The Healing Process Chapter 13 NU 211

Phases Regeneration Repair – Fig 13-4 Primary Intention Secondary Intention Tertiary Intention

Factors Delaying Wound Healing Table 13-8 Nutritional deficiency Inadequate blood supply Corticosterioid drugs Infection Mechanical friction Age Obesity Diabetes

Complications of Healing Table 13-9 Hypertrophic scars – keloid formation Contracture Dehiscence Excess granulation tissue Adhesions

Nutritional Therapy Increased fluid intake necessary to promote wound healing Also replaces fluid lost to exudates High protein, carbohydrate diet Vitamin requirements: Vitamin C, B-complex, Vitamin A

Red – Yellow – Black Table 13-7 Sloughing tissue Necrotic tissue Granulating tissue

Pressure Ulcers Staging of ulcers (Figure 13-13) Staging may be difficult due to slough, and/or eschar Stage I Stage II Stage III Stage IV

Pressure Ulcers Nursing Intervention/Prevention Identification of clients at risk – Braden Skin Scale Impaired circulation Obesity Fever Anemia Contractures Confusion Physical dependence Immobility Incontinence Old age

Nursing Interventions PREVENTION Assessment of risk, implementation of prevention measures: special bed, turning schedule, elevation and protection of extremity, nutritional assessment referral Enterostomal Therapist: usually RN who sees clients with wounds and ostomies Health promotion: protect skin from sun exposure, use SPF 15+ NCP 13-1 Patient with a Pressure Ulcer Local care Debridement, wound cleaning, dressing and removal of pressure source

CMS – Centers for Medicare/Medicaid Services Never Pay! Stage 3 and Stage 4 pressure ulcers CMS Never Pay List

Problems of the Integumentary System Chapters 23 & 24

Structures of the Skin and Appendages Epidermis- Melanocytes Keratinocytes Dermis Supportive connective tissue layer Hypodermis Subcutaneous tissue

Epidermal appendages Hair Nails

Glands Sebaceous Apocrine Eccrine

Functions of the Integumentary System Surface barrier to the external environment Protection of underlying structures Sensory perception Pain, heat and cold, pressure and vibration Heat regulation Vasoconstriction Vasodilitation Aesthetic function - beauty

Effects of Aging on Integumentary System See Table 23-1 p.439 Skin  subcutaneous fat  extracellular water, lipids and sebaceous gland activity, blood supply Dry skin, bruising Hair  Melanin, oil, density Dry coarse hair Nails Thick, brittle nails  capillary refill time

Assessment of the Integumentary System Past health history Medications Surgery OBJECTIVE Data: See Table 23-8 Common Assessment Abnormalities Inspection (main diagnostic tool): color, pigmentation, vascularity, lesions or discolorations Palpation: temperature, turgor and mobility, moisture, and texture

Primary Lesions Table 23-4, 23-5 Characteristics of Primary and Secondary Skin Lesions Papule: raised, small, palpable Macule: flat, small

Vesicle – fluid filled

Plaque – sl. Elevated, circumscribed

Wheal – raised, itchy, blotchy, irregular

Table 23-7 Lesion Distribution Terminology Annular – circular Linear – in a line

Assessment of dark skin Easier if you assess areas where epidermis is thin: lips, mucous membranes

Diagnostic Studies See Table 23-9 Inspection is primary assessment technique Biopsy Punch, excisional, incisional, shave Cultures: viral, bacterial, fungal

Wound Culture Collection Exudate collection - label specimen as exudate Wound collection – clean wound bed then collect specimen

Integumentary Problems “The actual seriousness of a skin problem and the emotional impact of the problem may often be two separate issues.” Health promotion issues: Sun exposure Irritants and allergens Self-care: Rest and Sleep, Exercise, and Hygiene Nutrition: essential for normal cell structure, function and repair

Sunburn

Malignant Conditions Risk factors Non-melanoma lesions Fair skin type, history of chronic sun exposure, family history of skin cancer, outdoor occupation, three or more severe sunburns before age 20 Non-melanoma lesions Actinic keratosis Basal cell carcinoma Squamous cell carcinoma

Malignant lesions Non-melanoma Squamous cell carcinoma Basal cell carcinoma Actinic keratosis

Malignant Melanoma Can metastasize to any organ Most deadly skin cancer – nearly 100% curable if caught early – Stage 0 ABCDE’s (Fig 24-4) Asymmetry, Border, Color, Diameter, Evolving/Elevated (also found in literature) Tumor thickness, node involvement and presence of metastasis are used in staging Wide excision, chemotherapy, chemo-immunotherapy, vaccine, and RT

Infections Bacterial (Table 24-4) Risk factors: Obesity, diabetes, moisture, dermatitis, antibiotic or corticosteroid usage.

Pictures of bacterial infections Cellulitis – inflammation of subcutaneous tissue, S. aureus, and streptococci Impetigo – Group A ß-hemolytic streptococci, staphylococci or both, contagious Folliculitis – staphylococci, small pustules, beard, scalp Furuncle – staphylococci, deep infection around hair follicle Carbuncle – staphylococci, multiple furuncles

Cellulitis

Folliculitis

Viral Infections Viral (Table 24-5) Difficult to treat Herpes Simplex Type 1 – generally oral Herpes Simplex Type 2 – generally genital Herpes Zoster Activation of varicella-zoster virus Immunosuppressed clients at risk Contagious

Herpes Zoster - varicella

Fungal Infections Fungal (Table 24-6) Candidiasis – candida albicans, warm moist areas Vagina, mouth, skin Tinea corporis – ringworm Tinea cruris – “jock itch” Tinea pedis – “athlete’s foot”

Fungal - onychomycosis

Candidiasis

Oral thrush – candida albicans

Infestations and Insect Bites Table 24-7 Bee and wasp stings Pediculosis Head, body, pubic lice Scabies Ticks

Common Benign Conditions of the Skin Table 24-9 Acne Moles Psoriasis Seborrheic Keratosis Skin tags Lipoma

Psoriasis

Seborrheic keratosis

Skin tags

Diseases with Dematologic Manifestations See Table 24-10 Endocrine Effect fat deposits, hair distribution, sweat gland activity: thyroid, adrenal, parathyroid, pituitary and pancreas hormones GI Skin color, skin lesions: liver disease Musculoskeletal Skin appearance: lupus, scleroderma Cardiovascular Skin color, nails, hair growth and distribution Hematologic Skin color, lesions, hair loss: anemia, clotting disorders Reproductive Lesions: syphilis, Paget’s disease

General Interventions for Acute Dermatological Problems Diagnostic and Surgical Therapy Punch biopsy Cryosurgery Excision Phototherapy Psoralen (photosensitizing drug) + UVA light = used to treat psoriasis, atopic dermatitis, pruritis Radiation Therapy Laser Therapy – expanding rapidly Drug Therapy Antibiotics Corticosteroids Topical, Intra-lesional, Systemic Antihistamines (for itching)

Nursing Interventions Wet dressings Dry exudative lesions Relive itching Suppress inflammation Debride a wound Baths Sedative and antipruritic effects Topical medications – creams, ointments and powders

Nursing Interventions Pruritis - itching Psychological effects of chronic problems www.aad.org American Academy of Dermatology – Support groups Camouflaged with cosmetics Physiological effects of chronic problems Scarring

Cosmetic Procedures Elective, to improve body image Laser surgery Face Lift Liposuction Men and women