Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Nursing: A Concept-Based Approach to Learning VOLUME ONE | SECOND EDITION MODULE 21 Tissue Integrity Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Definition • A nurse’s most important responsibilities include assessing and monitoring skin integrity; identifying problems; and planning, implementing, and evaluating interventions to maintain skin integrity. 2 Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved The Concept of Tissue Integrity • Integumentary system includes: Skin Hair Nails Sebaceous, sweat, and mammary glands • Important nursing functions Maintain skin integrity Promote wound healing Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Normal Presentation of the Skin • Functions of the skin Protect underlying tissues Nerves, skin enable perception • • • • Touch Pain Pressure Heat Body temperature regulation Synthesize vitamin D Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Physiology Review • Epidermis Outermost layer: stratum corneum • keratin Stratum granulosum Stratum spinosum Stratum basale • Melanin Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Physiology Review, continued • Dermis Second, deeper layer of skin Papillary layer Reticular layer • Subcutaneous tissue Loose connective tissue Stores half of body's fat cells Cushions, insulates Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Genetic and Lifespan Considerations • Changes normal in the aging process Occur slowly Skin's thickness and collagen content decrease with age which causes skin to become thinner and less elastic over time Epidermal cell turnover slows Subcutaneous fat decreases and is redistributed Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Genetic and Lifespan Considerations, continued • Epidermis of older individual Atrophic Stratum corneum replacement slows Skin takes on a rough, dry appearance Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Genetic and Lifespan Considerations, continued • Epidermis of older individual Reduced cell turnover has a negative effect on skin's barrier function and healing processes Decreased exchange of nutrients between the layers Melanocyte activity, function and distribution decreases Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Genetic and Lifespan Considerations, continued • Dermis Becomes thinner with aging Fibroblasts decrease in number Collagen decreases Elastin quality declines, quantity increases wrinkling, sagging Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Genetic and Lifespan Considerations, continued • Subcutaneous tissue Distribution of remaining fat changes Tissue loses fat during the aging process Thins prone to fractures and pressure sores over bony areas Problems with thermoregulation Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Alterations and Manifestations • Skin disorders Infectious Inflammatory Neoplastic Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Alterations and Manifestations, continued • Skin lesions Vary in shape, color, and texture characteristics Examples: Table 21-2 and Table 21-3 Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Alterations and Manifestations, continued • Wounds Intentional (Table 21-4) • Occur during therapy Unintentional (Table 21-4) • Accidental Degree of contamination • • • • Clean wounds Clean contaminated wounds Contaminated wounds Dirty, infected wounds Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Wounds-Drainage…what does it mean? • Serous • Purulent • Serosanguineous • Sanguineous 15 Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Alterations and Manifestations, continued • Untreated wounds Control severe bleeding Prevent infection Control swelling, pain Assess for signs of shock Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Wounds-Repair • Partial-Thickness: Example: Surgical wounds Involve dermis and epidermis Heal by primary intention (page 1507) • Full-Thickness: Example: Pressure ulcers Involve dermis, epidermis, subcutaneous, muscle and bone Heal by secondary intention (page 1507) 17 Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Primary and Secondary Intention Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Alterations and Manifestations, continued • Treated wounds Observe wound or dressing Presence of pain Exemplar 21.4 Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Concepts Related to Tissue Integrity (Page 1449) • Immunity Immune system assessment • Infection Chain of infection Standard precautions Infection assessment • Mobility Mobility assessment Independent interventions and therapies Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Risk Factors • Age: circulation slows; clotting process changes; inflammatory response becomes impaired; fibroblastic activity and collagen synthesis decrease • Obesity: adipose tissue provides a weak defense against microbial invasion; impairs delivery of nutrients to the wound; risk for wound dehiscence and infection • Smoking: vasoconstriction, decreased hemoglobin levels, and impaired oxygenation; hypercoagulability • Medications: drugs affecting the immune response, anticoagulants, aspirin, nonsteroidal anti-inflammatory drugs, steroids • Stress: triggers release of catecholamines and vasoconstriction Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Screenings • Regular self-examinations Identify problems as they occur Develop familiarity with skin • Professional examinations Common for identifying skin disorders Dermatologist Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Assessment • Be alerted to skin abnormalities even when providing routine care • Remove medical, assistive devices to assess skin condition underneath • Detect variations in skin color using good lighting Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Nursing Assessment • Review of systems Skin diseases Previous bruising General skin condition Skin lesions Usual healing Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Assessment Interview • Page 1456 • When did you first notice your current skin problem? • Are lesions slow to heal on your skin? • Have you noticed any drainage from your skin lesions? Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Nursing Assessment • General Assessment • Color,odors • Impaired Skin Assessment • Lesions • • • • • Turgor Edema Hair Scalp Nails • Temperature • Texture Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Assessment Skin Cancer Focused • Health questionnaire Changes in mole, wart, birthmark, scar Sunburn history Tanning • Skin assessment: Head to toe order Inspect, palpate skin Measure and record all skin lesions Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Diagnostic Tests • Skin biopsy • Cultures • Infection: Immunofluorescent studies,Wood lamp, Tzanck test,Potassium hydroxide • Allergy: Patch tests • Laboratory Data Leukocyte count Hemoglobin Blood coagulation Albumin level Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Wound Culturette Tube Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Nursing Diagnosis Risk for infection Impaired tissue integrity Imbalanced nutrition: less than body requirements Impaired physical mobility Ineffective peripheral tissue perfusion Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Acute or chronic pain Impaired skin integrity Risk for impaired skin integrity Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Planning • Goals: Control severity Prevent infection Promote healing Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Planning • Expected outcome Patient’s skin will show evidence of healing within 3 days, as evidenced by a decrease in redness, a decrease in drainage, an increase in pink, clean tissue. Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Independent • • • • • Home remedies Good hygiene Teach infection prevention measures Exercise Nutrition Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Independent • Topical skin care and incontinence management • Protect bony prominences, skin barriers for incontinence. • Positioning • Turn every 1 to 2 hours as indicated. • Support surfaces • Decrease the amount of pressure exerted over bony prominences. Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Collaborative • Treatment in some cases requires pharmacologic therapy Over-the-counter • Lice, minor sunburn Extensive or long-term prescription therapy • Eczema, dermatitis Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Collaborative • Corticosteroids • Hydrocortisone • Antibiotics • Antifungals • Clotrimazole (Lotrisone) • Creams • Curel Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Evaluation • Was the etiology of the skin impairment addressed? Were the pressure, friction, shear, and moisture components identified; and did the plan of care decrease the contribution of each of these components? • Were issues such as nutrition assessed and a plan of care developed that provided the patient with the calories to support healing? Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved Alterations and Therapies Tissue Integrity (Page 1453-4) Alteration Manifestations and Treatment • Impaired Skin Integrity • Pain • Inflammation • Infection • Pruritus • Eschar • Edema • Exudate • Bruising Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved