skin
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Integumentary SystemMed Surg Certification
Amy Dunbar RN, MSN, CWOCN6-2-05
ObjectivesIdentify the functions of the skinIdentify the nursing assessment of the skinIdentify common pathophysiologic events associated with skinDetermine ostomy care
Layers of Skin
Epidermis
Dermis
Appendages
HairSebaceous glandsExocrine GlandsAprocrine GlandsNails
Changes with AgingEpidermal turnover increases Skin is drierDecreased skin elasticityChanges in thermoregulationDecreased melanocytes
Skin AssessmentItchingPain RashDry, rough, scalyBlistersHot/cold spots
ObjectivesInspection
Palpation
*color
*hair
*lesions
*turgor
*moisture
*temperature
Psoriasis
No cureTreated with topical steroids and photo therapy
Scleroderma
Usually treated with steroids and cholinergics
ShinglesContagious when exudate from blisters is present
May benefit from antiviral
Skin Cancer
Malignant melanoma can metastasizePrevention
Rule of 9’s
-Head = 9
-Each arm = 9
-Front of trunk = 18
-Back of trunk = 18
-Each leg = 18
Concernsimpaired gas exchange
fluid replacement
Interventions Skin Grafts -may be autologous -additional wound will be present
Fasciotomy-relieves pressure when edema is extreme
Stage I Pressure Ulcer
Stage II Pressure Ulcer
Stage III Pressure Ulcer
Stage IV Pressure Ulcer
Unstageable Pressure Ulcer
Post Operative considerations Stoma appearance
Pouch maintenanceReleasing gas
Pouch emptying
Stoma Appearance
Pouch Maintenance
Releasing Gas
Pouch Emptying
SummarySkin/Wound is complexNursing assessment and intervention crucialOstomy care is daily