Management of Clients with Integumentary Problems

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Management of Clients with Integumentary Problems
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Brief Review of Integumentary System

• Comprised of skin, hair and nails
• First line of defense
• Barrier between internal and external environment
• Largest organ of the body

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Brief Review of Integumentary System (Table
66-1, p. 1498)

• Physiologic Functions
• Protection
• Water balance
• Temperature regulation
• Sensory organ
• Vitamin synthesis
• Psychologic Function
• Psychosocial

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Integumentary Assessment History

• An accurate history is needed before physical
  examination
• Demographic data
• Many integumentary changes are a result of aging
  (Chart 66-1, p. 1499)
• Personal and family history
• Medication history
• Diet history
• Socioeconomic background
• Current health problems

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Integumentary Assessment Exam

• Inspection
• Observe all areas
• Systematic assessment
• obvious changes in color or vascularity
• Presence of absence of moisture
• Edema
• Skin lesions
• Skin integrity
• Palpation

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Integumentary AssessmentPsychosocial and
Laboratory

• Psychosocial
• Assess for altered perceptions in body image or
  disturbances in self concept
• Assess for social isolation
• Laboratory Tests
• Microscopic examination
• Cultures
• Biopsies

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Pruritis

• Itching caused by stimulation of itch-specific
  nerve fibers at the dermal-epidermal junction
• Scratching brings relief, but causes the
  itch-scratch cycle
• Associated with local (skin lesions) or systemic
  (liver, venous) disorders
• Care goal promote comfort and prevent
  alterations in skin integrity
• Therapeutic baths
• Antihistamines /or topical steroids

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Urticaria

• White or red edematous papules or plaques of
  varying sizes
• Usually caused by exposure to a specific noxious
  stimulus which causes release of histamines
• Exact cause not always identified, possible
  factors
• Drug -- Foods -- Infections --
  Autoimmune disease
• Malignancies -- Physical stimuli --
  Psychogenic reactions
• Treatment aimed at removal of potential stimulus
  and relief of symptoms
• Antihistamines
• Avoidance of overexertion, alcohol consumption,
  and warm environments

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Skin Trauma

• Varies from neat, aseptic surgical incision to
  grossly infected, draining wound
• Stimulates a series of events for repair and
  re-establishment of the skin as a barrier
• Phases of wound healing
• Inflammatory
• Fibroblastic
• Maturation
• Length of each phase dependent upon type of
  injury and whether wound heals by first, second
  or third intention

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Pressure Ulcers

• Lesion from unrelieved pressure causing damage of
  underlying tissue or a localized area of cellular
  necrosis resulting from vascular insufficiency in
  tissues under pressure
• Occurs with limited mobility
• Once formed, pressure ulcers are slow to heal
• Result from mechanical forces
• Occurs most often over bony prominences

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Pressure Ulcers

• Mechanical
• Forces
• Pressure
• Friction
• Shear
• Causes
• Mechanical
• Trauma
• Tissue
• Anoxia

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Pressure Ulcers Prevention

• Recognize high risk clients
• Risk assessment scale (Braden or Norton)
• Mental status
• Active vs. Passive participant
• Activity/mobility status
• Level or mobility a direct factor
• Nutritional status
• Positive nitrogen balance is essential
• Incontinence
• Urine/feces are irritants to skin

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Pressure Ulcers Prevention

• Aggressive approach to pressure relief
• Must consider capillary closing pressure
• Amt. of pressure needed to occlude skin capillary
  blood flow in the area at risk
• Normal 12-32 mm HG
• Pressure relief and reduction devices
• Dynamic vs. Static
• Positioning
• 30º rule
• Change positions at least every 2 hours

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Pressure Ulcers Key Things to Remember

• Pressure relieving/reducing devices do not take
  the place of observation of skin color,
  integrity, and temperature at intervals to
  determine capillary blood flow.
• In some clients pressure can occur in less than 2
  hours the actual turning/repositioning schedule
  should be individualized based upon assessment
  data

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Pressure Ulcers Wound Assessment

• Appearance changes with the depth of injury
• Assess for
• Location, size, color
• Extend of tissue involvement
• Condition of surrounding tissue
• Presence of foreign bodies
• Cellulits
• Eschar
• Undermining

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Stages of Pressure Ulcers

• Stage I

• Stage II

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Stages of Pressure Ulcers

• Stage III

• Stage IV

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Pressure Ulcers Nursing Diagnosis

• Impaired skin integrity
• Pain
• Disturbed body image
• Ineffective coping
• Imbalanced nutrition less than body requirements
• Deficient knowledge

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Pressure Ulcers Impaired Skin Integrity

