Module 12 Pt.1 Integumentary System
Inclass PowerPoint
Tube feeding stops when there is an absent bowel sound and 30 degrees minimum
Erikson 8 stages ( activity ) by age
FOCUS ON STAGE 1
Pruritus:
Pathophysio: Skin gets irritated and sends a signal to the brain causing itchiness
Diagnosis:
Physical and questions about medical history
CBC: Check for anemia and inflammation
Test of liver, kidney, and thyroid: hyperthyroidism causes itchiness
Chest X-ray: Shows enlarge lymph nodes causing itchiness
Skin Biopsy: Bacterial or fungal infection to R/O cancer
S/S
Itchiness, raised redded vesicles, dryness
Leathery and scaly patches
Intervention
Administration of antihistamines ( itching)
Benadryl treats pruritus and relieves symptoms of itching and fever
Corticosteroids ( inflammation)
reduce inflammation in your body such as Prednisone
Hyperglycemia is a side effect of corticosteroid
Use of soothing agents such as oatmeal baths
Avoid scratching to prevent secondary infections
Mittens
Use cool to lukewarm water
Gentle detergents
Avoid too many baths
Avoid hard chemicals that dry the skin
Avoid allergy triggers
Start of lecture
Case Study 1:
Paralyze on the R side refuses to change position and has mood changes
No feeling
Underlying dementia
High risk for pressure ulcer
Pathophysiology: Prolong staying in one place will cause skin breakdown and shearing preventing the tissue from perfusing and healing
Skins need nutrition, sunlight, hygiene, oxygen, hydration
Risk Factors: Age, mental status, immobility, Sensory impairment, poor nutrition and hydration, incontinence
Case Study 2
What to do?
Turing and positioning 2hr
Maintain hydration level
Nutrition status
Prealbumin versus Albumin
Continued to inspect skin during therapy
Promote healing with vitamin C and protein
Nursing Assessment
Evaualte level of mobility
Assess neurovascular
Eval circulatory, nutrition, and hydration status
Review labs, determine the presence of incontinence, and review current meds
Obese patients have to examine the folds
Total skin condition 2 times a day
Assess areas of erythema, and palpate skin for increased warmth
Note drainage and odor
Case Study 3 Scabies
Pathophysio of scabies: Scabies caused by mite Sarcoptic scabiei which are 8 leg parasite that lives in burrowing tunnels in the stratus corunme
Eggs hatch 3-4 days and develop into 1-2 week maturationi
Patients have allergic reaction to the mites protein and feces and scabies burrow causing intense itch and rash
Diagnosed
Examine the skin and rash to make a diagnosis
Scraping of skin to look for microscopic evidence of mites
Prescibre cream or oral pills
No OTC for scabies
Treatment is 5% permethrin cream to the whole body washed off after 8-12 hours
Crusted scabies requires multiple treat oral and topicmedsmds
Itching can be relieved with lotion, antihistamines and corticosteroid
Itching and the rash may remain for 4 weeks after treatment despite killing all the mites
Scabies is highly contagious and must be kept out until they complete treatment
Avoid re-exposure
All people who live in the same household, have a sex partner, and have close skin-to-skin contact with the affected peris are treated.
Heat kills mites and their eggs important to wash all bedding, clothes, and towels in hot water and dry them in high heat each time treatment is administered.
No seafood since it causes ithciness
S/S
Scabies in Adults
Wrist, elbow, armpit, area between the fingers , waist
Extermly itchy rash on tour skin and rash spread slowly over 6 weeks or month s
Intense itching which si worse at night that could make it hard to sleep
Sore or painful numps sometimes infected because of scratching
Burrowing tracks or bumps as raised, skin colored lines
Spread all over the body
Dx
Skin scraping: small scraping of affect skin to see presence of mites, egg or fecal mattter
Skin Microscopy: Visual non invasive test examination of skin for scabies signs
Burrow Ink Test: Apply burrow ink and wipe of excess scabies
Adhesive Tape Test: Sticky tape pressed against the skin to examine under a microscope
Nursing Intervention
Prescibe prescription cream and wash all clothing in high heat
Permethrin 5% ( Elimite) - Apply at night and bathe in the morning
Treatall house hold measure and close contact
Questions
Powerpoint
What nursing measure would help prevent a stage 1 pressure ulcer from forming now?
