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Integumentary Assessment Kozier Ch 30 What are the Functions of the Integumentary System? Functional Review • Protector and barrier between internal organs and external environment • Barrier against foreign body intrusions – against invading bacteria and foreign matter • Transmits sensation – nerve receptors – allows for feelings of temperature, pain, light touch and pressure Skin Functions • Regulates body temperature – regulates heat loss • Helps regulate fluid balance – absorbs water – prevents excessive water & electrolyte loss. – Slow loss up to 600 ml daily by evaporation • Immune Response Function – inflammatory process Skin Functions • Vitamin production – exposure to UV light allows for the conversion of substances necessary for synthesizing vitamin D – Necessary to prevent osteoporosis, rickets Skin Assessment • • • • • Visual inspection Palpation Olfactory senses Adequate lighting Remove necessary clothing while providing respect and privacy • Appropriate client positions p.568 Visual inspection Skin color: • Palor • Cyanosis • Jaundice • Erythema • Hyperpigmentation • Hypopigmentation – vitiligo Visible changes if the Skin • Changes in skin color texture – Eczema, infections • Assess the vascularity & hydration of skin • Edema – swelling, pitting edema 1+ 2 mm 2+ 4 mm 3+ 6 mm 4+ 8 mm p.579 • Nails – configuration, consistency, color • Hair – color and distribution, aloplecia, location p.579 Gerontology Considerations Watch for significant changes in aging: • Decrease immunity functions • Susceptibility to infections • Poor nutrition • Decrease collagen production – loss of subcutaneous • Thinning of epidermal skin layers • Increase skin problems Gerontology Considerations • • • • • Taking more medications Excessive environmental exposure Dryness, wrinkling Uneven pigmentation Various proliferative lesions Assessing light to dark skin Description Light skin Dark skin Cyanosis - bluish Bluish tinge Ashen gray Pallor - paleness Loss of rosy glow Ashen gray (drk skin) Yellowish brown (brown skin) Erythema - redness Visible redness Diffused; rely on palpation of warmth or edema Petechiae – small size pinpoint ecchyumosis Purplish pinpoints Usually invisible; check oral Mucosa, conjunctiva, eyelids, conjunctiva covering eyeballs. Assessing light to dark skin Description Jaundice - yellow Light skin Dark skin Yellow sclera, Reliable on sclera, hard skin, fingernails, palate, palms and soles. soles, palms, oral mucosa Ecchymosis – large Purplish to diffused bluish black yellow-green Difficult to see, check mouth or conjunctiva Brown-Tan – cortisol Bronze; deficiency, increased Tan to light melanin production brown Easily masked. Assessing Lesions • Vary in size, shape and cause • Primary vs. Secondary • Erruptions: cysts, wheals, bullous, pustules, psoriasis, eczyma, vesicles, bullae, nodules, papules • Discoloration: macules (café-au-lait), Disorders Affecting the Skin Skin Lesions p.755 • Etiology – – – – – – Infections –herpes, impetigo, HIV, melanoma Toxic chemicals: skin irritation Physical trauma: burns, lacerations Hereditary factors External factors: allergens, contact dermitis Systemic diseases: measles, lupus, nutritional deficiency Skin Lesions • Nursing Process Care: – Assessment: descriptions; pt. history, causative factors – Evaluation of skin – identify problem – Nursing Diagnosis – Interventions for skin care to promote healing and prevent further injury – Pain management & comfort – Infection control – Nursing evaluation & reassessment Systemic Skin Diseases: Skin Disorders in Diabetes • Diabetes Dermapathy – shin spots, caused by break- down of small vessels that supply the skin. • Stasis Dermatitis – compromises circulation to the distal extremities due to damage of larger vessels. Problem: Injuries heal slow; increase risk for ulcerations; risk for skin infections Fungal infections of the Skin • • • • Tinea Pedis (athlete’s foot) Tinea Corporis (ringworm of the body) Tinea Capitis (scalp ringworm) Tinea Cruris (ringworm of the groin) – Jock itch jock, common in diabetes. • Tinea Unguium (ringworm of the nails) – onychomycosis Parasitic Infections • Pediculosis capitis - lice • Pediculosis corporis/pubis • Sarcoptes scabiei – scabies – Raised burrows found between fingers, wrists, elbows, nipples, feet, groin, gluteal folds, penis, scrotum – Poor hygienic living conditions – Increase; contagious – Secondary lesions: vesicles, papules, crust, excoriations Parasitic Infections – Appear 4 wks after exposure – Elderly patients from long term facilities – Lindane, crotamiton (Eurax), permethrin Nursing Diagnosis • Skin Impairment r/t: • GOAL: – Protect the skin – Prevent secondary infections – Promote healing Skin Care Review of wound dressings Wound Dressings • Occlusive – airtight cover applied to skin lesions • Wet –(obsolete) wet compresses applied on acute weeping, inflamed lesions • Moisture-retentive –more efficient wet drsg for removing excudate: impregnated with saline, petrolatum, zinc-saline, hydrogel, antimicrobial agents. – Avoids maceration , less infections, scarring & reduces pain. Wound Dressings • Hydrogels – polymers with 90% water content – superficial wounds, abrasions, skin graft sites, draining venous ulcers • Hydrocolloids –impermeable to water, O2 – Remain intact during bathing. – Produce foul-smelling yellowish covering – May leave on wound for 7 days – Promote debridment & granulation tissue Wound Dressings • Foam – hydrophilic absorption and hydrophobic backing to prevent leaking of exudate – Nonadherent; require secondary dressing – Used over bony areas and weeping wounds • Calcium alginates – absorbent fiber packing made from seaweed. – Absorbes exudate, best for macerated wounds, packing deep wounds, sinus tracking, heavy drainage - nonadherent