Integumentary

Anatomy + Physiology

Anatomy of the skin

Functions of the skin
● Epidermis
○ Protection from injury
○ Inhibits proliferation of microorganisms
○ Prevents dehydration and electrolyte loss
○ Sweat glands allow for temperature regulation, dissipation of heat
○ Transmits tactile stimulation through neuroreceptors
○ Synthesizes vitamin D

Functions of the skin

● Dermis
○ Cells for wound healing
○ Nerve receptors - signal skin injury and inflammation
○ Responds to inflammation
■ Lymphatic + vascular tissue
Functions of the skin
● Hypodermis
○ Absorbs mechanical shock - protects from injury
○ Temperature regulation
■ Fat cells insulate and retain body heat

Terminology
● Lesions → “area of tissue that has
suffered damage”
○ Primary → direct result of a disease
process
○ Secondary → develop as a
consequence of the client’s activities
● Pruritus
○ Itching
● Urticaria
○ Hives
● Lichenified
○ Thickened
Terms to describe lesions
● Annular → ringlike with raised borders around flat centers of normal skin
● Circinate → circular
● Circumscribed → well defined, sharp borders
● Clustered → several lesions grouped together
● Diffuse →widespread
● Linear → occurs in a straight line
● Macular → flat
● Papular → raised
Pressure
Injuries
Risk factors
● Lack of mobility
● Exposure to excessive moisture
○ Urinary incontinence
○ Fecal incontinence
● Undernourishment
● Aging skin
Stage 1
Stage 2

Stage 3
Stage 4

Unstageable
Determine risk
a. Use a reliable scale (e.g., Braden Scale) to assess risk, and assess entire skin daily.
b. Use a proven skin care bundle so that all health care professionals are following
consistent interventions.
c. Ensure that a nutrition consultation takes place.
d. Ensure that fluid intake is 2000 to 3000 mL/day.
e. Help the patient consume the determined amount of protein and calories.
f. Monitor changes in weight, skin turgor, urine output, renal function, serum sodium,
and calculated serum osmolality.
g. Document interventions thoroughly, and communicate with the interprofessional
team regularly to promote continuity of care.
Ways to reduce pressure
a. Do not keep the head of the bed elevated above 30 degrees to prevent shearing.
b. When positioning a client on their side, position at a 30-degree tilt (avoiding 90-degree positions).
c. Examine the source of pressure, and determine how to reduce it.
d. Help clients in chairs or wheelchairs to stand and march in place, five steps per hour (if they are able).
e. Use pressure-offloading devices or foam dressings for bony prominences (e.g., float the heels off of a
sturdy pillow.
f. Use devices such as air-fluidized beds or surfaces and powered mattress overlays to manage the
microclimate (the area between the patient’s skin and the support surface).
g. Refrain from using donut-shaped pillows; these can damage capillary beds and increase tissue necrosis.
h. For patients who cannot stand or turn themselves, turn and reposition a minimum of every 2 hours or as
needs are assessed.

Burns
1st degree
● Most superficial burn
● The skin remains intact; no break in integrity of epidermis
● Redness (erythema)
● No blisters
● Can be painful to the touch
Rule of 9’s
 Rule of 9’s Worksheet

Complications of Burn Injuries

Hypovolemic Shock
● Increase in capillary permeability
● Third spacing occurs
○ Plasma moves from the intravascular space, to the interstitial space
○ Sodium
○ Albumin
● Decreased intravascular volume = decreased BP = hypovolemia
● Cardiovascular system recognizes hypovolemia - increases HR to
compensate
○ Increased HR
○ Decreased cardiac output
○ Decreased blood pressure
● Hypovolemic shock leads to decreased perfusion of kidneys and renal
damage

Hyperkalemia
● Most potassium is stored in the cells
● Injury causes lysis of cells, which then release potassium into bloodstream
● Causes hyperkalemia
● K >5.5
● Signs and symptoms:
○ Muscle weakness
○ Cramps
○ Nausea
○ Chest pain
○ Arrhythmias
○ Tall, peaked T-waves
Hyponatremia
● Water follows sodium
● Sodium is leaving the intravascular space and going to the interstitial space
● Due to increased capillary membrane permeability
● Water follows this sodium and the client becomes hyponatremic
● Na < 135
● Signs and symptoms:
○ Headache
○ Confusion
○ Restlessness
○ Irritability
○ Seizures
○ Coma

Emergency Management
● Begins with the burn injury and lasts until the capillary membrane
permeability has been restored
● Usually 24-48 hours
● Focus is on fluid replacement
● client is at risk for:
○ Hypovolemic shock
○ Respiratory distress
○ Compartment syndrome
Fluid Replacement
● Crucial in the first 24 hours
● Due to the increase in capillary permeability, this is when the client is losing
large volumes of fluid and is at risk for hypovolemic shock.
● Fluids:
○ Lactated Ringers
■ Expands the intravascular volume
○ Colloids
■ Albumin
● Helps pull fluids back into the intravascular system
● Monitor urine output
● Fluids are titrated to ensure adequate UOP (30cc/hr)
● Correction of imbalances
○ Sodium? Potassium?
Parkland Burn Formula
worksheet