1. Slide 1 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Textbook For Nursing Assistants Chapter 24 - The Integumentary System

2. Slide 2 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Structure of the Integumentary System

3. Slide 3 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Skin: Structure

4. Slide 4 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The skin is made up of two layers The epidermis The dermis The epidermis is the outer layer of the skin The dermis is the deepest layer of the skin Skin: Structure

5. Slide 5 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The epidermis is Thickest on the soles of the feet and the palms of the hands Very thin in areas such as the eyelids The epidermis contains no blood vessels It has two sub-layers A deep layer where the new cells are produced  Produces keratin and melanin A surface layer The Epidermis

6. Slide 6 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Keratin causes cells to: Thicken Become resistant to water Melanin is a dark pigment that: Gives our skin, hair, and eyes color Helps to protect the skin from exposure to sunlight The Epidermis

7. Slide 7 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The dermis: Consists of elastic connective tissue that allows it to stretch and move without damage Rests on a layer of fat called the subcutaneous tissue Blood vessels and nerves that supply the skin originate in the subcutaneous tissue and send branches into the dermis The sensory receptors that allow us to feel pressure, pain, and temperature are located in the dermis The sebaceous glands, the sweat glands, and the hair follicles are also found in the dermis The Dermis

8. Slide 8 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The skin’s accessory structures include: Sebaceous glands Sweat glands Hair Nails Accessory Structures

9. Slide 9 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Sebaceous glands secrete sebum, an oily substance that: Lubricates the skin Helps to prevent it from drying out Helps to protect the skin from harmful bacteria that may be present on its surface Is slightly acidic Accessory Structures: Sebaceous Glands

10. Slide 10 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Eccrine glands: Are found in the skin that covers most parts of our bodies Produce a thin, watery liquid that contains salt and small amounts of other bodily wastes Help cool the body through the process of evaporation Apocrine glands: Are found in the skin of the armpits (axillae) and the perineum Produce a thicker substance Produce what we know as “body odor” Become active when a person reaches puberty Become less active as we age Accessory Structures: Sweat Glands

11. Slide 11 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Hair covers the entire body, except for the soles of the feet and the palms of the hands. Hair that covers the scalp helps to keep us warm Most of the hair that covers the body is soft and fine In men: Body hair tends to thicker and more noticeable because of the action of certain hormones In both men and women: The hair covering the scalp, armpits, and pubic area is thicker and coarser than the hair on the rest of the body Accessory Structures: Hair

12. Slide 12 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Hair develops in the dermis of the skin from a sheath called a follicle The part of the hair that we can see consists of dead cells that have been hardened by keratin Living cells that produce new hair cells are found at the bottom of the follicle or hair root Melanin gives the hair its color Blonde hair contains a small amount of melanin Brunette hair contains much more melanin Accessory Structures: Hair

13. Slide 13 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Nails are made of special skin cells that have been hardened by the presence of keratin Nail growth occurs from the nail root Nails help to protect the ends of our fingers and toes Accessory Structures: Nails

14. Slide 14 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Function of the Integumentary System

15. Slide 15 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Protection Maintenance of fluid balance Regulation of body temperature Sensation Vitamin D production Elimination and absorption Function of the Integumentary System

16. Slide 16 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The body’s first line of defense against the invasion of harmful microbes is intact skin The skin: Is a physical barrier that prevents microbes from entering the body Offers protection against harmful substances that may be encountered in the environment Protection

17. Slide 17 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The skin helps to maintain the body’s fluid balance by preventing excessive loss or absorption of water Being water-resistant, skin forms a protective barrier between your internal organs and the outside world Maintenance of Fluid Balance

18. Slide 18 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. When a person gets warm: Blood vessels in the dermis of the skin dilate, allowing more blood to flow close to the surface of the skin The heat contained in the blood radiates out from the body, lowering the temperature of the blood The cooled blood then travels back to the central areas of the body, thus lowering the body temperature Regulation of Body Temperature

19. Slide 19 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. When a person gets cold: Blood vessels in the dermis of the skin constrict, causing less blood to flow close to the surface of the skin The blood remains in the warmer, central areas of the body, minimizing the amount of heat lost to the outside environment Regulation of Body Temperature

20. Slide 20 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Skin contains millions of sensory receptors that allow us to detect pain, pressure, temperature, and touch Skin produces vitamin D when exposed to the sun Skin is an active organ that is capable of: Removing substances from the body, and Taking substances into the body Other Functions of the Skin

21. Slide 21 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The Effects of Aging on the Integumentary System

22. Slide 22 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Changes in physical appearance Fragile, dry skin Thickening of the nails Less efficient temperature regulation The Effects of Aging on the Integumentary System

23. Slide 23 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Wrinkles form due to: The loss of collagen, a protein that supports connective tissue Thinning of the adipose (fatty) tissue with age Gray hair is caused by the loss of melanin from the hair “Age spots” (or “liver spots”) are caused by deposits of melanin in certain areas, such as the back of the hands or on the face Changes in Physical Appearance

