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1 NRSG 102: Tissue Integrity Tissue main purpose is to protect against infection
Spring 2015
2 The Skin
1 • Alteration of skin increases risk for physical and psychological disorders.
• Figure 15-1, physical disorders are delayed wound healing, fluid & electrolyte imbalance, temperature (if body temerature is
page 378 too hot the body sweats to cool it off)
• Psychological disorder is disturbed body image
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3 The Epidermis
• Outermost layer
• Consists of epithelial cells There are 5 layers over the palms of the hands and the soles of the feel - 4 layers everywhere
• Layers else
• Stratum basale is the deepest layer of the epidermis Melanin protects against UV rays
• Melanin - melanocytes are cells that produce the pigment melanin and they protect the nerve endings in the dermis
• Keratin -is a water-repellent protein that gives the epidermis its tough, protective quality. Keratinocytes as they mature
• Stratum spinosum are moved up through the epidermis layer, becoming dead cells at the surface of the skin
***
• Stratum granulosum -only 2-3 cells thick. Keratinization a thickening of the cells begins in this layer
• Stratum lucidum -only present in areas of thick skin
• Stratum corneum -outermost layer of the epidermis; is the thickest layer making up 75% of the epidermis total thickness.
• Consist of dead cells made up of keratin arranged in shingles that flake off as dry skin
•*** Mitosis occurs at the Stratum Spinosum layer
4 Skin Layers
• The Dermis is where the sebacous glands and hair folicules are.
• Second, deeper layer composed of flexible connective tissue
• Layers
• Papillary layer contains capillaries and receptors for pain and touch
• Reticular layer contains blood vessels, sweat and sebaceous glands, deep pressure receptors, & dense collagen fibers
• Superficial Fascia
• Subcutaneous tissue under the dermis
• Composed of adipose tissue - helps the skin adhere to underlying structures
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5 Glands of the Skin
• Sebaceous glands (oil)
• All over the body except hands and soles of feet
• Secrete oily substance called sebum -softens and lubricates the skin and hair, decreases water loss from the skin
• Protects the body from infections by killing bacteria if they become blocked a white head or pimple appears
• Sudoriferous (sweat) glands Secretes water/salt/waste products when it oxidixes and dries become blackheads
• Eccrine located in the dermis secretion is composed mostly of water and sodium
• Forehead, palms, soles
• Apocrine secretion is similar to Eccrine glands but also contains fatty acids and proteins
• Axillary, anal, and genital areas
• Ceruminous glands are modified apocrine seat glands
• Secrete waxy cerumen
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• **The Sudoriferous glands are regulated by the sympathetic nervous system and it serves to maintain body temperature and is
6 Skin Color in response to emotion
• Result of varying levels of pigmentation
• Melanin is darker and is produced in greater amounts in individuals with dark skin color then in light skin color. Exposure
• Yellow-to-brown pigment to the sun causes a buildup of melanin and a darkening of the skin
• Carotene found in areas of the body where the stratum corneum is thickest; palms of hands. Abundant in the skin of
• Yellow-to-orange pigment Asian ancestry
• Erythema
• Reddening of the skin
• Seen in blushing, fever, hypertension, inflammation
Cyanosis

