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12 Lecture Note PowerPoint Presentation The Integument 15/12/2010 LEARNING OUTCOME 1 Describe normal skin changes associated with aging. 2 NORMAL STRUCTURE AND FUNCTION OF THE SKIN 15/12/2010 Skin consists of 15–20% of the total body weight Epidermis Consists of five continually regenerating and shedding layers Dermis 3 15/12/2010 FIGURE 12-1 CORPUSCLES AND THEIR DISTRIBUTION IN THE SKIN. 4 NORMAL STRUCTURE AND FUNCTION OF THE SKIN 15/12/2010 Subcutaneous layers A specialized connective tissue attached to muscles Contains blood vessels, lymphatic channels, hair follicles, and sweat glands 5 NORMAL STRUCTURE AND FUNCTION OF THE SKIN 15/12/2010 Accessory structures Hair Nails Glands Sebaceous glands Apocrine sweat glands 6 NORMAL STRUCTURE AND FUNCTION OF THE SKIN 15/12/2010 Function Protection Regulation of immune functions Thermoregulation Vitamin synthesis Sensory receptor for CNS 7 SKIN CHANGES ASSOCIATED WITH AGING Intrinsic factors 15/12/2010 Genetic makeup and the normal aging process Extrinsic factors UV lighting Smoking Environmental pollutants 8 15/12/2010 9 FIGURE 12-2 NORMAL CHANGES OF AGING IN THE INTEGUMENTARY SYSTEM. SKIN CHANGES ASSOCIATED WITH AGING Epidermal changes Thinning Reduced moisture leading to a dry, rough appearance Mitosis slows after age 50 by 30% Increased healing time Increased risk of infection 15/12/2010 10 SKIN CHANGES ASSOCIATED WITH AGING Epidermal changes Rete ridges flatten: in the dermal layer, less collagen is being produced. The elastin fibers also wear out. Such factors will cause the skin to sag and wrinkle. The rete ridges, meanwhile, will flatten out. This will cause the skin to be fragile. Increased risk of skin breakdown Reduced melanocytes 15/12/2010 Paler complexion Increased risk of UV damage 11 SKIN CHANGES ASSOCIATED WITH AGING Epidermal changes Scattered pigmented areas 15/12/2010 Nevi (skin moles) Age spots Liver spots Increased number and size of freckles (clusters of concentrated melanin) 12 SKIN CHANGES ASSOCIATED WITH AGING Dermal changes Decreased thickness and function begin in 3rd decade of life Elastin decreases in quality 15/12/2010 Wrinkling and sagging Collagen less organized Loss of turgor 13 SKIN CHANGES ASSOCIATED WITH AGING Dermal changes Reduced vascularity Paler complexion Capillaries thin and are easily damaged 15/12/2010 Senile purpura Easy skin bruising in older people Reduced touch and pressure sensations 14 SKIN CHANGES ASSOCIATED WITH AGING Subcutaneous layer Tissue thins in the face, neck, hands, and lower legs 15/12/2010 Visible veins in exposed areas Hypertrophy of tissue in certain body areas Increased body fat Increased body fat in abdomen and thighs 15 HAIR CHANGES WITH AGING 15/12/2010 Reduced number of functioning melanocytes Replacement of pigmented strands of hair with nonpigmented hair Hormone levels decline Loss of hair in pubic and axillary areas Growth of facial hair in women Growth of nasal and ear hair in men Increased baldness 16 NAIL CHANGING WITH AGING Color changes Dull Yellowing or grayness Slowed growth 15/12/2010 Thicker nails prone to splitting Longitudinal striations Related to damage at the nail matrix (the ROOT of the nail) 17 NAIL CHANGING WITH AGING Longitudinal pigmented bands Single or multiple brown or black bands on thumb and index finger Frequently seen in African-Americans over age 20 Increased visibility in the older adult 15/12/2010 18 GLANDULAR CHANGES WITH AGING Eccrine or sweat glands Decreased number; decreased ability to regulate body temperature 15/12/2010 Sebaceous glands Increased size; decreased activity; increased water evaporation causes cracked, dry skin 19 15/12/2010 LEARNING OUTCOME 2 Identify risk factors related to common skin problems of older adults. 