Integumentary System

Functions

§         Protection, barrier

§         Insulation

§         Receives sensory stimuli

§         Controls heat regulation

§         Excretion

§         Method of medication administration

§         Displays emotions and physical identity

Healing Processes:

  Regeneration

  Repair

•     Replacement of lost cells & tissues with cells of the same type

no scar, like a scratch

Tissue Repair

•     Healing as a result of lost cells being replaced by connective tissue

•     Occurs by primary, secondary, or tertiary intention

Factors Delaying
Wound Healing

•      Nutritional deficiencies-protein, vitamin, a c, zinc

•      Inadequate blood supply

•      Corticosteroid drugs

•      Infection-get rid of it first for it to heal

•      Mechanical friction- granulation is fragile

•      Obesity

•      Diabetes mellitus

•      Poor general health

•      Anemia- less oxygen without hemogloblin

smoking -vasoconsctrictive

age

• thining of dermal layers
• decreased elastility
• decreased sensation
• less padding over bony prominences

Nursing Care to Promote
Wound Healing

Use Precautions w/

Drug Therapy

     Antibiotic Resistance

     MRSA (staph), VRE 

Nutritional Therapy- high fluid, high protein

Vital signs, fever

Rest & Immobilization-helps but not too immobile

Elevation-in the event of edema

Oxygenation

Heat & Cold

Wound Management

Wound Management

•      Clean the wound first, usually with normal saline

•      Assess the wound

     --location

     --size, (length, width, depth, extent of     tunneling)

     --drainage (type, amount, odor, color)

     --color of wound and surrounding tissue

     --assess pain associated with the wound         

Wound Classification
Red Color

•      Red (pale pink to beefy red) – typically  indicates granulation tissue; wound is in the inflammatory or proliferative phase of wound healing;  protect the wound and keep it moist

Wound Classification
Yellow Color

•      Yellow (pale ivory to various shades of yellow green brown) – indicates presence of slough (dead but moist tissue);  actively generates wound fluid and may need to be debrided;  may need treatment of infection

Wound Classification
Black Color

•      Black ( black/brown, tan) – indicates the presence of dead tissue that is dehydrated;  may be covered with eschar (black leather);  the wound cannot be assessed until the eschar is removed;  eschar is an excellent medium for bacterial proliferation. 

Necrotic tissue should be removed (an exception -- the heel) 

mechanical debridement (wet to moist dressing change)

Is there infection?

Taking a wound culture – Nursing – swab culture;  MD looks up tissue biopsy

clean with saline then swab

Treatment:  oral or IV, and/or topical

Pressure Ulcers

•      Other terms: pressure sore, bedsore, decubitus ulcer

•      Caused by compression of soft tissue between two hard surfaces

•      Occlusion of capillary closing pressure

•      Tissues become ischemic and die

•      Factors:  pressure intensity;  pressure duration;  tissue tolerance

Risk Factors for Development of Pressure Ulcers

•      Decreased mobility

•      Decreased sensory perception

•      Fecal and/or urinary incontinence

•      Poor nutrition

•      Tools to assess risk

Interventions for Prevention

•      Assess skin

•      Reposition pt at least every 2 hours;  individualize the repositioning schedule

•      Keep bony prominences from direct contact with each other

•      Relieve pressure on heels

•      Limit time HOB ↑

•      On side, avoid pressure on trochanter

•      Consider pressure relieving device (ex. air mattress)

Interventions for Prevention

•      Minimize skin exposure to moisture

•      Avoid massage over bony prominences; it can increase tissue damage

•      Use lifting device or linen to lift patient to avoid shearing pressure

•      Avoid agents that dry the skin

•      In chair, shift weight every 15 minutes

•      Evaluate nutrition

•      Evaluate mobility

•      Consult PT or OT as indicated

•     Arterial ulcer

• minimize trauma
• support moist wound bed
• support bodys defense system
• non-toxic wound cleansures
• remove infectin, debris, necrotic tissue
• protect surrounding tissue

• does it blanch?
• crater. top layer of skin broken
• subcutaneous, larger deeper
• beyond faschia bone
•  

Bone Marrow

•     The soft material that fills the core of bones

•     Site of production of blood cells

•     All blood cells develop from a common stem cell

Blood

Functions:

§           Transportation of oxygen, nutrients, hormones and waste products

§           Regulation of fluid, electrolyte, and acid-base balance

§           Protective role – coagulation and fighting infections

Blood Cells

•     Erythrocytes – RBCs

•     Leukocytes – WBCs

•     Thrombocytes –

            platelets

Red Blood Cells

•     Transport of gases and maintenance of acid-base balance

•     Hemoglobin

•     Erythopoiesis

•     Reticulocyte

•     Hemolysis

White Blood Cells

•     Neutrophils

•     Basophils

•     Eosinophils

•     Lymphocytes

•     Monocytes

Thrombocytes

•     Platelets

•     Blood clotting

Spleen

•     Produces RBCs during fetal development

•     Filters out old RBCs

•     Filters out microorganisms

•     Stores lymphocytes and monocytes

•     Stores platelets

Lymph System

•      Carries lymph fluid from the interstitial spaces to the blood

•      Removes proteins and fat from the GI tract to the circulatory system

•      Returns excess interstitial fluid to the blood

•     Acts as a filter

•     Produces all the clotting factors necessary for homeostasis and blood coagulation

Anemia

•     A deficiency in the number of RBCs, the quantity of hemoglobin, and /or the volume of packed RBCs.