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• Cyanosis results from poor oxygenation or low hemoglobin
• Bluish discoloration
• Pallor
• Paleness
• Seen in shock, fear, anger, anemia, hypoxia
• Jaundice can be seen in the skin and in the scaleria of the eyes (white part)
• Yellow-to-orange color Seen in bilrubin because of the breakdown in red blood cells.
• Most often result of hepatic disorder
•
• skin color can be influenced by emotion and or illness
7 The Hair -is everywhere except the lip, nipples, parts of the external genitals, palms of hands and soles of feet
• The hair shaft is produced by a bulb. eyelashes & eyebrows protects the eyes. Nose hair traps bacteria and prevents it
• Root is enclosed in a hair follicle. from entering the respiratory tract.
• Shaft
• Exposed part
• Consists of dead cells
• Nutrition and hormones effect hair growth. Hair acts as insulation (on the head) to help regulate body temperature
8 The Nails
• Modified scale-like epidermal
structure consisting of dead cells
• Lunula is the white cresent
• Nail folds is the sides of the nails overlapped by skin
• Eponychium
(cuticle)
• Thickening of the nail bed can be a sign of a fungus
9 Diagnosis
• Tests
• Biopsy differentiate benign lesions from skin cancers-NI apply dressing, provide info about self-care & suture removal
• Culture scraping from a lesion - done to identify fungal, bacterial, or viral skin infections
• Immunofluorescent slides Identify IgG antibodies, herpes zoster. Samples placed on slide & examined microscopically
• Oil slides determine type of skin infestation present; scraping placed on slide w/oil & examined microscopically
• Patch test determine specific allergen. Small amount of allergen is placed on the skin under a patch
• Scratch tests needle is used to place small amount of allergen into the skin - NI pt needs to return 48hrs to have read
• Potassium hydroxide (KOH) specimen from hair or nails is examined for fungal infection
• Tzanck smear Used to diagnose herpes infections - doesn't differentiate herpes simplex from herpes zoster
• Wood lamp uses ultraviolet light causes organisms to fluoresce - skin is examined under special lamp - NI explain that the
• room will be dark to allow visualization of fluorescence
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10 Diagnosis
• Nurse's responsibilities
• Explain procedure and any special preparation needed
• Assess medication use that may affect outcome of tests
• Support patient during examination
• Document procedures as appropriate
• Monitor results of tests
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11 Genetic Considerations
• Integumentary disorders or abnormalities in immediate family members
• Gender
• Manifestations that indicate genetic disorder
• If data found that indicates genetic risk factors, ask about genetic testing and refer for appropriate
genetic counseling
• Ex: male pattern balness is genetically predetermined
• Family history of skin cancer is a risk factor for skin cancer
12 Health Assessment Interview to determine problems with the integumentary system
Ask about changes in health, rashes, itching, color changes, dryness or oiliness, growth or changes

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• Ask about changes in health, rashes, itching, color changes, dryness or oiliness, growth or changes
in warts or moles, presence of lesions
• Precipitating causes such as medications, new soaps, pets, stress, dietary changes
• Hair problems ask about thinning or baldness
• Nail problems splitting or breakage, discoloration, infection
• Medical history skin problems can be a sign of cardiovascular disease, hepatic disease, hematologic disorders
• Occupational and social history travel, exposure to toxic substance, use of alochol
• Assess presence of risk factors for skin cancer
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13 Physical Assessment
• Inspection and palpation
• Conduct examination in warm, private room
• Protect patient's modesty
• Assess skin
• Odor, lesions, color, alterations, temperature, texture, moisture, edema, turgor
• Assess lesions
• Location, distribution, color, pattern, edges, size, elevation, and type of exudate
• Primary skin lesions
• Secondary skin lesions
• Vascular skin lesions
• Assess hair
• Color, quality, quantity
• Scalp lesions
• Assess nails
• Shape, color, contour, condition
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14 Common Skin Problems and Lesions
• Pruritus –Itching
• Causes
• Insects, animals, plants, fabrics, metals, medications, allergies, emotional distress
• Itch-scratch-itch cycle
• Secondary effects
• Skin excoriation, erythema, wheals, changes in pigmentation, infections
• Management
• Identify and eliminate the cause
• Provide medications to relieve the itch
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15 The Patient with Xerosis
• Dry skin
• Xerosis
• Causes
•Old age, environmental heat and low humidity, sunlight, excessive bathing, decreased
intake of liquids
• Types of severe dry skin
• Xeroderma
• Ichthyosis
• Manifestations
• Pruritus
• Visible flaking of surface skin
• Observable pattern of fine lines
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16 The Patient with Benign Skin Lesions
• Cysts
• Benign closed sacs lined with epithelium and contain fluid or semisolid material
• Epidermal inclusion and pilar common
• Keloids
• Elevated, irregularly shaped, progressively enlarging scars from excessive amt of collagen during scar formation
• Young adults, familial tendency, and in those of African, Asian descent
• Nevi (moles)
• Rounded, well-defined borders
• Nevocellular or dysplastic
• Angiomas (hemangiomas)
• Benign vascular tumors
• Types include nevus flammeus, cherry, spider, telangiectasis, venous lake.
port-wine stain
• Skin tags
• Soft papules on a pedicle
• Keratoses
• Benign overgrowth and thickening of cornified epithelium
• Adults over 50
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17 The Patient with Psoriasis there is no cure, treatment can decrease severity & pain of the lesions
• Raised, reddened, round circumscribed plaques covered by silvery white scales
• Most common type is plaque psoriasis
• Occurs most often in Caucasians
• Precipitating factors
• Sunlight
• Certain drugs
• Family history
• Skin trauma from surgery
• Sunburn
• Excoriation
• Stress
• Seasonal changes
• Hormone fluctuations
• Steroid withdrawal
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18 Pathophysiology
• Psoriatic skin cells have shorter cycle of growth.
• Hyperkeratosis
• Abnormal keratin that forms thick, flaky scales at the surface of the skin; normally on elbows, knees, and scalp
• Manifestations
• Characteristic lesions that shed thick, silver-grey flakes
• Nails shows
• Pitting, yellow, or brown discoloration
• Separation from bed thicken and crumble
• Psoriatic arthritis a specific form of arthritis involving skin lesions and inflammation of joints
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19 Diagnosis / Medications
• Skin biopsy
• If atypical
• Differentiates psoriasis from other inflammatory, infectious skin disorders
• Ultrasound