24. Slide 24 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Skin becomes fragile and dry due to: Loss of collagen from the dermis The subcutaneous layer thins Skin becomes thinner, more fragile, and more prone to injury Decrease in blood flow to the dermis Cells of the epidermis do not replace themselves as rapidly Skin takes longer to heal itself when an injury occurs Person is more at risk for developing an infection Fragile, Dry Skin

25. Slide 25 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Number of sebaceous glands decrease with age The output of sebum decreases, leading to drying of the skin The risk for skin tears and injuries increases The bacteria that normally live on the surface of our skin have more chance to cause trouble Fragile, Dry Skin

26. Slide 26 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Nails thicken and become yellow Toenails become tough and difficult to cut A nurse or a podiatrist is usually responsible for trimming an elderly person’s toenails The nurse or podiatrist may use a tool that looks like a sander to accomplish this task safely Thickening of the Nails

27. Slide 27 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Less efficient temperature regulation occurs because: Sweat glands decrease in number Production of sweat decreases Decreased blood flow to the skin interferes with the skin’s ability to participate in temperature regulation An older person is at increased risk for heat- related problems, such as heat stroke Less Efficient Temperature Regulation

28. Slide 28 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Disorders of The Integumentary System

29. Slide 29 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Pressure ulcers, also known as decubitus ulcers or bed sores, form when: A part of the person’s body presses against a surface for a long period of time A person is lying on wrinkled bed linens or on an object in the bed A person sits on a bedpan for a long period of time A person wears a splint or brace that presses against the skin Skin breakdown leads to the formation of pressure ulcers Pressure Ulcers

30. Slide 30 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Necrosis is tissue death as a result of a lack of oxygen The necrotic (dead) skin and underlying tissues peel off or break open, creating an open sore The weight of the person’s body squeezes the soft tissue between the bone and the surface the person is resting on Blood to the tissue is disrupted Lack of blood flow to the tissue deprives the tissue of oxygen and nutrients, causing it to die Pressure Ulcers

31. Slide 31 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. The most common sites for pressure ulcers to form are: Heels Ankles Knees Hips Toes Elbows Shoulder blades Ears Back of the head Along the spine These areas are referred to as pressure points Pressure Points

32. Slide 32 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Pressure Points

33. Slide 33 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Risk Factors for Developing Pressure Ulcers Advanced age Poor nutrition and hydration Moisture on the skin Cardiovascular and respiratory problems Friction and shearing injuries

34. Slide 34 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Stages of Pressure Ulcers – Stage 1 A reddened area of skin that does not return to the normal color after the pressure is removed The reddened area may then become very pale or white and develop a shiny appearance If the skin stays red, feels hot to the touch, or is painful, report this to the nurse immediately!

35. Slide 35 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Stages of Pressure Ulcers – Stage 2 The pressure ulcer looks like a blister, an abrasion, or a shallow crater The epidermis peels away or cracks open, creating a portal of entry for microbes The dermis may be partially worn away

36. Slide 36 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Stages of Pressure Ulcers – Stage 3 Epidermis and dermis are gone Subcutaneous fat may be visible in the crater Drainage from the wound may occur

37. Slide 37 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Stages of Pressure Ulcers – Stage 4 The crater of damaged tissue extends from the tissues to the muscle or bone

38. Slide 38 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Prevention of Pressure Ulcers Avoid allowing a person to remain in one position for a long period of time Do not leave the person sitting on a bedpan for a long period of time Reposition the person at least every 2 hours or according to the nursing care plan

39. Slide 39 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Prevention of Pressure Ulcers Use your observation skills Look carefully at the skin of your patients or residents every time you provide care Check for reddened areas on the side of the body that had been bearing the person’s weight Look carefully at the person’s skin when assisting a person with  Bathing  Changing wet or soiled linens  Giving a person a back massage

40. Slide 40 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Prevention of Pressure Ulcers Provide good skin care When assisting with a bath, clean skin gently and thoroughly and rinse off the soap well Use lotion to keep the skin’s surface healthy and soft Clean and dry areas where skin touches skin, such as under the breasts or other skin folds Apply a light dusting of a powder containing corn starch to help keep the skin dry Provide frequent back massage to help stimulate circulation in the skin

41. Slide 41 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Prevention of Pressure Ulcers Provide good perineal care Promptly remove urine or feces from the skin Clean and dry the perineal area Apply a product to the perineal area that helps to protect the skin from wetness, such as Desitin ointment

42. Slide 42 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Prevention of Pressure Ulcers Anticipate toileting needs Assist your patients or residents to the bathroom (or provide a bedpan or urinal) frequently  This prevents soiling of the person’s clothing or bed linens If a person is incontinent, check on him or her every hour or so

43. Slide 43 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Prevention of Pressure Ulcers Encourage mobility Ask the patient or resident to take a walk with you every 2 hours, if she is able If a person is paralyzed, remember to:  Change his position in his chair  Have him move between the chair and the bed to prevent skin breakdown

