1. Lecture 2B Fluid & electrolytes (Chapter 7) Integumentary System (chapters 44- 45)

2. Structure & Function of the Integumentary System 2 regions – Epidermis – Dermis

3. Epidermis Location: – Outermost part Melanin – Color – Protects from UV light Keratin – Water repellent

4. Epidermis Function – Protect!

5. Dermis Location – Deeper layer Contains – Blood vessels – Nerve endings – Lymphatic vessels – Hair follicles – Sebaceous glands – Sweat glands

6. Skin Assessment History – C/O Onset Duration Characteristics Relief factors Exacerbation – Changes Skin Meds

7. Skin Assessment Assess all skin areas – Redness – Swelling – Lesions – Pain Measure lesions

8. Common skin lesions Macule, patch – Flat, nonpalpable change in skin color. – Macule < 1 cm – Patch > 1 cm – i.e. freckles, Mongolian spots

9. Common skin lesions Papule, plaque – Elevated, solid, palpable mass with circumscribed border. – Papule < 0.5 cm – Plaque > 0.5 cm – i.e. moles, warts, psoriasis

10. Common skin lesions Nodule, tumor – Elevated, solid palpable mass extending deeper into the dermis than a papule – Nodule 0.5 – 2cm – Tumor > 2cm

11. Common skin lesions Vesicle, bulla – Elevated, fluid filled, round/oval shaped, palpable mass with thin translucent walls – Vesicle < 0.5 cm – Bulla >0.5 cm – i.e. herpes simplex, chicken poxs, burns

12. Common skin lesions Wheal – Elevated, often reddish, irregular borders, caused by diffuse fluid in the tissue rather than free fluid in a cavity – i.e. Insect bites, hives

13. Common skin lesions Pustule – Elevated pus-filled vesicle or bulla with circumscribed border. – i.e. acne, impetigo, carbuncles

14. Older skin Normal changes –  Subcutaneous tissue – Dermal thinning –  Elasticity –  Turgor –  Hair and nail growth

15. Common diagnostic test for integumentary disorders Biopsy – Skin sample – To rule out malignancy Nrs. Responsibility consent form signed Supplies Apply dressing Send specimen to the lab

16. Pressure ulcers AKA – Decubitus ulcers Ischemic lesions Caused by – External pressure – Friction – Shear

17. Pressure ulcer development Pressure  blood flow  oxygen ischemianecrosisulceration

18. High Risk Areas for Pressure ulcers Bony prominence – Heels – Greater trochanter – Sacrum – Ischia – Shoulder

19. Usual pressure ulcer locations Over Bony Prominences 1.Occiput 2.Ears 3.Scapula 4.Spinous Processes 5.Shoulder 6.Elbow 7.Iliac Crest 8.Sacrum/Coccyx 9.Ischial Tuberosity 10.Trochanter 11.Knee 12.Malleolus 13.Heel 14.Toes

20. Other locations… Any skin surface subject to excess pressure Examples include skin surfaces under: – Oxygen tubing – Urinary catheter drainage tubing – Casts – Cervical collars

21. Pressure Ulcers from other sources of pressure Boots/boot straps Heel protectors/protector straps Oxygen tubing Stockings Any device that can lead to pressure induced ischemia on the skin

22. High risk clients: pressure ulcers Immobile Elderly Incontinence Nutritional deficit Smoking

23. Complications Pain

24. Pain with Pressure Ulcers 59% report some degree of pain Only 2% receive pain medication within 4 hours of dressing change 45% report pain as distressing or horrible

25. Complications Pain Infection

26. Infection COMPLICATIONS Sepsis Localized infection Cellulitis Osteomyelitis

27. Complications Pain Infection Quality of life Cost Death

28. Mortality 40% die per year 60% die within 1 year after hospital discharge

29. Prevention!!! General Skin Care Assess Clean & Dry Avoid massage  Pressure Well balanced nutrition

30. Protect skin from Moisture Clean Moisturize Barriers Bowel & Bladder program

31. Pressure Reduction Rehabilitation   mobility Repositioning Pressure reduction devices Float Heels No sliding

32. nutrition and fluid Support Dietician Preferences Provide assistance & time Snacks and fluids Supplements Assess lab values

33. Pressure Ulcer Monitoring and Treatment

34. Description of Ulcers Stage Ulcer Location Size Wound bed Granulation tissue Necrotic tissue Wound edges Drainage Infection Pain

35. STAGING OF PRESSURE ULCERS Stage I: Persistent nonblanchable erythema of intact skin.

36. STAGING OF PRESSURE ULCERS Stage II: Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial and presents as an abrasion, blister, or shallow crater.

37. STAGING OF PRESSURE ULCERS Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

38. STAGING OF PRESSURE ULCERS Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts may also be present. Used with permission LWW

39. STAGING OF PRESSURE ULCERS Unstageable: Full thickness tissue loss in which slough (yellow, tan, gray, green or brown), eschar (tan, brown or black), or both in the wound bed cover the base of the ulcer.

40. Granulation tissue Intermediate step in healing Very fragile Appearance: Shiny red & grainy When inadequate blood flow exists, granulation tissue may pale in color.

41. Slough non-viable tissue and requires debridement Appearance – stringy mass Color – white, yellow/tan, brown Becomes thicker and harder to remove Easily confused with normal tissues (tendons)

42. Eschar Dead tissue, Color: – Tan, brown, black Leathery, dry hard Soft, with purulent discharge – Slimy.

43. Prevention Reposition – at least every 2 hours (may use pillows, foam wedges) Keep head of bed at lowest elevation possible Use lifting devices to decrease friction and shear Remind patients in chairs to shift weight every 15 min “Doughnut” seat cushions are contraindicated, may cause pressure ulcers Pay special attention to heels (heel ulcers account for 20% of all pressure ulcers)

44. PREVENTING HEEL ULCERS Assess heels of high-risk patients every day Use moisturizer on heels (no massage) twice a day Apply dressings to heels:

45. PREVENTING HEEL ULCERS Have patients wear:  Socks to prevent friction (remove at bedtime)  Properly fitting sneakers or shoes when in wheelchair Place pillow under legs to support heels off bed Place heel cushions to prevent pressure Turn patients every 2 hours, repositioning heels

46. PRESSURE-REDUCING SUPPORT SURFACES **Use for all older persons at risk for ulcers**

47. Nrs. Dx: Impaired tissue integrity Document Track progress Do not “reverse stage”  Ulcers do not replace lost muscle, subcutaneous fat, or dermis before re-epithelializing  E.g. Stage IV cannot become stage III

48. Dressing Keep wound bed moist Keep surrounding tissue clean & dry Do not use antiseptic agents

49. Types of Dressings Gauze Transparent films Hydrocolloid Hydrogel Alginates Foam Composite

50. Nrs. Dx: risk for infection Wound cleansing and dressing –  frequency when purulent or foul-smelling drainage is first observed – Avoid topical antiseptics because of their tissue toxicity topical antibiotics Cultures

51. Bacterial Infection Clinically Infected – redness – purulent drainage – foul odor – edema

52. Nrs. Dx: Alt. nutrition, less than body requirements nutritional assessment q day wts  Protein Lab – Albumin

53. MANAGEMENT: SURGICAL REPAIR used for stage III and IV Risks to benefits All wounds with necrotic tissue should be debrided

54. SUMMARY Older adults are at high risk for development of pressure ulcers Pressure ulcers may result in serious complications Techniques that reduce pressure, moisture, friction, and shear can prevent pressure ulcers Pressure ulcers should be treated with proper cleansing, dressings, debridement, or surgery as indicated