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• Topical medications
• Photochemotherapy
• Corticosteroids, tar preparations, anthralin, calcipotriene, a vitamin D derivative, adalimumab and
tazarotene are topically used. Corticosteroids decreases inflammation & itching. Tar surpresses mitotic activity (mitosis)
• Ustekinumab injectable antibody that decrease the immune response - Stelara
• Medications that impact inflammatory and immune responses may be indicated.
• Methotrextate
20 Treatments
• Based on type, extent and location, age of patient, degree of disfigurement
• No cure
• Phototherapy Used if 30% of body is effected - Experience redness for up to 8 hrs after treatment
• UVB or narrowband UVB decreases the growth rate of epidermal cells
• Photochemotherapy Methoxsalen is administered orally and pt is exposed to UVA light 2 hours later. 2-3x/week
• High rate of remission
• Side effect of aging skin, cataracts, altering immune function
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21 Nursing Care
• Priorities of care
• Ensure adequate treatment of underlying process
• Support physical and psychological responses to this disease is a nursing priority
• Provide emotional support
• Teach patient and caregivers strategies for self-care
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22 Diagnoses, Outcomes, and Interventions

• Impaired Skin Integrity

• Psoriatic skin lesions increase risk of infection, can further compromise healing
***• Teach methods to reduce injury to skin when taking therapeutic baths or treatments
• Teach how to apply topical medications apply thin layer more often. Can irritate eyes & mucous membranes can
• Impaired Skin Integrity cause maceration (skin breakdown) in skin folds due to prolonged moisture
• Teach manifestations of infection; how to contact healthcare provider
• Teach manifestations of the complications of treatment meds/treatment can damage cells through chemical burns
• Disturbed Body Image or excessive exposure to UV light.
• Establish trusting relationship
• Demonstrate lesions are not contagious by touching pt during interaction - lets them know lesions are not offensive
• Encourage expression of self-perception and asking of questions body image process; recognition, acceptance, &
• Promote social interaction (family,support groups) resolution
*** • Use warm water and soft cloth; gently rub in a circular motion. Pat dry.w/soft cloth. Moisturize skin. Hot water and dry skin
• can make pruritus worse - stimulating the scratch-itch cycle making psoriasis worse
23 Nursing Care
• Continuity of care
• Address chronic nature of the disease
• Address factors that may precipitate an exacerbation ways to reduce stress
• Address interventions for pruritus and dry skin, specific care for psoriasis expose skin to sun but avoid burns, avoid
• Resources trauma to skin, avoid exposure to
• National Psoriasis Foundation contagious illness (flu) discuss meds -
• The National Institutes of Health certain meds can exacerbate psoriasis
• The American Academy of Dermatology
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24 The Patient With Bacterial Infections
• Pyoderma
• Infection that occurs when a break in the skin allows invasion by pathogenic bacteria
• Common infections
Gram-positive Staphylococcus aureus

