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The Integument; Sensation: Hearing, Vision, Taste, Touch 1.

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Presentation on theme: "The Integument; Sensation: Hearing, Vision, Taste, Touch 1."— Presentation transcript:

1 The Integument; Sensation: Hearing, Vision, Taste, Touch 1

2  You are assigned to care for MX, an 87 year old obese (264 lbs) woman.  She arose from a sitting position and experienced severe low back pain 3 weeks ago.  Diagnosis: herniated disks L4-5 and L5-S1.  She states her legs feel like “noodles” and she can’t feel them very well.  Her temperature has increased from 98.2 to

3 What additional information do you need?  Subjective information  Objective information  Psychosocial information 3

4  Regulation of body fluids—prevent loss from deeper layers  Regulation of temperature—blood vessels in dermis  Regulation of immune function—prevent microbe invasion  Production of vitamin D activated by UV light  Sensory reception—detect touch, pressure, temperature, pain 4

5 5

6  Fine and coarse wrinkles  Rough, leathery texture  Mottled hyperpigmentation  Telangiectasia (dilated red splotches)  Actinic keratoses  Facial expression  Body image 6

7  Pigmentation changes—photoaging  Decrease in eccrine (total body), apocrine (armpits, genital, areolar, anal), sebaceous glands → dry skin  Decrease in number of blood vessels  Loss of eyelid elasticity  Decreased elastin, wrinkling  Adipose tissue redistributes to waist & hips 7

8  Changes in pigmentation  Decreased melanocytes with decreased photoprotection  Delayed wound healing  Onychomycosis common  Decreased touch receptors, corresponding slowing of reflexes and pain sensation 8

9  Contains less moisture  Epidermal mitosis slows, healing takes longer  Manufacture of vitamin D less efficient 9

10  Vitamin D promotes anti-inflammatory actions systemically to reduce the risk of coronary heart disease  Vitamin D level is inversely correlated with coronary artery calcification  Vitamin D promotes absorption of calcium and phosphorus by bone 10

11 Skin cancers Skin tears Pressure ulcers 11

12  Avoid drying of the skin in the elderly!  Promote skin nutrition and hydration through bath oils, lotions and massage  Vitamins and vitamin supplements  Avoid excessive bathing  Early treatment of pruritis 12

13  Elastin decreases in quality but increases in quantity leading to wrinkles  Vascularity decreases  Capillaries become thinner and more easily damaged  Decline in touch and pressure sensations 13

14  Subcutaneous tissue thinner in the face, neck, hands and lower legs  More visible veins  Fat distribution more obvious in abdomen and thighs in women, the abdomen in men 14

15  Gray or white hair  Hair becomes more coarse and thin  Gradual loss of pubic and axillary hair  Facial hair in women  Ear and nose hair in men  Hair loss, men > women  Nails duller, yellow or grey  Nail growth slows  Longitudinal striations 15

16  Decreased sweating and thermoregulation  Amount of sebum decreases, causing less water in stratum corneum resulting in xerosis 16

17  Most common dermatologic complaint in the elderly  Drying of the skin by any means  Diabetes, atherosclerosis, hyperthyroidism, urea, liver disease, cancer, pernicious anemia, some psychiatric diseases  Problem: traumatizing scratching 17

18  Bath oils, massage  Moisturizing lotions  ZnO 2 may be applied topically 18

19  Photoaging—long-term UVR damage  Exposed areas of the face, neck, arms, and hands  Freckling, loss of elasticity, damaged blood vessels, weathered appearance  May result in actinic keratosis, a precancerous lesion 19

20  Avoid tanning and sunburn  Sunscreen daily, SPF 30  Moisturize  Protective clothing  Protective accessories that block UV rays: umbrellas, sunglasses, window shades and car window tints 20

