Our Lady of the Lake College

NURS 2750 Nursing Fundamentals Exam 2 Notes

Fundamentals Exam 2
Chapters: 4, 5, 27, 28, 31, 32, 39, and 48
Protection & Adaptation – Integumentary System
Overview
 The skin is the body’s largest organ, comprising 15% of the total body weight.
 The skin (1) acts as a protective barrier against disease-causing organisms, (2) is a
sensory organ for pain, temperature, and touch, and (3) synthesizes vitamin D.
 Injury to the skin poses risks to safety and triggers a complex healing response.
 Knowing the normal healing pattern will assist in recognizing alterations that require
intervention.
Integumentary System
 Refers to skin, hair, scalp, nails
 Begin with health history (subjective data)
 Followed by the physical examination (objective data) – visible surfaces
 Sight, smell, and touch – inspection and palpation
 Patient’s health status – oxygenation, circulation, nutrition, local tissue damage, and
hydration
Integumentary Assessment
 Adequate lighting
 Equipment - gloves, penlight, and small centimeter ruler
 Room temperature
 Inspection
 Skin odors
Subjective Data
 Health History Questions – Table 31-7, 31-10, 31-11
o Past history of skin disease, allergies, hives, psoriasis, or eczema?
o Change in pigmentation or color?
o Change in mole size, shape, color, tenderness?
o Excessive dryness or moisture?
o Pruritus or skin itching?
o Excessive bruising?
o Rash or lesions?
o Medications: prescription and over-the-counter?
o Hair loss?
o Change in nails’ shape, color, or brittleness?
o Environmental or occupational hazards?
o Self-care behaviors?
 Additional history for infants and children
o Does child have any birthmarks?
o Any change in skin color as a newborn?
 Physiologic jaundice?
 Cyanosis?
o Does child have any rash or sores?
o Does child have diaper rash?
o Does child have any burns or bruises?
 Where?
 How did it happen?
o Has child been exposed to:
 Contagious skin conditions: scabies, impetigo, lice?
 Communicable diseases: measles, chicken pox, scarlet fever?
 Toxic plants: poison ivy?
o Does child have habits such as nail biting or twisting hair?
o What steps are taken to protect child from sun exposure?
 Additional history for adolescents
o Skin problems such as pimples, blackheads?
 Additional history for aging adults
o What changes have you noticed in your skin in last few years?
o Any delay in wound healing?
o Any change in feet: toenails; bunions, wearing shoes?
o Falling: bruises, trauma?
o History of diabetes or peripheral vascular disease?
Objective Data: Physical Examination - Color
 Varies but usually uniform over the body
 Pigmentation
o Ivory or light pink to ruddy pink in light skin
o Light to deep brown or olive in dark skin
o Older adults – increases unevenly causing discoloration
 Cyanosis
 Jaundice
 Erythema
Objective Data: Physical Examination - Moisture
 Refers to wetness and oiliness
 Normally smooth and dry
 Skin folds e.g. axillae – moist
 Minimal perspiration or oiliness
 Use ungloved fingertips to palpate skin surfaces
 Observe for dullness, dryness, crusting, and flaking – lightly rubbed
 Excessive dryness – older adults, soap, lack of humidity, exposure to sun, smoking,
stress, excessive perspiration, and dehydration
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Objective Data: Physical Examination - Temperature
 Depends on the amount of blood circulating
o Increased – localized erythema or redness
o Decreased – pallor
 Color variations – Table 31-8
 Cold exam room – temperature and color
 Palpate with the dorsum or back of the hand - warm
o Skin should be warm, and temperature equal bilaterally; warmth suggests normal
circulatory status
o Hands and feet may be slightly cooler in a cool environment
 Hypothermia
 Hyperthermia
Objective Data: Physical Examination - Texture
 Character of the surface of the skin and how the deeper layers feel
 Palpate lightly with the fingertips