Turing and position and inspecting every 2 hours and look for any reddened areas
Monitor hydration
Nutritional status
Prealbumin ( liver) versus albumin
Prealbumin (15-36) (under 15 is malnutrition) must be screened for all patients especially the ones with wounds for one nutrition status and it’s not affected by the patient's hydration status, unlike for the fo the albumin test.
Its shorter half-life makes it possible since the time frame is 1-2 weeks and albumin takes 3 weeks for reliable protein improvement since an early rise of albumin in 2 weeks.
Albumin has a longer half-life than prealbumin
Albumin has a greater serum pool than prealbumin
Preablumin is a more reliable and faster indication for assessing nutritional level.
Albumin gives a longer-term picture of patient nutrition status while prealbumin reflects the change in the protein level from shorter time frames.
Continuation inspection of patient skin during therapy
Promote healing by incorporating protein and vitamin C
Most common finding
Redness ( erythema) over body prominence that is intact and doesn’t blanch in response to pressure and partial thickness in the epidermis and part of the dermis
Skin Assessment Tool called Braden Scale
The score from six categories is added and the total score indicates a patient's risk for developing pressure injury based on these ranches. Updated on every shift
Mild risk: 15-18
Moderate risk: 13-14
High risk: 10-12
Severe risk: less than 9
Classification of pressure ulcers
Stage 1: Intact skin with nonblanchable redness of localized areas usually over a bony prominence. Dark-pigmented skin may not be visible.
Stage 2: Partially thickness loss of dermis presenting as a shallow open ulcer with red pink would bed without slough may present as an intact or open ruptured serum-filled blister
No sub yet
Stage 3: Full-thickness tissue loss, Subcutaneous fat may be visible but bone, tendon, or muscle isn’t exposed. Slough may be present but doesn’t increase the depth of tissue loss.
Stage 4: Full-thickness tissue loss with exposure to tendon or muscle. Slough or eschar may be present on some parts of the wouldn't bed.
Can see a bony place too
Deep tissue injury: Purple or maroon localized area of color intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or share
Unstageable: Full-thickness tissue loss in which the base of the ulcer is covered by slough ( yellow, tan, gray, green, or brown) and /or eschar ( tan, brown, or black) in the wound bed
Physical Findings of stage one pressure ulcer
Redness(erythema) over the area of bony prominence that is intact and doesn’t blanch in response to pressure.
Symptoms
Bedsores are classified into stages depending on the severity of skinskinages
Stage 1( earliest signs of skin damage): white people or people with pale skin developed a lasting patch of red skin that doesn’t turn white when pressed and in darker people patch may be red purple or blue but is more difficult to detect; skin may be tender, itchy, warm or cold and firm
Stage 2: Injured skin blistered or developed an open sore or abrasion that doesn’t extend through the full thickness of the skin but may surround an area of red or purple with mild swelling and some oozing
Stage 3: Ulcer becomes a crater that goes below the skin surface
Stage 4: Crater deepens and reaches into a muscle, bone, tendon, or joint
Interventions
Braden scale
Wound care
Keep skin dry and clean with barrier creams, turn q2 hours, watch friction and shear, special bed
Heel boots and ankle pad
High caloric
Wound vac, special dressing, hyperbaric O2
NSAID
Other factors
Shearing and friction: causes the skin to stretch and blood vessels to kink can impair blood circulation and slide across the bed sheets
Moisture: Wetness from perspiration, urine, or feces makes skinn under pressure likely to suffer injury; more common in people who can control their bladder or bowel and are at high risk
Decreased movement: Bedsores are more common for people who can’t lift themself. Without small movement, the skin is pressed against the bed and doesn't supply a steady supply of oxygen and nutrition, Decreased sentient is More common in people who feel pressure on the skin and this can prolong the effects of pressure on the skin.
Circulation Problem: People with atherosclerosis, circulatory problems from long-terminates, or localized selling may be more likely to develop stresses because the blood flow in the skin is weak even before the pressure is applied
Poor nutrition: Bedsoress are more likely in people who do not get enough protein, vitamins, and seminars
Age: Elderly people especially those over 85 are more likely to develop bedsores because the skin becomes more fragile with age
Bedsores can lead to severe medical complications such as osteomyelitis and septicemia.