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• Gram-positive Staphylococcus aureus
• MRSA
•Methicillin-resistant Staphylococcus aureus (MRSA) infection
•Potentially fatal
•Healthcare-associated infections (HA-MRSA) and community-associated infections (CA-
MRSA)
• Beta-hemolytic streptococci
• bacterial infections of the skin can arise from the hair follicle -localized infection or from open wounds which invades tissue and
25 Pathophysiology causes systemic infection - life threatening.
• Folliculitis infection of hair follicle
• Caused by S. aureus -poor hygeine, poor nutrition, prolonged skin moisture, tight fabrics
• Scalp and extremities legs of women who shave, bearded men, stye on eyelids
• Pustules surrounded by area of erythema
• Furuncles and carbuncles caused by S. aureus start as folliculitis but infection spreads down hair shaft and through the wall
• Boils of the follicle into the dermis
• Cysts may drain substantial amounts of purulent drainage poor hygiene, moisture, diabetes mellitus & hematologic
• Carbuncle malignancies
• Group of infected hair follicles
• Common in hot, humid climates
• Cellulitis
• Localized infection of dermis, subcutaneous tissue
• Spreading factor (hyaluronidase) spreading occurs as a result of this substance; it breaks down the barriers that normally
• localize the infection. Pt may have fever, chills, malaise, headache & swollen lymph
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26 Interprofessional Care
• Diagnosis
• Test drainage or blood culture for identification
• Test culture from external nares to identify carriers
• Medications
• Antibiotic, topical or oral multiple treated w/ cloxacillin
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27 Nursing Care
• Priorities of care
• Adequate treatment of infection
• Infection control
• Teaching patient and caregivers strategies to prevent spread of infection & restore normal skin integrity
• Promoting comfort and prevention of recurrence
• Diagnoses, outcomes, and interventions
• Risk for Infection
• Practice good hand washing and teach importance -most effective in preventing the spread
• Assess for and teach how to identify infection fever, tachycardia, chills; inc. erythema, size of lesion, drainage
• Expected outcome: pt infection will be managed as evidence by skin integrity and body temperature w/i normal range
• Cover draining lesions w/sterile gauze; handle soiled linens w/stand precautions; wear gloves & mask to prevent spread
28 Nursing Care
• Continuity of care
• Maintain good nutrition
• Maintain cleanliness through hand hygiene and proper handling and disposal of dressings
• Prevent spread of infection by not sharing linens and towels and washing clothing and linens in
hot water
• Do not squeeze or open a pimple, boil
• Take the full course of prescribed antibiotics
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29 The Patient with a Fungal Infection Fungal-free living, plantlike organisms that live in soil, on animals & humans
• Dermatophytes
Fungi that cause superficial skin infections

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• Fungi that cause superficial skin infections
• Dermatophytoses (tinea) - ringworm - increased in areas where moisture content is high; skin folds, between toes etc.
•Tinea pedis (soles of feet) athletes feet - most common tinea infection
•Tinea corporis (body)
•Tinea cruris (groin) jock itch and it may extend from groin to inner thigh & buttocks. Active people, obese
• Mycoses
• Candidiasis - yeast
• Most commonly seen in women as vaginal infections
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30 Interprofessional Care
• Diagnosis
• Cultures
• Microscopic examination using KOH
• Examination of skin with ultraviolet light (Wood's lamp)
• Medications
• Treat with OTC drugs
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31 NursingCare Fungal disease is contagious so....
• Do not share linens or personal items
• Use a clean towel and washcloth each day
• Carefully dry all skin folds -under breast, between toes, under the arms
• Wear clean cotton underclothing each day
• Do not wear same pair of shoes every day
• Wear socks that permit moisture to wick away from the skin surface
• Do not wear rubber- or plastic-soled shoes
• Use talcum powder or an OTC antifungal powder twice a day
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32 The Patient with a Parasitic Infestation
• More common in developing countries
• Affect people of all social classes
• Associated with crowded, unsanitary living conditions
• Pediculosis
• Lice infestation
• Common types
• Pediculosis corporis (body lice) spread by contact w/infected clothing, bedding
• Pediculosis pubis (pubic lice, or "crabs") spread through sexual activity
• Scabies
• Mite infestation (Sarcoptes scabiei)
• Pruritus in response to mite, egg
• Found in webs between fingers, inner wrist & elbow, axille, penis, waist band
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33 Interprofessional Care
• Diagnosis
• Pediculosis
• Examine hair shaft, clothing to identify the lice or nits
• Scabies
• Skin scrapings
• Microscopic examination for mites or feces
• Medications
• Lice
• Topical medications for body and pubic lice
• Shampoos containing lindane for hair lice- fine tooth comb used to remove dead nits