•     Can lead to tissue hypoxia

Anemia

Causes

•           ↓ Erythrocyte production

•           Blood loss

•           ↑ Erythrocyte destruction

Clinical Manifestations
depend on severity

•      Mild anemia – Hemoglobin 10-14

•      Moderate – Hemoglobin 6-10

•      Severe – Hemoglobin less than 6

Mild to moderate:

       Pale, palpitations, exertional dyspnea

Severe:

       Tachycardia, impaired thought processes, weight loss, lethargy, anorexia

Common in older adults

•            Chronic disease

•            Poor nutrition

•            Aging?

Oxygenation:  Perfusion

Cardiac System

Heart layers

     Heart structure

     Conduction system

Heart layers

     Heart structure

     Conduction system

Valves

Coronary circulation

Cardiac output

Oxygenation: Perfusion

The Vascular System

•     Specific conditions:  hypertension, syncope, fatigue

•     Nursing Care of the Patient with Cardiovascular Problems

Cardiac Output

•      The amount of blood pumped by the heart each minute

•      In the resting adult = 4 to 8 Liters

•      A function of two factors, HR and SV

•      Stroke volume is the amount of blood the heart ejects with each beat

•      CO = HR X SV

the amount of blood in the ventricles at the end of diastole, before the next contraction;  relates to amount of “stretch” and amount of contractility

Vascular System

•     Distribution of blood flow

– Arteries

– Capillaries

– Veins

•     Tissue perfusion

•     Blood

Tissue Perfusion

•      The flow of blood through the body tissues

•      How to assess:  skin temperature; color of skin, mucus membranes, nailbeds;  capillary refill;  palpation of pulses;  edema;  hair distribution;  blood pressure

Factors Affecting Cardiovascular Function

•     Cigarette smoking

•     High blood pressure

•     Nutrition

•     Lack of exercise

•     Diabetes

•     Obesity

•     Family History

•     Medications

•     Stress

•     Aging

Effects of Aging

Normal changes promote atherosclerosis, hypertension, and cardiac failure.

• ↓ cardiac contractility

• ↓ cardiac response to ↑ work

• valve incompetence

• ↓ number of pacemaker cells

• ↑ blood pressure

•      Unmodifiable Risk Factors

     age

     gender

     ethnicity

     genetic inheritance 

•      Modifiable Risk Factors

     ↑ lipids

     hypertension

     smoking

     obesity

     physical activity

Contributing

     diabetes

     stress

Hypertension

•      BP = CO X SVR

•      90-95% is Primary Hypertension – without identified cause

New definition of

   ñ BP, per AHA

Prehypertension – BPs between 120-139/80-90

Likely to develop ↑BP

Lifestyle changes can help

Fatigue

•      Subjective sensation ð loss of endurance

•      Frequently indicates a worsening of the chronic cardiac process

•      Use scale 1-10 to assess

Syncope

•      Brief loss of consciousness

•      May be “vasovagal,” due to cardiac arrhythmia, or orthostatic hypotension

•      Needs cardiac workup

Data Collection

Objective Data

•      Vital Signs

•      Inspection/Palpation

     Skin color & temperature, abnormal skin findings (pg 698 M-S), hair distribution, venous blood flow, extremities

   Capillary refill

   Pulses

   Edema

•      Auscultation

Diagnostic Tests and Procedures

•      Chest x-ray

•      EKG

•      Cardiac monitoring

•      Exercise treadmill test

•      Echocardiogram

•      Nuclear cardiology

•      Cardiac catheterization

Diagnostic Lab Tests

Cardiac enzymes

     CK-MB

     Myoglobin

     Troponin

Serum lipids

     Cholesterol

            HDL

            LDL

     Triglycerides

Findings That May Indicate Cardiovascular Problems

•     Chest pain

•     Fluid retention

•     Irregular heartbeat

•     Fatigue

•     Syncope

•     Tenderness in calf

•     Altered neurologic function

Nursing Interventions for Altered Cardiovascular Function

•      CV assessment

•      Client teaching to modify risk factors

•      Reduce edema (peripheral/fluid in lungs)

•      Prevent venous stasis (concern about DVT)

•      Diet teaching

•      Positioning

•      Pain management

•      Increase activity/energy conservation.