Nursing care of the integumentary System
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Nursing Care of the Nursing Care of the Integumentary SystemIntegumentary System
HACCHACCCentral Pennsylvania’s Community CollegeCentral Pennsylvania’s Community College
N 103 AN 103 A
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Anatomy Overview of SkinAnatomy Overview of Skin
Epidermis Epidermis Outer layerOuter layer Shields underlying tissueShields underlying tissue
DermisDermis Contains collagen and elastic fibersContains collagen and elastic fibers Nerve fibers, blood vessels, sweat glands, sebaceous Nerve fibers, blood vessels, sweat glands, sebaceous
glands and hair folliclesglands and hair follicles
SubcutaneousSubcutaneous Contains blood vessels, nerves, lymph, and loose Contains blood vessels, nerves, lymph, and loose
connective tissueconnective tissue
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Skin Cross-SectionSkin Cross-Section
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Normal Functions of SkinNormal Functions of Skin
ProtectionProtection HomeostasisHomeostasis Temperature RegulationTemperature Regulation Sensory Organ/SensationSensory Organ/Sensation Excretion/secretionExcretion/secretion Vitamin SynthesisVitamin Synthesis PsychosocialPsychosocial
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Perspiration and EvaporationPerspiration and Evaporation Evaporation is the transfer of heat energy Evaporation is the transfer of heat energy
when a liquid is changed to a gas. The body when a liquid is changed to a gas. The body continuously loses heat by evaporation. continuously loses heat by evaporation.
By regulating perspiration the body promotes By regulating perspiration the body promotes additional evaporative heat loss.additional evaporative heat loss. Exercise, emotional and mental stress causes Exercise, emotional and mental stress causes
increased metabolic rateincreased metabolic rate Diaphoresis is visible perspiration primarily Diaphoresis is visible perspiration primarily
occurring on the forehead, upper thorax, and occurring on the forehead, upper thorax, and other places on the bodyother places on the body Excessive evaporation causes skin scaling and Excessive evaporation causes skin scaling and
itchingitching
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Factors Affecting Factors Affecting Temperature RegulationTemperature Regulation
AgeAge ExerciseExercise Hormone levelsHormone levels Circadian RhythmCircadian Rhythm StressStress EnvironmentEnvironment
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Problems with Temperature Problems with Temperature RegulationRegulation
Hyperthermia: elevation in body Hyperthermia: elevation in body temperature over normal limitstemperature over normal limits
Hypothermia: body temperature lower than Hypothermia: body temperature lower than normalnormal
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Hyperthermia/PyrexiaHyperthermia/Pyrexia
What is normal body temperature?What is normal body temperature?
Low grade elevation: 98.8-100.6Low grade elevation: 98.8-100.6
High grade elevation: >100.6High grade elevation: >100.6
Hyperthermia: over 104.9Hyperthermia: over 104.9
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Hyperthermia’s CausesHyperthermia’s Causes
InflammationInflammation AllergyAllergy InfectionInfection Drug reactionDrug reaction Cerebral or Neurological injuryCerebral or Neurological injury Idiopathic (FUO)Idiopathic (FUO)
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SymptomsSymptoms
ColdCold HeadacheHeadache MalaiseMalaise Skin flushingSkin flushing DiaphoresisDiaphoresis TachycardiaTachycardia TachypneaTachypnea
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Nursing Interventions: FeverNursing Interventions: Fever
Promote cool environmentPromote cool environment
Encourage fluidsEncourage fluids
Antipyretic medicationsAntipyretic medications
Reassess temperature frequentlyReassess temperature frequently
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Drugs Acting on Thermal Drugs Acting on Thermal RegulationRegulation
acetylsalicylic acid (Aspirin)acetylsalicylic acid (Aspirin)
acetaminophen (Tylenol)acetaminophen (Tylenol)
ibufrofen (Advil, Motrin)ibufrofen (Advil, Motrin)
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HypothermiaHypothermia
Prolonged exposure to coldProlonged exposure to cold Body temp lower than normal: mild to Body temp lower than normal: mild to
profoundprofound Cell function in all body cells declinesCell function in all body cells declines
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Signs of HypothermiaSigns of Hypothermia
Decrease in vital signs, shivering, chillsDecrease in vital signs, shivering, chills Waxy, pale cool skinWaxy, pale cool skin Decreased urinary outputDecreased urinary output Decreased muscle coordinationDecreased muscle coordination DisorientationDisorientation Drowsiness progressing to coma Drowsiness progressing to coma
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Nursing InterventionsNursing InterventionsHypothermiaHypothermia
Warm environmentWarm environment Warm blankets, dry clothingWarm blankets, dry clothing Warm oral/intravenous fluidsWarm oral/intravenous fluids Keep limbs close to bodyKeep limbs close to body
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Application of Heat and ColdApplication of Heat and Cold
Physician’s order neededPhysician’s order needed
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Assessment Prior to Therapy Assessment Prior to Therapy Warm or ColdWarm or Cold
Temperature toleranceTemperature tolerance Circulatory stateCirculatory state Neurological responseNeurological response Medication decreasing sensitivityMedication decreasing sensitivity Age Age New tissue (skin)New tissue (skin)
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Application of HeatApplication of Heat
HEATHEAT VASODILATION (Increasing blood flow), VASODILATION (Increasing blood flow),
MUSCLE RELAXATION, PAIN RELIEF, MUSCLE RELAXATION, PAIN RELIEF, INCREASES ROM, REDUCES JOINT INCREASES ROM, REDUCES JOINT STIFFNESSSTIFFNESS
MAY BE MOIST OR DRY FORMATMAY BE MOIST OR DRY FORMAT
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Application of ColdApplication of Cold
COLD: VASOCONSTRICTION (reduces COLD: VASOCONSTRICTION (reduces blood flow)blood flow)
REDUCES PAIN, DECREASES REDUCES PAIN, DECREASES BLEEDING, LOCAL ANESTHETIC BLEEDING, LOCAL ANESTHETIC EFFECT, DECREASES INFLAMMATIONEFFECT, DECREASES INFLAMMATION
MOIST OR DRY FORMATSMOIST OR DRY FORMATS
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Skin AssessmentSkin Assessment
Inspect the skin for:Inspect the skin for: ColorColor TextureTexture ThicknessThickness TurgorTurgor TemperatureTemperature HydrationHydration
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Common Nursing DiagnosesCommon Nursing Diagnoses
Risk for Impaired Skin IntegrityRisk for Impaired Skin Integrity Impaired Skin IntegrityImpaired Skin Integrity Disturbed body imageDisturbed body image Risk for imbalanced Body temperatureRisk for imbalanced Body temperature HyperthermiaHyperthermia HypothermiaHypothermia Ineffective ThermoregulationIneffective Thermoregulation
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Health TeachingHealth Teaching
Monitor skin dailyMonitor skin daily Report alterations/changesReport alterations/changes Keep well moisturizedKeep well moisturized Use sunscreenUse sunscreen Avoid direct sunlight between 10AM and Avoid direct sunlight between 10AM and
2PM2PM Know your family history of skin cancerKnow your family history of skin cancer
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Thank You!Thank You!
Questions/comments?Questions/comments?