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• Scabies
• Lindane lotion applied to skin surface for 12 hours
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34 Nursing Care
• Wash clothing and linens in soap and hot water, or dry clean
• Iron the clothes kills any lice eggs
• All family members and sexual partners must also be treated.
• Lice and mites may infest anyone.
• If pt is in hospital isolation precautions are used.
35 The Patient with a Viral Infection are pathogens that consist of an RNA or DNA core surrounded by a protein coat
• Viruses depend on live cells for reproduction. They are classified as intracellular pathogens
• Invade keratinocyte
• Reproduce
• Increase cellular growth or cause cellular death
• Commonly used drugs such as birth control, corticosteroids, antibiotics are attributed. because they have
• immunosuppressive properties that allow viruses to multiply. Antibiotics kill off normal skin bacteria that would protect skin.
36 Pathophysiology
• Warts (verrucae) are lesions of the skin caused by HPV. Nongenital warts are benign lesions; genital warts may be
• Types precancerous.
• Common wart (verruca vulgaris) may be anywhere but commonly on finger- domed shaped, ragged boarders
• Plantar warts appear at pressure points on soles of the feet-extend deep beneath the skin & often painful
• Flat wart small, flat lesion unusally on the forehead or dorsum of the hand
• Treatment
• Medication
• Cryotherapy Freezing warts off - pt will still have virus in body even after wart is removed
• Electrodesiccation
• Curettage
• Removal
• Acid therapy common method of removal
• Cryosurgery
• Electrodesiccation electric current followed by excision of the dead tissue
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• Transmitted through skin contact
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37 Herpes Virus
• Herpes simplex
• Fever blister, cold sore most often on lips, face, mouth
• Caused by HSV I and HSV II
• Forms in response to sunlight, menstruation, injury, stress
• Initial infection often severe
• Oral acyclovir used prophylactically
• Herpes zoster AKA: Shingles
• Caused by reactivation of varicella zoster after chickenpox
• Most common in adults over 60, patient's with Hodgkin disease, types of leukemia, lymphomas,
immunocompromised
• Complications
• Postherpetic neuralgia -sharp spasmodic pain along the course of one or more nerves - burning or stabbing
• Visual loss
• Death may occur in the immunocompromised patient.
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38 Interprofessional Care treatment for viral skin infections focuses on stopping infection and treating responses such as
• Diagnosis itching

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• Manifestations and appearance of lesions
• Tzank smear identifies the herpes virus but does not differentiate herpes zoster from herpes simplex
• Cultures of fluid from vesicles is used to differentiate diagnosis of herpes virus types
• Antibody tests also used to differentiate diagnosis of herpes virus types
• HIV test should be considered for patients under 55 with a history of HIV risk factors.
• Medications
• Antiviral drugs are used to treat herpes zoster infections
• Acyclovir (Zovirax) a type of antiviral drug that interferes wit viral synthesis & replication. Not a cure for herpes but it does
• Pain management decrease the severity of the illness & decreases pain.
• Nerve blocks used to treat initial pain
• Narcotic and nonnarcotic analgesics are prescribed fro pain management
• Antihistamines prescribed for relief of pruritus (itching)
• Eye involvement
• Topical steroid ophthalmic ointments and mydriatics
• Zostavax (weaker form of varicella-zoster live virus) is a vaccine used for adults age 60 yrs or older to prevent herpes
• zoster, It increases the immune system response and if patient experiences an outbreak after vaccination the
• nerve pain may be prevented. Can not be taken if allergic to gelatin or neomycin or people w/weakened immune
• system or taking steroids
39 Nursing Care
• Priorities of care
• Adequate treatment of viral skin infection
• Teach patient and caregivers strategies for prevention
• Optimize comfort
• Promote safe home and work environments
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40 Diagnoses, Outcomes, and Interventions

