1. The Healing Process
Chapter 13
NU 211

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

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

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

5. 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

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

7. 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

9. 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

10. 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

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

12. Problems of the Integumentary System
Chapters 23 & 24

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

14. Epidermal appendages
Hair
Nails

15. Glands
Sebaceous
Apocrine
Eccrine

16. 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

17. 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

18. 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

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

20. Vesicle – fluid filled

21. Plaque – sl. Elevated, circumscribed

22. Wheal – raised, itchy, blotchy, irregular

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

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

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

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

27. 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

28. Sunburn

29. 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

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

31. 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

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

33. 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

34. Cellulitis

35. Folliculitis

36. 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

37. Herpes Zoster - varicella

39. 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”

40. Fungal - onychomycosis

41. Candidiasis

42. Oral thrush – candida albicans

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

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

45. Psoriasis

46. Seborrheic keratosis

47. Skin tags

48. 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

49. 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)

50. 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

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

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