PREMED

Functional ReviewProtector and barrier between internal

organs and external environmentBarrier against foreign body intrusions

against invading bacteria and foreign matter

Transmits sensation – nerve receptorsallows for feelings of temperature, pain,

light touch and pressure

Skin Functions

Regulates body temperatureregulates heat loss

Helps regulate fluid balance absorbs water prevents excessive water & electrolyte loss. Slow loss up to 600 ml daily by evaporation

Immune Response Functioninflammatory process

Skin Functions Vitamin production

exposure to UV light allows for the conversion of substances necessary for synthesizing vitamin D

Necessary to prevent osteoporosis, rickets

Skin Assessment Visual inspectionPalpation Olfactory sensesAdequate lightingRemove necessary clothing while

providing respect and privacyAppropriate client positions

p.568

Visual inspectionSkin color:PalorCyanosis JaundiceErythemaHyperpigmentationHypopigmentation – vitiligo

Visible changes if the SkinChanges in skin color texture

Eczema, infectionsAssess the vascularity & hydration of skinEdema – swelling, pitting edema

1+ 2 mm 3+ 6 mm 2+ 4 mm 4+ 8 mm p.579

Nails – configuration, consistency, color p.579

Hair – color and distribution, aloplecia, location

Gerontology Considerations

Watch for significant changes in aging:Decrease immunity functionsSusceptibility to infectionsPoor nutritionDecrease collagen production – loss of

subcutaneousThinning of epidermal skin layersIncrease skin problems

Gerontology ConsiderationsTaking more medicationsExcessive environmental exposureDryness, wrinklingUneven pigmentationVarious proliferative lesions

Description Light skin Dark skin

Cyanosis - bluish Bluish tinge Ashen gray

Pallor - paleness Loss of rosy glow Ashen gray (drk skin)

Yellowish brown (brown skin)

Erythema - redness Visible redness Diffused; rely on palpation of warmth or edema

Petechiae – small size pinpoint ecchyumosis

Purplish pinpoints

Usually invisible; check oral

Mucosa, conjunctiva, eyelids, conjunctiva covering eyeballs.

Description Light skin Dark skin

Jaundice - yellow Yellow sclera, skin, fingernails, soles, palms, oral mucosa

Reliable on sclera, hard palate, palms and soles.

Ecchymosis – large diffused bluish black

Purplish to yellow-green

Difficult to see, check mouth or conjunctiva

Brown-Tan – cortisol deficiency, increased melanin production

Bronze; Tan to light brown

Easily masked.

Assessing LesionsVary in size, shape and causePrimary vs. Secondary Erruptions: cysts, wheals, bullous,

pustules, psoriasis, eczyma, vesicles, bullae, nodules, papules

Discoloration: macules (café-au-lait),

Skin Lesions Etiology

Infections –herpes, impetigo, HIV, melanoma

Toxic chemicals: skin irritationPhysical trauma: burns, lacerationsHereditary factorsExternal factors: allergens, contact

dermitisSystemic diseases: measles, lupus,

nutritional deficiency

Skin LesionsNursing Process Care:

Assessment: descriptions; pt. history, causative factors

Evaluation of skin – identify problemNursing Diagnosis Interventions for skin care to promote

healing and prevent further injuryPain management & comfortInfection controlNursing evaluation & reassessment

Systemic Skin Diseases: Skin Disorders in Diabetes

Diabetes Dermapathy – shin spots, caused by break- down of small vessels that supply the skin.

Stasis Dermatitis – compromises circulation to the distal extremities due to damage of larger vessels.

Problem: Injuries heal slow; increase risk for ulcerations; risk for skin infections

Fungal infections of the SkinTinea Pedis (athlete’s foot)Tinea Corporis (ringworm of the body)Tinea Capitis (scalp ringworm)Tinea Cruris (ringworm of the groin)

Jock itch jock, common in diabetes.Tinea Unguium (ringworm of the nails)

onychomycosis

Parasitic InfectionsPediculosis capitis - licePediculosis corporis/pubisSarcoptes scabiei – scabies

Raised burrows found between fingers, wrists, elbows, nipples, feet, groin, gluteal folds, penis, scrotum

Poor hygienic living conditionsIncrease; contagiousSecondary lesions: vesicles, papules, crust,

excoriations

Parasitic InfectionsAppear 4 wks after exposure Elderly patients from long term facilitiesLindane, crotamiton (Eurax), permethrin

Nursing DiagnosisSkin Impairment r/t:GOAL:

Protect the skinPrevent secondary infectionsPromote healing

Skin Care

Review of wound dressings

Wound DressingsOcclusive – airtight cover applied to skin

lesionsWet –(obsolete) wet compresses applied on

acute weeping, inflamed lesionsMoisture-retentive –more efficient wet

drsg for removing excudate: impregnated with saline, petrolatum, zinc-saline, hydrogel, antimicrobial agents. Avoids maceration , less infections, scarring & reduces pain.

Wound DressingsHydrogels – polymers with 90% water

content

superficial wounds, abrasions, skin graft sites, draining venous ulcers

Hydrocolloids –impermeable to water, O2

Remain intact during bathing.Produce foul-smelling yellowish covering

May leave on wound for 7 daysPromote debridment & granulation tissue

Wound DressingsFoam – hydrophilic absorption and

hydrophobic backing to prevent leaking of exudateNonadherent; require secondary dressing

Used over bony areas and weeping wounds

Calcium alginates – absorbent fiber packing made from seaweed.Absorbes exudate, best for macerated wounds, packing deep wounds, sinus tracking, heavy drainage - nonadherent

Muchas Gracias Al final..