• Acute Pain
• Monitor location, duration, intensity of pain
• Explain the rationale for taking prescribed medications on regular schedule delay could cause pain to reach a
• Teach measures to relieve pruritus to avoid itching & secondary infection level that makes meds less effective
• Encourage the use of distraction relaxation techniques
• Risk for Infection
• Monitor white blood cell count
• Assess for lymph gland enlargement
• Interventions to decrease itch-scratch-itch cycle to prevent secondary bacterial infection
• Infection control procedures - strict isolation for immunocompromised patients, gloves & gown to prevent spreading of
• infection. Pregnant women must avoid exposure to people with herpes zoster because
• the virus can cross the placental barrier
41 Nursing Care
• Continuity of care
• Vaccine to prevent herpes zoster
• Herpes zoster
• Self-limiting and heals completely
• Second occurrences rare
• Do not have social contact with children or pregnant women contagious to people who haven't had chickenpox
• Use pain medications regularly
• Follow suggestions to help reduce itching, scratching, and pain
• Report any increase in pain, fever, chills, drainage, or a spread in the blisters
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42 The Patient with Dermatitis
• Inflammation of the skin characterized by erythema and pain or pruritus
• May be acute or chronic
• Contact dermatitis common causes: poison ivy/oak, dyes, perfume, chemicals, metals
• Allergic
Cell-mediated or delayed hypersensitivity response

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• Cell-mediated or delayed hypersensitivity response
• Irritant
• Chemicals, soaps, detergents
• Atopic dermatitis is an inflammatory skin disorder also called
• Eczema
• Type I hypersensitivity reactionimmune response interacts w/the allergen to create a chronic inflammatory condition
• Seborrheic dermatitis chronic inflammatory disorder of the skin that involves ...
• Scalp, eyebrows, eyelids, ear canals, nasolabial folds, axillae, trunk
• Seen in patients with Parkinson, AIDS lesions are yellow or white plaques w/scales & crusts
• Exfoliative dermatitis inflammatory skin disorder
• Excessive peeling, shedding of skin
• Preexisting skin disorder or reaction to certain medications
• Systemic and localized manifestations
• Systemic manifestations include weakness, malaise, fever, chills, and weight loss
• scaling, erythema, & pruritus may be localized or effect the whole body. Patient may lose hair & nails
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43 Interprofessional Care
• Diagnosis
• Based on:
• Manifestations
• History of exposures to irritants
• Suspected foods
• Scratch tests used to identify a specific allergen
• Intradermal tests
• Medications
• Minor cases
• Antipruritic medications
• Severe cases
• Oral antihistamines
• Oral and/or topical corticosteroids
• Wet dressings for weeping lesions
• Topical immunosuppressive modulators
• Possible link to skin cancer, lymphoma
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44 Nursing Care
• Provide information for self-care at home
• Treatments only relieve symptoms. they do not cure the disease
• Itch-scratch-itch cycle dry skin increase pruritus stimulating scratching, increasing flare up and risk of infection
• May be necessary to change diet or environment to avoid contact w/allergen
• Antihistamines cause drowsiness.
• Corticosteroid, topical steroid use
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45 The Patient with Acne
• Acne
• Disorder of pilosebaceous structure (hair and sebaceous gland)
• Opens to skin surface through the pore
• Sebum production responds to direct hormonal stimulation. teticular androgens in men & adrenal and ovarian androgens
• Noninflammatory or inflammatory in women
• Inflammatory acne lesions
• Comedones
• Pimples, whiteheads, and blackheads
• Erythematous pustules -inflammation close to the skin surface
• Cysts -deeper inflammation
Acne vulgaris