20 “THE SUN NEVER FORGETS” Ultraviolet radiation (UVR) Ultraviolet A (UVA) 15/12/2010 21 “THE SUN NEVER FORGETS” Responsible for premature aging and decreased immune function 15/12/2010 Ultraviolet B (UVB): The elderly have reduced capacity to synthesize vitamin D in skin when exposed to UVB radiation. Intense, intermittent exposures Basal cell carcinoma Malignant melanoma Chronic sun exposure Squamous cell carcinoma Photoaging: refers to the damage that is done to the skin from prolonged exposure, over a person's lifetime, to UV radiation Actinic keratosis: is a premalignant condition of thick, scaly, or crusty patches of skin 22 SKIN TEARS Traumatic separation of the epidermis from the dermis 15/12/2010 23 PRESSURE ULCERS 15/12/2010 Impact between 1 and 3 million people annually in the United States Localized injury to the skin and underlying tissue Usually over a bony prominence Results from pressure or pressure and shear force and/or friction 24 PRESSURE ULCERS High-risk populations Hospitalized patients Individuals over age 65 15/12/2010 25 CELLULITIS 15/12/2010 Acute bacterial infection of the skin and subcutaneous tissue Risk factors Skin breaks Chronic illness Age-related skin changes 26 CONDITIONS OF THE FINGER AND TOE NAILS Risk factors Trauma Age-related changes Systemic diseases 15/12/2010 27 15/12/2010 LEARNING OUTCOME 3 Delineate skin changes associated with benign and malignant skin types. 28 SKIN CANCER IS THE LEADING CANCER IN THE UNITED STATES 15/12/2010 Malignancies are associated with the time spent in the sun Older and light-skinned persons are at an increased risk Darker-skinned persons may be at risk 29 ACTINIC KERATOSIS Most common precancerous lesion; it is seen more in men than women 15/12/2010 1:1,000 will progress to skin cancer Also known as solar keratosis or senile keratosis Sore, rough, scaly, erythematous papules or plaques 30 BASAL CELL CARCINOMA 15/12/2010 Most common skin cancer for Caucasians Metastasis rare Originates in lowest layer epidermis Manifests as small, fleshy bumps 31 SQUAMOUS CELL CARCINOMA 15/12/2010 Second most common skin cancer for Caucasians Most common skin cancer for persons with dark skin Originates in upper levels of epidermis Manifests as flesh-colored erythematous, scaly plaques, papules or nodules Metastasis can occur 32 MELANOMA 15/12/2010 Most dangerous skin cancer; responsible for more than three quarters of all skin cancer deaths Originates in the melanocytes Lesions may be brown, black, or multicolored; develop nodules or; plaques (a broad papule ) and have a black, irregular spreading outline 33 SKIN TEARS Category 1 Linear or flap tear without tissue loss Category 2 15/12/2010 Caused by friction or shearing forces Payne-Martin classification for skin tears Tears with partial tissue loss Category 3 Tears with full thickness complete tissue loss 34 PRESSURE ULCERS 15/12/2010 The majority occur in persons over age 70 Stages Stage I: Nonblanchable erythema of intact skin Stage II: Partial-thickness skin loss involving dermis and/or epidermis Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to underlying fascia 35 PRESSURE ULCERS Stages Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supportive structures 15/12/2010 Types of pressure ulcers Necrosis of epidermis and dermis Deep or malignant pressure ulcers Full-thickness wounds 36 PRESSURE ULCERS Mechanisms of Tissue Breakdown Occlusion of blood flow to the skin Damage to the lining of the arterioles and smaller vessels Direct occlusion of blood vessels by long periods of pressure 15/12/2010 37 WOUND HEALING Phases Inflammation and destruction Proliferation Maturation 15/12/2010 38 DELAYED WOUND HEALING 15/12/2010 A wound that does not heal within 6 weeks is termed chronic Signs Wound size is increasing Exudate, slough, or eschar is present Tunnels, fistula, or undermining has developed Epithelial edge is not smooth and continuous and does not move toward wound 39 DELAYED WOUND HEALING Causes Aging Inadequate nutrition Inadequate blood supply Immunocompetence Damage to wound 15/12/2010 40 CELLULITIS 15/12/2010 Acute bacterial infection of skin Characterized with inflammation, intense pain, heat, redness, and swelling 41 NAIL PROBLEMS 15/12/2010 Fungal infection Inflammation of the nail matrix Hypertrophy of the nail plate 42 15/12/2010 LEARNING OUTCOME 4 List nursing diagnoses related to common skin problems. 