head 18% (8.5 front, 8.5 back)

each arm 9% (front 4.5, back 4.5)

chest 18%

back 18%

each leg 14% (6.5 front, 6.5 back)

genitals 1%

upper body: 72:% (71%)

genitals: 1 %

lower body: 28%

scars: normal

flat and similar to skin color

scars: hypertrophic

a healed wound w thick fibrous tissue that remains WITHIN the original wound border

scars: keloid

excessive scar tissue grows OUTSIDE of the original margins of the wound