N210 Week 2 Lecture Tissue Integrity

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N210 Week 2 Lecture Tissue Integrity
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N210 Week Lecture Tissue Integrity
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  1. 1. Summarize the physiology of the integumentary system related to skin integrity. (Ch. 31, pp. 955-957)
    • a. Skin, integument, largest organ in the body
    • The Integumentary System is made up of…
    • 1. Skin
    • a. Consists of 2 layers
    • 1. Epidermis: Protective waterproof barrier
    • 2. Dermis: Nerves, hair follicles, glands, and blood vessels are in this layer
    • 2. Subcutaneous layer directly under the skin
    • a. It is the underying layer that anchors the skin layers to the underlying tissues of the body
    • 3. The appendages of the skin
    • 4. Includes glands in the skin, hair, and nails
    • 5. Also includes the blood vessels, nerves, and sensory organs of the skin
    • b. Functions of the skin and mucous membranes
    • • Skin
    • a. Protection
    • b. Temperature regulation
    • c. Psychosocial
    • d. Sensation
    • e. Vitamin D production
    • f. Immunolgic, absorption
    • g. Elimination
    • • Mucous Membranes
    • a. Line body cavities that open to the outside of the body
    • b. Found in digestive tract
    • c. Respiratory passages
    • d. Urinary and Reproductive tracts
    • e. They have receptors that act as body protection
  2. 2. Examine the relationship between tissue integrity and other concepts/systems. (Ch. 31, pp. 957-958)
    • a. Healthy, unbroken skin help and mucous membranes are the first line of defense against harmful agents
    • b. Resistance to injury of the skin and mucous membranes varies among people
    • 1. Factors influencing resistance includes
    • a. Person's age
    • b. The amount underlying tissue
    • c. Illness conditions
  3. • Therapeutic Measures
    • A. Bed rest
    • 1. Bed rest predisposes patients to skin breakdown
    • 2. Harsh detergents on hospital laundry compound this problem
    • 3. Pressure points need to be examined frequently and protected
    • B. Casts
    • 1. Casts easily irritate skin
    • 2. Careful assessment, covering the edge of the cast, and skin care are indicated
    • C. Aquathermia unit
    • 1. Wet heat is beneficial but if applied too long, may macerate the skin
    • 2. Follow protocol in length of application
    • 3. Examine skin carefully between treatments and allow to dry
    • D. Medications
    • 1. May cause allergic skin reactions, such as rashes
    • 2. When evaluating a patient's response to a new drug, examine the skin for redness and itching
    • E. Radiation Therapy
    • 1. Exposes skin cells as well as cancer cells in treatment field to effects of radiation
    • a. Potential for erythema and mooist desquamation (loss of skin integrity)
  4. 4. Differentiate common assessment procedures used to examine tissue integrity. (Ch. 31, pp. 974, Focused Assessment Guide 31-1, Ch.24, pp.638-841)
    • • Assessments for Skin Integrity (YOU HAVE TO ASK QUESTIONS and BE DILIGENT IN YOUR OBSERVATIONS FOR YOUR PATIENT ASSESSMENTS)
    • • Appearance of skin
    • 1. Discolored areas of skin
    • 2. Areas of skin warmer / colder than others
    • 3. Moisture: damp, dry, mild
    • 4. Thinner skin
    • 5. Swelling in feet, ankles, or fingers
    • 6. Skin care
    • a. Bath / shower
    • b. How often
    • c. Oils / lotions
    • b. Recent changes in skin
    • 1. Developing sores
    • a. How many
    • b. Where are they
    • c. Size change
    • d. Any drainage from them
    • 2. Redness of skin over the hips and backbone if you sit up or lie in one position for a long time
    • a. Doesit disappear in a short time when you are up
    • b. Recent tattoos / piercings
    • c. Activity / Mobility
    • 1. Assistance walking / moving
    • 2. Confined to a bed or chair when up
    • 3. Ability to change positions independently
    • d. Nutrition
    • 1. Recent weight gain / loss
    • 2. Description of usual meals a day
    • 3. Glasses / cups of liquid per day
    • 4. Food supplements or vitamins
    • 5. Preparation of own meals
    • 6. Dentures
    • a. Do you wear them
    • b. How do they fit
    • 7. Difficulty swallowing
    • 8. Anemic by doctor's diagnosis
    • e. Pain
    • 1. If you have a sore, is it painful
    • 2. Anything taken for pain
    • a. How much
    • b. How often
    • c. Does it help
    • f. Elimination
    • 1. Any problems with bowels or urination, if so, describe
    • 2. Pad or special pants use because of uncontrollable urine or stool
  5. 5. Explain management of tissue integrity and prevention of impaired tissue integrity. (Ch.31, pp. 960, Table, Focus on the older adult, Nursing strategies…changes in skin)
    • • Age-related changes (ARC)
    • Subcutaneous and dermal tissue become thin
    • a. Skin is more easily injured
    • b. Skin has less capacity to insulate
    • c. Skin wrinkles more easily
    • d. Sensation of pressure and pain is reduced
    • • Nursing strategies (NS)
    • a. Do not apply tape to skin unless necessary
    • b. Check skin frequently to observe for signs o pressure ulcer
    • c. Pad bony prominences if necessary
    • d. Assess pressure tolerance by checking pressure points for redness after 30 minutes
    • • Age-related causes
    • Activity of the sebaceuos and sweat glands decreases
    • a. Skin becomes dryer
    • b. Pruritis (Itching) may occur
    • • Nursing strategies
    • a. Clean perineal area daily but do not bathe full body on a daily basis
    • b. Apply lotions as needed
    • c. Encourage adequate hydration
    • • Age-related causes
    • Cell renewal is shorter
    • a. Healing time is delayed
    • • Nursing strategies
    • a. Perform careful skin assessments, looking for signs of skin break down
    • • Age-related causes
    • Melanocytes (cells that make pigment that colors hair an skin) decline in number
    • a. Hair becomes gray-white
    • b. Skin may be unevenly pigmented
    • • Nursing strategies
    • a. Assist patient with skin check, observing for any signs of melanoma or other skin abnormalities
    • • Age-related causes
    • Collagen fiber is less organized
    • a. Skin loses elasticity
    • • Nursing strategies
    • a. Check skin frequently for tears, irritation, or breakdown
  6. 6. Compare and contrast common independent and collaborative interventions for clients with alterations in tissue integrity.