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• Acne vulgaris most common skin condition
• Common in adolescents, young adults
• most on face and neck
• Acne rosacea
• Middle, older adults
• Erythema over cheeks, nose
• Acne conglobata
• Occurs primarily on the back, buttocks, and chest
• Causes serious skin lesions
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46 Interprofessional Care
• Diagnosis
• Location and appearance of lesions
• Culture of drainage performed in case of pustules
• Medications
• Tailored to individual, based on severity of lesions
• Comedones
• Tretinoin (retinoic acid, Retin-A)
• Benzoyl peroxide topicial
• Azelaic acid
• Topical clindamycin (Cleocin T) a bacteriostatic agent that decreases the amt of fatty acid on the skin - mild acne
• Oral or topical antibiotics Tetracycline, erythromycin & minocycline - moderate acne
• Treatments
• Scars can alter self-confidence and can be removed by:
• Dermabrasion
• Laser treatment
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47 Nursing Care
• Individualized
• Conducted through teaching in clinics or healthcare provider offices
• General guidelines for skin car, health, specific guidelines for care of acne lesions
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48 The Patient with a Pressure Ulcer
• Ischemic lesions of skin and underlying tissues caused by unrelieved pressure that impairs flow of
blood and lymph causing tissue necrosis and eventually ulceration (bed sores or decubitus ulcers)
• Incidence normally occur over a bony prominence (heals, greater trochanter, sacrum, and ischia
• Complications 60,000 patients die each year from pressure ulcer complications
• Infections
• Loss of function
• Pain
• Causes
*** • External pressure compressing blood vessels
• Shearing forces When one tissue layer slides over another the stretching & bending of blood vessels cause injury &
• Secondary bacterial invasion common thrombosis. Shearing can happen when the head of the bed is elevated and
• Classifications the torso slides down also when pulling a pt. up in bed so always lift pt w/sheet
• Stage I–IV see pg421 box16-10
***external
• pressure that is greater than capillary pressure & arteriolar pressure interrupts blood flow. When pressure to skin on a
bony
• prominence occurs for 2 hrs it causes tissue ischemia & hypoxia causing irreversible tissue damage.
49 Risk Factors
• Older adults with limited mobility and fractured hips
• Quadriplegia
• Patients in the critical care setting

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• Other patients
• With fractures of large bones
• Undergone orthopedic surgery
• Sustained spinal cord injury
• Patients with chronic illnesses or infection (renal failure, anemia, edema or infection)
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50 Interprofessional Care
• Diagnosis
• Determine presence of secondary infection
• Differentiate cause of ulcer
• Deep or infected ulcers
• Drainage or biopsied tissue cultured to determine the cause
• Medications
• Topical and systemic antibiotics specific to the organism eradicate any infection present
• Products to promote healing
• Surgical treatment
• Surgical debridement may be necessary if pressure ulcer is deep, subcutaneous tissue involved or eschar has formed
• Skin grafting in case of large wounds over the ulcer, preventing healing from granulation.
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51 Nursing Care
• Priorities of care
• Adequate prevention in high risk patients
• Treat pressure ulcer while providing care that promotes healing and promotes infection
prevention
• Teach strategies to prevent development or progression of ulcers
• Promote comfort and maintain asepsis
• Diagnoses, outcomes, and interventions
• Risk for Impaired Skin Integrity
• Expected outcome
•Wound healing through primary intention as indicated by progressive approximation of
wound borders
• Continuity of care
• Teach care for pressure ulcer and prevention
• Referrals to home health agency or community health department
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52 Disorders of the Peripheral Arteries
• Acute or chronic
• Physiology review
• Delivers oxygen to skin, extremities
• Three layers include intima, media, and adventitia.
• Vasoconstriction occurs when contraction narrows the vessel lumen
• Vasodilation occurs when smooth muscle relaxation expands the vessel
• Resistance opposes blood flow. Blood flows from an area of higher pressure to an area of lower pressure. Resistance is
created by friction of the blood, although primary reason for vascular resistance is the diameter & length of blood vessels.
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53 The Patient with Peripheral Vascular Disease Arteriosclerosis is the most common arterial disorder; thickening, loss
• Narrowed peripheral arteries of elasticity & calcification of arterial walls.
• Impaired blood supply to peripheral tissues
• Pathophysiology
• Types of PVD
• Type 1: aorta and iliac arteries
• Type 2: aorta, common and external iliac arteries
• Type 3: aorta, iliac, femoral, popliteal, and tibial arteries
• Arteriosclerosis in the abdominal aorta leads to aneurysms as plaque erodes the vessel wall.

