Date post: | 27-Dec-2015 |
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Causes of Skin Disturbances and examples
• Congenital
• Inflammation
• Obstruction
• Malignant Lesions
• Unknown Causes
• Degeneration
• Aging
• Trauma
Promotion, maintenance and Restoration
• Potential Nursing Diagnosis
• Psycosocial Responses
• Local Care
• Pharmathereapeutics
• Physicial agents
Function of the Skin
regulation of body temperature
protective surface
sensory structure
excretion
immunity
blood reservoir
synthesis of vitamin D
Physical Assessment
• Includes mucous membranes, scalp, hair, and nails
• Skin is a reflection of overall health
• Disorders often correspond to disease in other organ systems
General Appearance
• colour
• temperature
• moisture
• dryness
• skin texture (rough or smooth)
• lesions
• vascularity, mobility, hair, nails
Diagnostic Evaluation
• Skin Biopsy
• Immunofluorescence
• Patch Testing
• Skin Scrapings
• Tzanck Smear
• Wood Light Exam
• Clinical Photos
Capillary vascular malformation
Angiomas(port wine, strawberry lessions)
• Benign vascular tumors involving the skin and the subcutaneous tissues
• present at birth
• violet red patches (port wine) to raised bright red nodular lesions (strawberry)
• Strawberry-involute in first few years
• port wine persist
Herpes Zoster
molluscum
Corticosteriods
• Steroids are absorbed at different rates from different parts of the body. A steroid that works on the face may not work on the palm. Conversely, a steroid which works well on the palms may cause side effects on the face.
Topical Absorption
• For example: Forearm absorbs 1%
Armpit absorbs 4%
Face absorbs 7%
Eyelids and genitals absorb 30%
Palm absorbs 0.1%
Sole absorbs 0.05%
Pressure Ulcers
• Tissue damage
• skin and underlying soft tissue compressed between bone and external surface
• Over a period of time
• Sacrum, hip, ankles, any body part
• Ischemia-infarction-necrosis
Clients At Risk
• Unable to feel
• Unable to communicate
• Limited mobility
• Can’t change position
• Friction and shear
Pressure Ulcer Prevention
Prevention
Assessment
Observation
Movement
Turning
positioning
Avoid Moisture
Avoid soap
No massage
Nutrition
Friction and Shear
Mental Status
Pressure Ulcer tx &mx
TX and MX
Moist, cleanse, dressing
Diet; fluid Mattress; room humidifyer
Debridment Lift with a lift sheet
Infection prevention
Burns: the Lund MethodAge (Years) • Area 0-1 1-4 5-9 10-15
• Head 19 17 13 10
• Neck 2 2 2 2
• Anterior trunk 13 13 13 13
• Posterior trunk 13 13 13 13
• Buttock 5 5 5 5
• Genitalia 1 1 1 1
• Arm 4 4 4 4
• Forearm 3 3 3 3
• Hand 2½ 2½ 2½ 2½
• Thigh 5½ 6½ 8½ 8½
• Leg 5 5 5½ 6
• Foot 3½ 3½ 3½ 3½
Depth of Burn
• Traditionally 1st, 2nd, 3rd
• More accurate to describe the level burned:
• Superficial
• Partial thickness
• full thickness
• subdermal
Figure 68-8The physiologic actions of the sympathetic nervous system compensatory responses to burn injury (early phase)
Consequences of Burns
• Cardiac Changes
• Pulmonary Changes
• Gastrointestinal Changes
• Metabolic Changes
• Immunologic Changes
Nursing Interventions
• Impaired skin integrity
• Risk for infection
• Imbalanced nutrition
• Impaired physical mobility
• Disturbed body image