Let’s Get Skintimate:

Integumentary System

PROFESSOR HILL, RN, MN, MSG

NURSING 102

At the End of This Lecture, the Learner Will Be Able to:

• Discuss the physiology & function of the skin

• Perform an integumentary assessment

• Discuss pressure ulcers

Integumentary System

Assessment Includes:

SKIN

HAIR

SCALP

NAILS

•Epidermis

•Dermis

•Subcutaneous tissue

•Sebaceous glands

•Sweat glands

Epidermis

Dermis •Collagen (connective tissue)

•Resilient elastic tissue

•Contains nerves Sensory receptors, Blood vessels

•Hair follicles

•Sebaceous glands

•Sweat glands Eccrine sweat gland

Apocrine sweat glands

Subcutaneous

Tissue

Insulating layer of fat

Contains blood vessels, nerves and remaining portions of sweat glands & hair follicles

Eccrine sweat gland

Sweat glands

Eccrine glands Open directly onto skin Odorless,colorless fluid Over all skin surface

Apocrine glands Released into hair follicle Thick, milky secretions In axillae, anogenital region

Sebaceous glands

Assoc w/hair root Oil glands Produce sebum Lubricate skin & hair Located everywhere but palms & soles

Major functions of the Skin

Protection Temperature regulation Sensation Vitamin D production Immunity Absorption & Excretion Psychosocial

Function

Waterproof Sebum

Barrier to bacteria and other pathogens

Protects underlying tissue from injury Thermal Mechanical Chemical

Thermoregulation Vitamin synthesis

Vitamin D Sensory organ

Heat Cold Pain Touch Pressure

Excretion Secretion

Now, We Know About the Integumentary System, what’s next?

Every day is Christmas!

Visual Skin Assessment

Look at your patient…what do you see? General color Areas of breakdown What risks are in front of you?

Tactile Assessment

When you touch your patient, how do they feel? Temperature Turgor/Elasticity Moisture Texture

Integumentary Assessment

• Mucus Membranes– Color– Moisture

• Hair– Texture– Lubrication– Thick or Thin

Integumentary Assessment

Nails– Color

– Shape and

Thickness

– Texture

– Capillary Fill Time – (CFT)

Integumentary Alterations

Mucus Membranes

Stomatitis

Glossitis

Gingivitis

Parotitis

Cheilosis

Integumentary Alterations

HAIRHAIR

TERMINAL - LONG, COARSETERMINAL - LONG, COARSEVELLUS - SMALL, SOFTVELLUS - SMALL, SOFT

HIRSUTISMHIRSUTISMALOPECIAALOPECIA

ASSESS – ASSESS – DISTRIBUTION, TEXTURE,DISTRIBUTION, TEXTURE,LUBRICATION, THICKNESS ORLUBRICATION, THICKNESS ORTHINNESSTHINNESS

Skin Changes in the Older Adult

Subcutaneous & dermal tissue thin

Sebaceous & sweat glands decrease

Cell renewal is shorter

Melanocytes decline in number

Collagen fiber decreases

NORMAL CHANGES WITH AGINGNORMAL CHANGES WITH AGING

Integumentary Alterations

• Skin Color

Changes

– Pallor

– Cyanosis

– Jaundice (icterus)

– Erythema

SKIN COLORSKIN COLOR

PALLOR (DECREASE IN COLORPALLOR (DECREASE IN COLOR))

CYANOSIS (BLUISH TINGE)CYANOSIS (BLUISH TINGE)

ERYTHEMA (REDNESS)ERYTHEMA (REDNESS)

JAUNDICE (YELLOW)JAUNDICE (YELLOW)

SKIN LESIONSSKIN LESIONS

INSPECT FORINSPECT FOR PALPATE FORPALPATE FOR

COLORCOLOR MOBILITYMOBILITYLOCATIONLOCATION CONTOURCONTOURSIZESIZE CONSISTENCYCONSISTENCYGROUPINGGROUPINGDISTRIBUTIONDISTRIBUTION

IF MOIST OR DRAINING, NOTE:IF MOIST OR DRAINING, NOTE:COLOR, CONSISTENCY, ODOR, AMOUNTCOLOR, CONSISTENCY, ODOR, AMOUNT

Integumentary Alterations

Skin Lesions

Primary

Vesicles

Bullae

Pustules

Nodules

Tumors

Skin Lesions

Primary

Papules

Wheals

Plaques

Macules

Patches

Integumentary Alterations

Integumentary Alterations

Integumentary Alterations

Hirsutism and Alopecia

EDEMAS/SCAUSEINSPECT FOR: LOCATION,

COLOR, SHAPEDEPENDENT EDEMA/

PITTING EDEMA

ANKLES, SACRUMFEET

PRINCIPILES r/t MAINTAINING SKIN INTEGRITY

Healthy & unbroken skin- first line of defense

Skin’s resistance to injury

Adequately nourished & hydrated cells

Adequate circulation to cells

What Skin Alteration remains the biggest challenge facing practitioners today?