43 THREE MAJOR NURSING DIAGNOSES FOR INTEGUMENT PROBLEMS 15/12/2010 Risk for Impaired Skin Integrity Impaired Tissue Integrity Damage to integument, cornea, or mucous membranes Impaired Skin Integrity Damage to epidermal or dermal tissue 44 NURSING DIAGNOSES FOR INTEGUMENT PROBLEMS 15/12/2010 Impaired Skin Integrity related to lesions and inflammatory response Risk for Impaired Skin Integrity related to physical immobility Risk for Impaired Skin Integrity related to decrease skin turgor 45 NURSING DIAGNOSES FOR INTEGUMENT PROBLEMS 15/12/2010 Risk for Impaired Skin Integrity related to the effects of pressure, friction, or shear Risk for Impaired Tissue Integrity related to decreased circulation Risk for Infection related to pressure ulcer 46 15/12/2010 LEARNING OUTCOME 5 Discuss the nursing responsibilities related to pharmacological and nonpharmalogical treatment of common skin problems. 47 DIAGNOSTIC TESTS FOR INTEGUMENTARY DISORDERS 15/12/2010 Total body photography: is established techniques for detecting and monitoring dysplastic and atypical nevi for early detection of malignant cutaneous melanomas Skin biopsy Wound cultures Laboratory tests Serum albumin Serum transferrin Lymphocyte count 48 PHARMACOLOGIC TREATMENT OPTIONS 15/12/2010 Topical antifungal agents Topical antibiotics Systemic antibiotics Selected antimicrobials Aminoglycosides Prescription creams 49 NONPHARMACOLOGICAL INTERVENTIONS Patient education Awareness and reporting of skin cancer Characteristics of darker skin 15/12/2010 Prevention Guidelines on sun exposure Wearing protective clothing 50 NONPHARMACOLOGICAL INTERVENTIONS Treatment Basal cell carcinoma and squamous cell carcinoma Malignant melanoma 15/12/2010 Excisional biopsy for diagnosis Wide excision for cure Adjuvant therapy Chemotherapy Chemoimmunotherapy Regional radiation therapy Biotherapy 51 NONPHARMACOLOGICAL INTERVENTIONS Preventing skin tears Avoid pulling or sliding Pad surfaces Keep environment free of obstacles Maintain safe environmental lighting Keep skin moist Use tape cautiously Encourage long sleeves and pants 15/12/2010 52 NONPHARMACOLOGICAL INTERVENTIONS Managing skin tears Clean with normal saline or other nontoxic cleaner Pat or air dry Gently place torn skin in its approximate normal position Apply dressings and change per protocol or product requirements Photograph if permitted Document all findings 15/12/2010 53 NONPHARMACOLOGICAL INTERVENTIONS Managing cellulitis Treat acute infection Immobilization Elevate limb Pain relief Possible anticoagulant therapy Prevent further complications 15/12/2010 54 NONPHARMACOLOGICAL INTERVENTIONS Management of Fingernail and Toenail Problems Onychomycosis 15/12/2010 Pain management Patient education Oral antifungal agents Chronic paronychia Keep affected nails dry Antibiotics 55 NONPHARMACOLOGICAL INTERVENTIONS Management of Fingernail and Toenail Problems Onychogryphosis:is a hypertrophy that may produce nails resembling claws or a ram's horn, possibly caused by trauma 15/12/2010 Keep nails short Podiatry consultation: is a branch of medicine devoted to the study, diagnosis and treatment of disorders of the foot, ankle and lower leg. Surgical intervention 56 15/12/2010 LEARNING OUTCOME 6 Explain the nursing management principles related to the care of pressure ulcers. 57 THE BRADEN SCALE 15/12/2010 Used to assess pressure ulcer risk Assesses mobility, activity, sensory perception, skin moisture, friction, shear, and nutritional status Used as an adjunct tool to nursing assessment and clinical judgment 58 MOBILITY AND ACTIVITY CONSIDERATIONS 15/12/2010 Repositioning q2h Avoid prolonged sitting Increase sitting 59 SKIN CARE FOR OLDER PERSONS 15/12/2010 Correct bathing procedures Keep skin clean and dry Lubricate with non–alcohol-containing moisturizer Prevent injury Evaluate and manage incontinence Provide dietary support 60 NURSING CARE OF PRESSURE ULCERS 15/12/2010 Assess and stage the wound Debride necrotic tissue Cleanse 61 TREATMENT 15/12/2010 Avoid contamination Colonization Infection Topical antibiotics Systemic antibiotics 62 NURSING CARE AND DOCUMENTATION OF SKIN PROBLEMS 15/12/2010 Assess risk factors Provide nursing interventions to minimize skin breakdown Document care Evaluate patient status 63 KNOWLEDGE-BASED DECISION MAKING 15/12/2010 Current literature Share with colleagues, patients, and their significant others 64 HELPFUL QUESTIONS WHEN ASSESSING WOUND CARE PRODUCTS 15/12/2010 What is the stage, drainage, moisture, or eschar? What are the wound needs? What products are available to manage the wound? 65 ONGOING EVALUATION OF NURSING CARE 15/12/2010 Family situation Available resources Patient needs and requests Patient and family understanding of the teaching and plan of care 66