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