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54 Manifestations
• Manifestations Pain is the primary symptom of peripheral atherosclerosis
• Intermittent claudication cramping,aching pain in calf, thigh,buttocks occurs w/activity. Pain w/weakness better w/rest
• Rest pain during inactivity; burning in lower leg. Increases when legs are elevated; decreases when hanging over bed. legs
• Paresthesias feel cold, numb along w/pain
• Numbness, decreased sensation
• Diminished or absent peripheral pulses
• Pallor with extremity elevation, dependent rubor when dependent
dark red
• Thin, shiny, hairless skin
• Thickened toenails
• Areas of discoloration or skin breakdown
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55 The Patient with Peripheral Vascular Disease
• Complications
• Gangrene
• Extremity amputation
• Rupture of abdominal aortic aneurysms
• Infection
• Sepsis
• Risk factors
• Diabetes mellitus
• Hypercholesterolemia
• Hypertension
• Cigarette smoking
• High homocysteine levels
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56 Interprofessional Care
• Diagnosis
• Segmental pressure measurements used to compare BP between upper and lower levels -w/PVD BP lower in legs
• Stress testing using treadmill - w/PVD pressure in ankle may decline even further with exercise
• Doppler ultrasound uses sound waves reflected off moving RBD to evaluate blood flow w/PVD wave forms are flat
• Duplex Doppler ultrasound combines sound w/image provides views of the affected vessel.
• Transcutaneous oximetry evaluates oxygenation of tissues
*** • Angiography or magnetic resonance angiography locates & evaluates the extent of arterial obstruction
• Medications
• Drugs to inhibit platelet aggregation (asprin/Plavix) reduce risk of arterial thrombosis
• Platelet inhibitors improves claudication (cramping, aching, pain) Ex:Cilostazol (Pletal)
• Drugs to decrease blood viscosity increases RBC flexibility; increasing blood flow to circulation & tissue of extremities
• Parenteral vasodilator prostaglandins given long term to decrease pain & facilitate healing; pts w/severe limb ischemia
• *** Angiography - contrast medium injected & vessels examined using fluoroscopy & x-ray
• Magnetic resonance angiography does not require injection of a contrast medium - may replace angiography
57 Interprofessional Care
• Treatments
• Smoking cessation is vital -nicotine promotes atherosclerosis & causes vasospasm, reducing blood flow to extremities
• Meticulous foot care vital to prevent ulceration & infection; avoid elastic support hose bcuz they reduce circulation to skin
• Exercise daily strenuous exercise is vital 30-45 min of walking
• Rest at the onset of claudication once pain is resolved - resume activity
• Control diabetes and hypertension
• Lower cholesterol levels
• Weight loss
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58 Interprofessional Care
Revascularization

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 3/2/2015

• Revascularization
• Nonsurgical procedures
• Transluminal angioplasty (PTA)
• Stent placement is placed to maintain vessel patency
• Atherectomy
• Balloon angioplasty to dilate the narrowed lumen
• Mechanical atherectomy to remove plaque
• Laser or thermal angioplasty to vaporize the occluding material
• Surgery
• Endarterectomy to remove occlusive plaque from the artery & bypass grafts
• Knitted Dacron bypass grafts
• Complementary therapies
• Interventions to improve circulation, reduce stress
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59 Nursing Care
• Diagnoses, outcomes, and interventions
• Ineffective Tissue Perfusion: Peripheral Read pg 990 bottom left & upper rt side of page
• Pain assess pain q 4. keep extremities warm, cooling causes vasoconstriction increasing pain
• Impaired Skin Integrity frequent assessment of skin, keep skin clean & dry apply moisturizer.
• Activity Intolerance encourage gradual increase in activity; rest w/extremities dependent reducing claudication
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