THE FINAL ANSWER IS:

PRESSURE ULCERS

What is a Pressure Ulcer?

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

National Pressure Ulcer Advisory Panel (NPUAP) Feb 2007National Pressure Ulcer Advisory Panel (NPUAP) Feb 2007

2.5 million patients treated yearly for PU

60,000 patients die yearly from complications

$11 billion yearly

How do Pressure Ulcers occur?

Pressure is Major Cause

Prolonged pressure at levels greater than capillary closing pressure will ultimately result in tissue necrosis.

Small amount of pressure over long period is just as damaging as large amount over short period.

Tissue tolerance

Friction-Visible on skin surface; two surfaces move against each other

Shear-Injury beneath skin surface; patient’s skin moves one way, bed sheets move opposite when moving patient

Not visible

Where are Pressure Ulcers located?

Area over any bony prominence is vulnerable! Sacrum Coccyx Heels Hips

In children, back of the head (occiput)

What Other Risk Factors Contribute to Pressure Ulcer

Development? Immobility Incontinence Inactivity Improper nutrition Impaired sensorium

MemoryJogger

Five I’s!

Pressure Ulcer Staging- Stage I

Intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Stage I Pressure Ulcer

NEW VOCABULARY!

Tissue Ischemia Hyperemia Blanching (pale & white) Blanching hyperemia Reactive hyperemia Non-blanching erythema Abnormal reactive hyperemia

Stage II Pressure Ulcer

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

May also present as an intact or open/ruptured serum-filled blister.

Stage II Pressure Ulcer

Stage III Pressure Ulcer

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.

Slough may be present but does not obscure the depth of tissue loss.

May include undermining and tunneling.

Stage III Pressure Ulcer

Stage IV Pressure Ulcer

Full thickness tissue loss with exposed bone, tendon or muscle.

Slough or eschar may be present on some parts of the wound bed.

Often include undermining and tunneling.

Stage IV Pressure Ulcer

Suspected Deep Tissue Injury

Purple or burgundy localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Suspected Deep Tissue Injury

Unstageable Pressure Ulcer

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Unstageable pressure ulcer

Reverse Staging

Stage III or IV pressure ulcers will not regenerate muscle, fat or dermis

During healing full thickness ulcers are filled with granulation tissue/ scar tissue

Staging Pressure Ulcers

As Registered Nurses, we must..

1. Conduct a pressure ulcer assessment on all patients upon admission

2. Inspect skin daily3. Manage moisture4. Optimize nutrition and hydration5. Minimize pressure

1. Conduct a Pressure Ulcer Admission Assessment

Assess for existing ulcers

Assess for risk factors

Use a validated risk assessment tool, such as the Braden scale or Norton Scale

Risk Assessment Scales

Braden Scale-Most widely used; focuses on intensity/duration of pressure & tissue tolerance for pressure; www.bradenscale.com

Norton Scale-Developed in United Kingdom; also used, but not as often

2. Inspect Skin Daily

When assisting to a chair or during bathing, for example

Pay attention to sacrum, back, buttocks, heels, and elbows

Check skin beneath tubes and devices Check areas such as the breasts, abdomen,

and knees in obese patients

3. Manage Moisture Clean the skin at routine intervals and

whenever the patient is incontinent Watch for excessive moisture due to

incontinence, perspiration, or wound drainage

Use appropriate cleaning agents Keep supplies at the bedside Clean soiled skin promptly Use moisture barriers as needed Use moisturizers for dry skin

4. Optimize Nutrition and Hydration

Unintentional weight loss may indicate risk Document intake Use supplements as needed Increase caloric intake by using an isotonic

nutritional supplement when administering medications

Respect dietary preferences Monitor hydration and offer water

5. Minimize Pressure Turn or reposition patients every 2 hours,

or more frequently for those with fragile skin or little subcutaneous tissue

Use alerts and cues as reminders for turning

Use lift devices or draw sheets Use heel and elbow protectors, or sleeves

and stockings Never drag the patient Keep the HOB at 30° or less Use pillows and cushions Use specialty pressure-relieving support

surfaces when appropriate Use bariatric beds when indicated

Remember..“Rule of 30”

ALTERNATIVES

Bariatric No Slip Wedge

Alternating Pressure Mattresses & Overlays

Location of pressure ulcer Size (length & width) Stage (indicates

depth/damage) Presence of sinus tracts Amount/color/consistency/ odor of exudate (drainage) Condition of periwound Any PU related pain/ per

patient

Documentation

Pressure Ulcer Treatment

Cleansing the wound bed

Maintain a moist wound bed, free from infection & necrotic tissue

Keep surrounding tissue dry

Last Words…

Dressings should be individualized!

Pain should be assessed & adequately managed!

Don’t massage bony prominences, Don’t use doughnut-type devices, or allow skin to become dried out!

YES, We can conquer

Pressure ulcers!

Nursing Responsibilities/Interventions

for Hygiene care

Practice of caring & patient comfort

Assessment of patient’s ability to perform basic hygiene care

Delegation considerations Types of baths Patients with special needs Maintaining patient’s environment