• Wound care techniques will vary
• Non-surgical Management
• Dressings (Table 67-5, p. 1527)
• Physical therapy
• Drug therapy
• Diet therapy
• Surgical Management
• Sharp debridement
• Skin grafting

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Pressure Ulcers Risk for Infection and Extension

• Frequent monitoring of ulcer progress
• Prevention of infection and wound extension
• Be alert for classic signs of wound infection
• Prevent further pressure damage
• Maintaining a safe environment
• Meticulous local wound care
• Minimize cross-contamination with pathogens
• Standard precautions
• Thorough handwashing before and after dressing
  changes

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Skin Infections

• Bacterial Infections
• Usually start at the hair follicle
• Folliculitis superficial infection of upper
  portion of follicle caused by staph
• Furuncles infection caused by staph is deeper in
  hair follicle (boil)
• Cellulitis is a generalized non-follicular
  infection of the deeper tissues caused by either
  staph or strep
• Can spread infection to other parts by scratching

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Viral Skin Infections

• Herpes Simplex
• Type I cold sore
• Type II genital lesions
• After primary infection virus remains dormant in
  the nerve ganglia
• Physical or psychological stressors can
  reactivate the infection
• Time between episodes and the severity of
  individual attacks will vary

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Viral Skin Infections

• Herpes Zoster
• Reactivation of latent varicella zoster virus
• Resides in dorsal root ganglia of the sensory
  cranial and spinal nerves
• Multiple lesions, segmentally distributed on skin
  area innervated by infected nerve
• Discomfort is experienced before eruptions and
  can persist after lesions are healed
  (postherpetic neuralgia)
• Herpes Zoster is contagious to those who have
  never had chickenpox

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Fungal Skin Infections

• Dermatophytoses (superficial)
• Term tinea plus the term for the location is used
  to describe
• Infection occurs when infecting organism come in
  contact with impaired skin surface of a
  susceptible host
• Most infections spread by direct contact
• Tinea capitus and tinea corporus can be spread by
  inanimate objects

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Skin Infections Assessment

• History clinical manifestations provide
  direction for data collection
• Physical exam many skin lesions are contagious,
  precautions to prevent spread must be taken
• Lab swab culture, blood culture, viral culture

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Skin Infections Interventions

• Non-surgical
• Meticulous skin care
• Antibacterial soaps or baths
• Astringent compresses
• Isolation precautions
• Minimize spread of microorganisms
• handwashing
• Drug therapy
• Topical medications (antibacterial, antifungal)
• Acyclovir for viral infections (topical or oral)
• Surgical Management
• Not indicated except for ID of furuncles or when
  lesion progresses to full-thickness in
  immunocompromised person

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Parasitic Disorders

• Pediculosis
• Lice infestation
• Transmitted by contact or sharing of combs, hats,
  etc.
• Pruritis- most prominent symptom
• Can result in secondary infection
• Lindane
• Wash clothing and linens
• Environment clean-up

• Scabies
• Contagious mite infestation which causes a
  hypersensitivity reaction
• Transmitted by close and prolonged contact
• Epidermal ridges skin between fingers, palms and
  volmar aspect of wrists
• Confirmed by skin scraping
• Lindane/topical sulfur
• Launder clothes and bed linens

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Skin Tumors (Benign)

• Cysts firm, flesh-colored nodules that contain
  liquid or semi-solid material
• Seborrheic keratoses benign epidermal neoplasm
  common in elderly
• Keloids overgrowth of scar from excessive
  accumulation of collagen and ground substance
  after skin trauma
• Nevi (mole) benign neoplasm of pigment forming
  cells
• Warts small tumors caused by papillomaviruses
• Hemangiomas blood vessel tumors

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Skin Cancers

• Actinic/solar keratosis
• Premalignant
• May progress to squamous cell
• Squamous cell
• Cancer of epidermis
• Potentially metastatic
• Basal cell
• Metastasis is rare
• Underlying tissue destruction
• Melanoma
• Originate in melanin-producing cells of epidermis
• Highly metastatic

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Skin Cancers Interventions

• Non-surgical management
• Drug therapy
• Topical chemotherapy
• Systemic chemotherapy
• Interferon after OR for melanoma
• Radiation therapy
• Limited to older clients with large, deeply
  invasive basal cell tumors or poor surgical risks
• Immunotherapy
• Experimental, melanoma vaccine

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Skin Cancer Interventions

• Surgical Management
• Cryosurgery
• Local application of liquid nitrogen
• Curettage/electrodesiccation
• For small lesions with well defined borders
• Excision
• For large of poorly defined skin cancers,
  recurrent tumors and deeply invasive cancers