o Normally smooth, soft, even, and flexible
o Thicker texture over the palms of the hand and soles of the feet
o Older adults – wrinkled and leathery
 Palpation
o Smooth or rough
o Thin or thick
o Tight or supple
o Indurated (hardened) or soft
Objective Data: Physical Examination - Turgor
 Elasticity of skin
 Aging – diminished elasticity (edema, dehydration)
 Grasp a fold of skin on the back of the forearm (don’t use back of hand) or sternal area
with the fingertips and release
 Lifts easily and falls immediately
 Poor turgor stays pinched and shows tenting
Objective Data: Physical Examination - Vascularity
 Circulation of the skin affects color
 Localized pressure areas when patients remain in one position
 Appears reddened, pink or pale
 Aging – capillaries become fragile and more easily injured
 Petechiae – nonblanching, pinpoint-size, red or purple spots
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 Multiple bruises at different stages of healing and excessive bruises above knees or
elbows should raise concern about physical abuse
 Needle marks or tracks from intravenous injection of street drugs may be visible on
antecubital fossae, forearms, or on any available vein
Objective Data: Physical Examination - Edema
 Swollen or edematous from buildup of fluid in the tissues
 Causes - Direct trauma and impairment of venous return
 Inspect for location, color, shape
 Appears stretched and shiny
 Palpate to determine mobility, consistency, and tenderness
 Pitting edema – Press the edematous area firmly with the thumb for several seconds and
release, record depth
Objective Data: Physical Examination - Lesions
 Any unusual finding of the skin surface
 Free of lesions, except for common freckles or age-related changes (skin tags, senile
keratosis (thickening of skin), cherry angiomas (ruby red papules), and atrophic warts
 Box 31-6
o Macule - freckle
o Papule - mole
o Nodule - wart
o Tumor – solid mass
o Wheal – hive
o Vesicle – chicken pox
o Pustule - acne
o Ulcer – venous stasis ulcer
o Atrophy – arterial insufficiency
 Inspect and palpate skin
o Lesions: if any are present note:
 Color
 Elevation
 Pattern or shape
 Size – in cm (height, width, & depth)
 Location and distribution on body
 Any exudate: note color and odor
 Use additional lighting
Question?
 What do the ABC and D stand for in the mnemonic to assess for skin cancer?
 ABCD:
o Asymmetry
o Border irregularity
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o Color
o Diameter
Skin Malignancies
 Basal Cell Carcinoma
 Squamous Cell Carcinoma
 Melanoma
Objective Data: Physical Examination - Hair
 Color
o Color varies – very light blond to black to gray
o Altered by rinses or dyes
o Older adult – dull gray, white, or yellow
 Distribution & Quantity
o Puberty – increase in amount and distribution
o Aging – thin over the scalp, axillae, and pubic areas
o Men – facial hair decreases
o Women – hirsutism, hair growth on the upper lip, chin, and cheeks, coarse over
the body.
o Extremities – reduced due to aging or arterial insufficiency
 Thickness, Texture, & Lubrication
o Hair loss – febrile illnesses or scalp disease
o Thyroid disease – fine and brittle
o Genetic tendencies or Endocrine disorders – hair loss (alopecia) or thinning
o Poor nutrition – stringy, dull, dry, and thin
o Androgen hormone stimulation – excessively oily
o Aging & excessive use of chemical agents – dry, brittle
Objective Data: Physical Examination – Scalp
 Normally smooth and inelastic, with even coloration
 Inspect for lesions – lumps or bruises
 Moles are normal – may bleed from vigorous combing or brushing
 Dandruff or psoriasis – scaliness or dryness
 Inspect hair follicles – lice (head/body) or other parasites
o Tiny eggs resemble oval particles of dandruff
o Grayish-white bodies, crab lice have red legs
o Requires immediate treatment
Objective Data: Physical Examination - Nails
 What do abnormalities in the nail bed reveal?