  7. 7. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of pressure ulcers. (Ch. Pp 966-967)
    • Pressure Ulcers (Bed sores): A wound with a localized area of injury to the skin and/or underlying tissue
    • A. Pathophysiology
    • 1. Results from blood vessel collapse caused by pressure, usually from body weight
    • 2. Two mechanisms contribute to pressure ulcer development
    • 1. External pressure that compresses blood vessels
    • 2. Friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin
    • B. Etiology (Causes)
    • 1. Caused by pressure
    • a. Soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue is undergoes pressure in combination with shear and/or friction
    • b. External pressure
    • 1. Ischemia (deficiency of blood in a particular area)
    • 2. Hypoxia (inadequate amount of oxygen available to cells)
    • 3. Edema
    • 4. Inflammation
    • 5. Necrosis
    • 6. Ulcer formation
    • c. Pressure ulcers can form in 1 to 2 hours if circulation of blood flow is stimulated
    • d. Friction and shear
    • 1. Occurs when two surfaces rub against each other
    • 2. Friction burns common on elbows, heels, and back
    • 3. Shear
    • a. When one layer of tissue slides over the another layer
    • 1. Small blood vessels and capillaries in the area are stretched and possibly tear
    • a. Causes decreased circulation
    • b. Can happen if patients are pulled and not lifted
  8. 8. Identify risk factors and prevention measures associated with pressure ulcers. (Ch. 31, pp. 966-968)
    • A. Immobility
    • 1. Patients who spend long periods of time in bed or are unable to shift body weight properly
    • a. Surgery
    • b. Use of tranquilizers and sedatives
    • B. Nutrition and hydration
    • 1. Protein-calorie malnutrtion
    • 2. Dehydration
    • 3. Edema (excess of watery fluid collecting in the cavities or tissues of the body)
    • C. Skin moisture
    • 1. Perspiration
    • 2. Urine
    • 3. Feces
    • 4. Drainage from wounds
    • D. Mental status
    • 1. The more alert a person is, the more likely they are to protect their skin by maintaining adequate hygiene
    • 2. Apathy, confusion or comatose state can diminish self -care abilities
    • E. Age
    • 1. Older adults are at greater risk
    • 2. Chronic diseases and debilitating diseases can affect circulation and oxygenation of dermal structure
  9. 9. Formulate priority nursing diagnoses appropriate for an individual with pressure ulcers. (Ch. 31, pp. 976-978)
    • A. Risk assessment
    • 1. Norton Scale
    • a. Physical condition
    • b. Mental condition
    • c. Activity
    • d. Mobility
    • e. Incontinence
    • 2. Braden Scale
    • a. Mental status
    • b. Continence
    • c. Mobility
    • d. Activity
    • e. Nutrition
    • B. Mobility
    • 1. Evaluating a patient's ability to…
    • a. Move
    • b. Turn
    • c. Reposition the body
    • 2. This evaluation is done upon admission to the facility or during the initial home care interview
    • C. Nutritional Status
    • 1. Adequate nutrition is needed especially in older adults
    • a. Advocates for optimal health and healing
    • D. Appearance of existing pressure ulcers
    • 1. Location of any lesion or ulcer
    • 2. Identification of stage
    • 3. Color and type of wound tissue
    • 4. Presence of abnormal pathways
    • a. Sinus tract or tunneling
    • 5. Visible necrotic tissue
    • 6. Presence of an exudate or drainage (amount and type)
    • 7. Odor
    • 8. Presence or absence of granulation tissue
    • 9. Visible evidence of epithelialization
    • 10. Periwound skin condition
  10. 1. An abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another

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