Integumentary

Professor Carolyn Brown in NUR 324 (Fundamentals of Nursing) acknowledges Dr. Jessica Thompson.

Largest organ in the body.
Two main layers:
- Epidermis: Outermost layer.
- Dermis: Beneath the epidermis.
Primary purposes of skin:
- Protection.
- Sensory perception.

Main components of skin assessment:
  - Color.
  - Moisture.
  - Temperature.
  - Texture.
  - Turgor.
  - Vascularity.
  - Edema.
  - Lesions.

Pitting Edema scales:
  - 1+: 2mm depression, barely detectable with immediate rebound.
  - 2+: 4mm deep pit that takes a few seconds to rebound.
  - 3+: 6mm deep pit, requiring 10-12 seconds to rebound.
  - 4+: 8mm very deep pit, taking >20 seconds to rebound.
Non-Pitting Edema: Not specified in detail.

Questions crucial for skin assessment:
  - Any changes in color, moisture, or texture?
  - History of skin issues?
  - Any risk factors for skin cancer?
  - Observations of swelling?

Pallor: Loss of color; in black skin tones, may appear grey; indicates anemia, shock, or lack of blood flow (check mucous membranes).
Cyanosis: Bluish discoloration; appears yellow-brown or grey in brown skin tones; check nail beds, lips, mucosa; indicates hypoxia, impaired venous return.
Jaundice: Yellow discoloration seen in sclera, skin, and mucous membranes; indicates liver dysfunction (due to RBC destruction).
Erythema: Redness, often difficult to assess in dark skin tones; necessitates palpation to check for warmth and texture changes; points to inflammation, vasodilation, and sun exposure.

Risk factors for impaired skin integrity:
  - Impaired sensory perception.
  - Impaired mobility.
  - Altered level of consciousness.
  - Specific risks:
    - Shear: Movement of skin and subcutaneous tissue when muscle and bone do not move simultaneously.
    - Friction: Occurs when two surfaces rub against each other.
    - Moisture: The amount and duration of moisture exposure can increase risk.

Pressure Injuries: Also known as pressure ulcers, decubitus ulcers, or bedsores; result from unrelieved, prolonged pressure leading to tissue ischemia.

Definition: A localized injury to the skin or underlying tissue due to sustained pressure.
Causing factors:
  - Pressure intensity.
  - Pressure duration.
  - Tissue tolerance; affected by low blood pressure, nutrition, aging, hydration status.

Stages:
  - Stage 1: Non-blanchable erythema of intact skin.
  - Stage 2: Partial thickness loss of skin; may present as an abrasion.
  - Stage 3: Full thickness skin loss; subcutaneous fat may be visible, but bone/tendon/muscle are not exposed.
  - Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle.
Deep Tissue Injury: Persistent, non-blanchable deep red, maroon, or purple discoloration; unclear involvement of layers.
Unstageable: Full thickness skin and tissue loss with obscured depth due to slough or eschar.

Caused by prolonged exposure to urine or stool.
Types:
  - Incontinence-related: Resulting from moisture exposure.
  - Intertriginous: Inflammatory dermatitis due to moist skin rubbing against itself.
  - Periwound/Peristomal: Associated with different types of wounds or stomas requiring protective measures against enzyme breakdown from exudate.

Types of Wounds:
- Acute Wounds: Heal through a normal process leading to restoration of function and integrity (e.g., trauma, surgical incision).
- Chronic Wounds: Fail to progress through normal healing processes (e.g., pressure ulcers, vascular insufficiency wounds).

Nutrition:
- Deficiencies (especially in protein, vitamins A, C, zinc, and copper) can delay healing.
- Sufficient caloric intake is crucial; monitor serum albumin and pre-albumin levels.
Tissue Perfusion:
- Adequate oxygenated blood supply essential for healing; diabetes and peripheral vascular disease may complicate perfusion.
Infection:
- Prolongs inflammation and delays healing; indicators include purulent drainage, change in color, fever, or pain.
Age:
- Influences all aspects of healing; older adults may experience delayed inflammatory responses, collagen synthesis, and slower epithelialization.

Braden Risk Assessment Scale to evaluate risk factors based on:
  - Sensory perception.
  - Moisture levels.
  - Activity.
  - Mobility.
  - Nutrition.
  - Friction/shear.
Scoring:
  - Total Braden Score interpretation:
    - 15-16: Mild Risk
    - 12-14: Moderate Risk
    - <12: High Risk     - Special note: 15-18 considered mild for those >75 years.

Score Categories:
  - Age: <40, 40-54, 55-69, >70.
  - Weight: Average, Obese, Cachectic.
  - Skin condition: Intact, red skin, grazed, necrosis.
  - Mental condition: Alert, agitated, apathetic, unresponsive.
  - Mobility: Fully ambulant, slight help, very limited, immobile.
  - Hemodynamics and respiration stability evaluated (with or without inotropic support).

Key Nurses' Roles:
  - Thorough and consistent assessments s critical for skin integrity.
  - Understand high-risk areas for pressure.
  - Implementing interventions centered around turning, nutrition, and maintaining skin integrity is essential.
Positioning Strategies:
  - Turn patients every 2 hours in bed and hourly in a chair.
  - Use lift assistive devices to avoid friction injuries.
  - Consider specialized mattresses, chair cushions, and heel cushions.
Nutrition:
- Critical for wound healing; patients may require supplemental nutrition (protein, calories).
Moisture Management:
- Maintain dryness by using moisture barriers and absorbent products to wick moisture.

Nutritional supplements (e.g., Juven for wound healing; contains collagen, amino acids).
Specialized equipment (e.g., fluid immersion simulation).

Develop a Pressure Injury Prevention Algorithm focusing on the risk assessment of pressure injuries and appropriate interventions based on Braden Scale scores.