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 Condition of nails reflects:
o General health
o State of nutrition
o Occupation
o Level of self-care
o Age
 Transparent, smooth, well rounded, and convex, 160°
 Cuticles – smooth, intact, without inflammation
Objective Data: Physical Examination - Nails
 Inspect and palpate nails
 Shape and contour
 Profile sign: view index finger at its profile and note angle of nail base; it should be about
160 degrees
 Consistency
 Color
 Capillary refill
 Depress nail edge to blanch and then release, noting return of color; indicates status of
peripheral circulation
 Color return is normally instant
 Sluggish color return takes longer than 1 or 2 seconds
 Clubbed nails results from a lack of oxygen – often seen in patients with emphysema and
COPD
Sample Documentation
 Skin pink, warm, and dry. Turgor brisk, skin elastic. Rough, thickened skin over heels,
elbows, and knees; otherwise, smooth. A 0.5 cm brown papule on right forearm and a
2.5 cm scar on left knee. Scalp dry with slight dandruff. Hair brown, clean, smooth,
straight, evenly distributed on the head. Axillary and pubic hair evenly distributed with
no infestations. Nails short and firm with no clubbing. Capillary refill <3 seconds. No
edema. Pulses palpable, 2+, and equal bilaterally.
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Protection/Adaptation – Skin Integrity and Wound Care
Pressure Ulcers
 Pressure ulcer – localized injury to the skin and other underlying tissue
 Pressure sore, decubitus ulcer, or bed sore
 Pathogenesis
 Pressure intensity
 Tissue ischemia
 Hyperemia (redness) blanchable or nonblanchable (Box 48-2)
o Blanchable- when you press the finger into the skin, it turns a lighter color and
then returns to normal
o Nonblanchable- doesn’t change color when pressing into the skin
 Induration
 Pressure duration
 Tissue tolerance
 3 components of the development of pressure ulcers
o intensity
o duration
o tolerance
Risk Factors for Pressure Ulcer Development
 Impaired sensory perception
 Impaired mobility
 Friction
 Alterations in level of consciousness
 Shear
 Moisture
o Softens skin and allows for the friction to break the first layer of skin
Category/Stages of Pressure Ulcers
 Stage 1: Intact skin with nonblanchable redness
 Stage 2: Partial thickness skin loss involving epidermis,
dermis, or both
 Stage 3: Full thickness tissue loss with visible fat
o Can start to go into the subcutaneous tissue
 Stage 4: Full-thickness tissue loss with exposed b one,
muscle, or tendon
o Deep tissue injury
 There are also ‘unstageable’ pressure ulcers
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Wound Classifications
 Onset and duration
o Acute – trauma, surgical incision
o Chronic – vascular compromise, chronic inflammation, or repetitive insults to
tissue
 Healing Process
o Primary Intention
 Wound edges are well approximated
 Wound heals from the outside in
 Scar at the surface
o Secondary Intention
 Wound heals from the inside out
 More pronounced scar
 Eventually heals through epithelialization and granulation
o Tertiary Intention
 Wound that starts from secondary intention
 Wound that gets infected and has to be opened up in order to heal and is
then sutured (back to primary intention)
 Largest scar
Healing Process
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Wound Repair
 Partial-thickness wound - superficial with minimal loss of tissue integrity from damage to
the epidermis and upper dermal layers
o Inflammatory response
o Epithelial proliferation (reproduction)
o Migration
 Full-thickness wound - loss of tissue integrity and damage extends into the lower layers
of the dermis and subcutaneous tissue
o Hemostasis (fibrin)
o Inflammatory phase
o Proliferative phase (epithelialization)
o Maturation
Complications of Wound Healing
 Hemorrhage: to bleed
o Hematoma: blood vessels that clot and puts pressure on the artery
o Sanguineous (bloody) drainage: not copious amounts (changing bandage every
hour is too much)
 Infection
o Drainage (Table 48-2)
o Serous: watery, clear
o Purulent: yellowing, pus
o Serosanguinous: watery/clear and some blood
 Dehiscence
o Wound that is well approximated (edges are touching each other), however a gap
develops
 Evisceration
o When organs begin to spill out through the gap
o Medical emergency
o Vaseline gauze will be placed bedside… incision should be covered and then
rushed to surgery
Nursing Knowledge Base
 Prediction and prevention of pressure ulcers
o Risk assessment (Braden Scale Table 48-3)
 Sensory perception, moisture, activity, mobility, nutrition, and friction and
shear
o Prevention
 Economic consequences
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Braden Scale for Predicting Pressure Ulcer Risk
 the higher the score, the lower the risk for developing a pressure ulcer