21  Antibiotics: Doxycycline, tetracycline, quinolones  Antidepressants: tricyclic antidepressants  Antihistamines: diphenhydramine  Nonsteroidal anti-inflammatories: ibuprofen  Diuretics: furosemide, hydrolorothiazide  Antihypertensives: Cardizem, diltiazem  Cholesterol drugs: simvastatin, lovastatin  Hypoglycemics: glipizide, glyburide  Sulfonamides: sulfadiazine, sulfamethoxazole 21

22  Most common precancerous lesion  More common in men  1 in 1000 will progress to skin cancer (usually squamous cell carcinoma) within 1 year  Ill-defined border  Back of hands, face, forearm, V of neck, nose, ears, bald scalp 22

23  Basal cell carcinoma—waxy, pigmented, may be erythematous, papular or scaly macular  Squamous cell carcinoma— firm to hard, erythematous, nodular or ulcerated nodular, especially on dorsum of hands, forearms and face 23

24  Those who have had one nonmelanoma skin cancer is at risk for future skin cancers  Any suspicious lesion should be biopsied  Risk for skin cancer associated with total amount of time spent in the sun  Basal cell rarely metastasizes  Squamous cell can metastasize 24

25  Occur easily in frail elderly  Classification ◦ Category 1: linear or flap type without tissue loss ◦ Category 2: partial tissue loss ◦ Category 3: full thickness tissue loss 25

26  Fragile skin that damages easily  Poor nutritional status  Reduced sensations of: pressure and pain  Elderly have more frequent encounters with conditions that contribute to skin breakdown 26

27  Serum albumin—indicator of protein stores ◦ g/dl is normal  Prealbumin—indicator of protein deficiency ◦ >15 mg/dl is normal  Lymphocyte count—indicator of protein malnutrition ◦ µL is normal 27

28  Can develop on any part of the body  Caused by tissue anoxia and ischemia  Most common sites: Sacrum (most distal portion of spine) Greater trochanter (head of femur) Ischial tuberosities (protuberance of proximal hip) 28

29 Risk of developing pressure ulcers based on evaluation of six areas: 1. Sensory perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and shear 29

30 30

31 Prevention is based on 6 areas of Evaluation:  Avoid unrelieved pressure  Encourage activity  Turn every hour  Pillow  Flotation pad  Encourage outside activities  Avoid shearing forces 31

32  High protein, vitamin rich diet  Good skin care  Bath oils and lotions  Keep skin dry  Massage bony prominences  Range of motion at least daily 32

33  Persistent redness (erythema or hyperemia)  Ischemia (erythema with edema and induration)  Skin is still intact  Erythema does not blanch when pressure applied 33

34  Partial skin thickness loss  Appearance of an abrasion, a blister, a shallow ulcer 34

35  Full skin thickness loss  Subcutaneous tissue is exposed  Appearance of deep ulcer  May or may not be undermining of surrounding tissue 35

36  Full skin thickness loss  Subcutaneous tissue loss  Muscle and or bone is lost  Deep ulceration  May be accompanied by: Necrosis Sinus tract formation Exudate Infection 36

37  Hyperemia—relieve pressure, use of adhesive foam  Ischemia—skin protectant solutions, clean with normal saline at least daily if skin broken  Necrosis—transparent dressing permeable to oxygen and water vapor, irrigate thoroughly, topical antibiotics  Ulceration—debridement is required 37

38  Debridement of nonviable (necrotic) tissue  Keep wound clean  Dress to keep moist wound bed  Prevent and treat infection 38

39  Occurs when one or more types of bacteria enter through a break in the skin  Most common types of bacterial causes of cellulitis ◦ Streptococcus ◦ Staphylococcus ◦ MRSA is increasing  The most common location is the lower leg 39

40  Skin surrounding eye becomes thinner  Eyelid musculature decreases ◦ Ectropion ◦ Entropion  Decreased visual acuity, color discrimination  Atrophy of lacrimal glands  Increase intraocular pressure (IOP)  Arcus senilis 40