Pathophysiology of Pressure Injuries
Localized area of necrotic soft tissue
Occurs when pressure applied to the skin greater than normal capillary closure pressure
Sometimes sufficient enough to cause tissue injury
Location of Pressure injuries
Head, ear, elbow, sacrum, greater trochanter, ischial tuberosities, medial condyle of tibia, fibular head, medial malleolus, lateral malleolus, heel
Assessment of Risk Factors for Pressure Injuries
Evaluation of mobility
Assess neurovascular status
Evaluate circulatory Status
Evaluate nutritional and hydration status
Review the result of patient labor studies
Determine the presence of incontinence
Review current medication
Assessment of Skin for patients with a pressure injury
Assess total skin condition at least twice a day
Inspect each pressure sit for erythema
Assess areas of erythema for the blanched response of the skin for increased warmth.
Inspect for dry skin moist skin and breathe skin
Note drainage and order
Nursing intervention for a patient with pressure injury #1
Relieving pressure
Tegaderm which is a transparent patch
Positioning the patient
Using pressure relieving devices
Improving: mobility, sensory perception, tissue perfusion
Improving nutritional status
Reducing friction eating
Minimizing irritation moisture
Avoid Recurrent pressure injury
Limit pressure on bony prominences
Change position 1 to 2 hours
Use the bridging technique to reduce pressure
Use special equipment as appropriate
Raise yourself from the start of the wheelchair every 15 minutes
Increase mobility
Remember to inspect potential pressure injury areas in the morning and evening.
Exercise to increase circulation
Elevate body parts susceptible to edema
Attain and maintain adequate nutritional status
Avoid friction and shear
Avoid semi-reclining position
Use heel protection when appropriate
Life body instead of sliding across surfaces
Maintaining clean, dry skin
Avoid prolonged contact with wet or soiled surface
Keep skin clean and dry
Nursing Intervention for Pressure Injury 2
Promoting pressure injury healing
Deep tissue injury
Immediate pressure relief
Stage 1
Maintain nutritional fluid and electrolyte balance
Reduce friction and shear
Avoid moisture on the skin
Apply transparent dressing change to protect the skin from moist and bacteria to allow oxygen
Stage 2
Clean while saline and dressing change
Nursing in Intervention Pressure Injury 3
Promoting pressure injury healing
Stage 3
Characterized by intensive tissue damage: slough; tunneling and undermining
Debridement to remove necrotic tissues
Explain the procedure and provide prescribed analgesia
Stage 4
Surgical intervention required
Nursing Intervention Pressure stage Injury 4
Other treatment method
Debridement using
Wet-to-dry dressing
Mechanical flushing of necrotic and infective exudate
Application of prescribed enzyme preparation that dissolves necrotic tissue
Surgical dissection
After the pressure ulcer is clean a topical treatment is prescribed to promote granulation
Vacuum-assisted closure or hyperbaric oxygen treatment may be used
Skin lesion
More than 90% of skin lesions are caused by place contact dermatitis and are localized and symptoms are generally less severe than those allergic to contact dermatitis.
Irritant contact dermatitis is caused by chronic exposure to mild irritants beginning with erythema and progressing to toe eczema with executive vesicles and papules most often in direct contact.
S/S are itching, stinging, and burning sensation
Scabies
Contagious skin infestation caused by tiny mites
Dig into the skin to feed and lay eggs and is transmitted by direct person-to-person contact or through just such as clothing and bleeding.
Most common in children and crowded population
Norwegian Scabies or crusted scabies is a severe infection that appears with a hick, yellow-gray crust on the skin usually occurs in elderly people and those with disabilities who can’t scratch or feel itchy and can occur with a weakened immune system.s
Infants can have rashes on their faces and necks and symptoms may take 2 to 6 weeks to appear after infestation.
Diagnosis and Nursing intervention/ discharge teaching
Examine the skin and rash to make a diagnosis
Scraping of skin to look for microscopic evidence of mites
Prescibre cream or oral pills
No OTC for scabies
Treatment is 5% permethrin cream to the whole body washed off after 8-12 hours
1 time in the day and washing
Wash linen every day with HOT water
Crusted scabies requires multiple treat oral and topicmedsmds
Itching can be relieved with lotion, antihistamines and corticosteroid
Itching and the rash may remain for 4 weeks after treatment despite killing all the mites
Scabies is highly contagious and must be kept out until they complete treatment
Avoid re-exposure
All people who live in the same household, have a sex partner, and have close skin-to-skin contact with the affected peris are treated.
Heat kills mites and their eggs important to wash all bedding, clothes, and towels in hot water and dry them in high heat each time treatment is administered.