44. Slide 44 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Prevention of Pressure Ulcers Minimize skin injury caused by friction or shearing Use lift devices Do not elevate the head of the bed more than 30 degrees Encourage good nutrition and hydration Offer refreshing drinks frequently Encourage your patients and residents to eat well Use pressure-reducing devices Elbow pads and booties may help prevent friction injuries

45. Slide 45 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Types of Wounds: An Intentional Wound An intentional wound is a result of planned surgical or medical intervention Insertion of intravenous (IV) lines, percutaneous endoscopic gastrostomy (PEG) tubes, or other medical devices that are inserted into the body through a “man-made” opening Surgical incision (e.g., open heart surgery, Caesarean delivery)

46. Slide 46 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Types of Wounds: Unintentional Wounds An unintentional wound is an unexpected injury that usually results from some type of trauma, such as: Falls Car accidents Gun and knife violence Unintentional wounds can be open, which means that the surface of the skin is broken Risk of infection is high with open wounds, because the open skin creates a portal of entry for microbes

47. Slide 47 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Wound Healing Factors that hinder wound healing are: M ultiple, severe injuries Chronic illness Impaired immune system Very young or very old age

48. Slide 48 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Wound Healing Factors that hasten wound healing are: Adequate blood flow to the injured area Good hydration to healing tissues Proper nutrition to healing tissues Adequate protein intake Some of the measures taken by the health care team to support the wound healing process include: Closing the wound Inserting drains Applying dressings

49. Slide 49 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Wound Closure First-intention wound healing Open wounds are closed surgically with sutures or staples Helps speed up the healing process Minimizes scarring Second-intention wound healing Infected or are contaminated wounds may be cleaned and rinsed and left open to heal from the inside out Results in a wider, more noticeable scar Prevents an unresolved infection from delaying the wound healing process Third-intention wound healing A wound is left open for a period of time to make sure that an infection is not going to occur Then the wound edges are cleaned and closed with sutures or staples to speed the healing process

50. Slide 50 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Wound Drains If a person you are caring for has a drain, note the characteristics of the drainage: Is there more drainage than you expected? Does it have a foul odor that it did not have before? Has its appearance changed? When repositioning a person with a drain, take care not to pull on the drain tubing Report any unusual observations to the nurse Drainage in the wound puts the person at risk for infection

51. Slide 51 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Wound Dressings The type of dressing used depends on several factors, including: Type of wound Location of the wound Amount of drainage associated with the wound Whether or not the wound is infected Whether or not the wound must be kept dry How often the dressing must be changed

52. Slide 52 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Burns – First-Degree Burns First-degree burns cause injury to the epidermis Examples include sunburns, burns caused by touching a hot stove or leaving a heating pad that is too warm in place for too long The associated redness and pain usually goes away after a few days

53. Slide 53 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Burns – Second-Degree Burns Second-degree burns penetrate into the dermis of the skin Often associated with blisters Very painful and the loss of the epidermis increases the risk of infection

54. Slide 54 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Burns – Third-Degree Burns Third-degree burns involve the: Epidermis Dermis Subcutaneous layer Underlying muscles and bones People with third-degree burns need surgery and skin grafts to heal Third-degree burns are associated with very high infection rates, because the skin has been destroyed The scarring that results from severe burns can cause severe disfigurement and contractures of the extremities

55. Slide 55 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Lesions Lesion is a general term used to describe any break in the skin Dermatitis is a general term for inflammation of the skin Eczema is a type of chronic dermatitis that is usually accompanied by severe itching, scaling, and crusting of the surface of the skin

56. Slide 56 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Types of Skin Lesions Macules are small, flat, reddened lesions that often looks like freckles Papules are small, raised, firm, lesions Vesicles are small, blister-like lesions that contain watery, clear fluid Pustules are vesicles that contains pus, which is a thick, yellowish fluid that is a sign of infection

57. Slide 57 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Types of Skin Lesions An excoriation is an abrasion, or a scraping away of the surface of the skin Excoriations can be caused by: Trauma Chemicals Burns (including friction burns) Urine or feces, if left on the skin for too long

58. Slide 58 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Types of Skin Lesions A fissure is a crack in the skin It can be caused by  Extreme dryness  Fungal infections, such as athlete’s foot An ulcer is a shallow crater that is formed when the tissue dies and the dead tissue is shed, leaving a crater behind

59. Slide 59 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Caring for a Person with Skin Lesions Be aware of any adjustments to the normal bathing and skin care routine that may be necessary Check the nursing care plan Ask the nurse about any necessary changes to the routine May need to use a special soap or lotion as part of the person’s skin care Help the person to choose clothing that does not rub or irritate the skin lesion

60. Slide 60 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Caring for a Person with Skin Lesions Discourage the person from scratching itchy or irritated skin. Scratching: Causes skin injury Puts the person at risk for infection Soft mitt restraints or gloves may be necessary to prevent a small child or confused adult from scratching the lesions

61. Slide 61 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. Caring for a Person with Skin Lesions Observe lesions for changes in: Color Bleeding Drainage Report any changes to the nurse immediately Note whether the lesions seem to be getting larger or spreading to other parts of the body

62. Slide 62 Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants. End of Presentation