41 More light required to see clearly ↓ Ability to see in dark ↓ Ability to recover from glare 41

42  Macula absorbs excess blue and UV light, promoting visual acuity. Macular degeneration affects central vision and visual acuity  Cataracts—clouding of the lens covering the eye  Glaucoma--⇧IOP causes optic nerve damage 42

43  Age > 50 years  Cigarette smoking  Family history of macular degeneration  Increased exposure to UV light  Caucasian  Light colored eyes  Hypertension or cardiovascular disease  Lack of dietary antioxidants and zinc 43

44 44

45  Increased age  Smoking and alcohol  Obesity  Diabetes, hyperlipidemia, hypertension  Eye trauma  Exposure to sun  Long term use of corticosteroid medications  Caucasian race 45

46 46

47  Increased IOP  Age > 60 years  Family history of glaucoma  Myopia, diabetes, hypertension, migraines  African American ancestry 47

48 48

49  Β-blockers → bradycardia, CHF, syncope, bronchospasm (Timoptic, Betagan)  Adrenergics → palpitations, hypertension, tremor (Lopidine)  Miotics/cholinesterase inhibitors → bronchospasm, N/V, abdominal pain (pilocarpine)  Carbonic anhydrase inhibitors → renal failure, hypokalemia, diarrhea (Trusopt, Azopt) 49

50  Hearing impairments and loss affect communication and desire to interact  Cerumen tends to be drier, harder  Pruritis of canal is common  Most hearing changes are attributable to exposure to loud sounds 50

51  Conductive hearing loss—process of the external or middle ear canal  Sensorineural hearing loss—process of the inner ear 51

52  Prompt and complete treatment of ear infections  Prevention of trauma  Regular audiometric exams  Evaluate for cerumen collection  Remove cerumen by gentle irrigation  Avoid cotton applicators in ear  Educate regarding effects of environmental noise 52

53 53

54  Ototoxicity—gentamycin, erythromycin, cisplatin, furosemide  Tinnitus—gentamycin, erythromycin, baclofen, propanolol, aspirin 54

55  Eliminate extraneous noise  Stand 2 to 3 feet from the patient  Eye contact  Use lower pitch of voice  Frequent pauses  Speak slowly and clearly  Ask for validation of understanding 55

56  Check surface of ear mo mold  Check the battery  Do the dials work?  Are the dials functioning?  Is the tubing patent and connected properly? 56

57  Slowing of conduction of nerve impulses  Causes decreased perception of pain and temperature  Creates risk for injury  Contributes to sensation of isolation and decreased interaction with others  Remember the value of therapeutic touch! 57

58  Frequent monitoring of skin for intactness  Note and educate regarding safety risks  Teach patient to assess skin regularly 58

59  What is your nursing diagnosis for MX?  What is your desired outcome?  What are appropriate interventions pertinent to your desired outcome? 59

60  Patient will have no alteration in body temperature by (date). ◦ Monitor for signs/symptoms of infection every 4 hours. ◦ Monitor skin and mucous membrane integrity every 2 hours. ◦ Monitor intake and output every hour. ◦ Provide cooling measures within parameters described by health care provider. ◦ Collaborate with health care team in identifying causative organisms. 60

61  Patient will identify behaviors contributing to her risk for injury and corrective measures by (date). ◦ Keep bed locked and in low position ◦ Assess patient safety status every hour and remind of location of call light. ◦ Provide night light. ◦ Assist patient with transfers and ambulation. 61

62  Patient will exhibit structural intactness of skin by (date). ◦ Perform active or passive ROM at least once per shift at time of bathing or position change. ◦ Reduce pressure on skin surfaces by using egg crate mattress. ◦ Collaborate with dietitian regarding well-balanced or weight reduction diet. ◦ Facilitate fluid intake by offering water every hour. ◦ Maintain good body hygiene using lotion and massage. 62


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