Janette Bisbee, RN-BC, BSN, NHA Walden University NURS 6510A-18 Synthesis Practicum

1. Nursing Care of the
Integumentary System
HACC
Central Pennsylvania’s Community College
N 103 A

2. Anatomy Overview of Skin
 Epidermis

Outer layer

Shields underlying tissue
 Dermis
 Contains collagen and elastic fibers
 Nerve fibers, blood vessels, sweat glands, sebaceous
glands and hair follicles
 Subcutaneous
 Contains blood vessels, nerves, lymph, and loose
connective tissue

3. Skin Cross-Section

4. Normal Functions of Skin
 Protection
 Homeostasis
 Temperature Regulation
 Sensory Organ/Sensation
 Excretion/secretion
 Vitamin Synthesis
 Psychosocial

5. Perspiration and Evaporation
 Evaporation is the transfer of heat energy
when a liquid is changed to a gas. The body
continuously loses heat by evaporation.
 By regulating perspiration the body promotes
additional evaporative heat loss.
 Exercise, emotional and mental stress causes
increased metabolic rate
 Diaphoresis is visible perspiration primarily
occurring on the forehead, upper thorax, and
other places on the body
 Excessive evaporation causes skin scaling
and itching

6. Factors Affecting
Temperature Regulation
 Age
 Exercise
 Hormone levels
 Circadian Rhythm
 Stress
 Environment

7. Problems with Temperature
Regulation
 Hyperthermia: elevation in body
temperature over normal limits
 Hypothermia: body temperature lower
than normal

8. Hyperthermia/Pyrexia
 What is normal body temperature?
 Low grade elevation: 98.8-100.6
 High grade elevation: >100.6
 Hyperthermia: over 104.9

9. Hyperthermia’s Causes
 Inflammation
 Allergy
 Infection
 Drug reaction
 Cerebral or Neurological injury
 Idiopathic (FUO)

10. Symptoms
 Cold
 Headache
 Malaise
 Skin flushing
 Diaphoresis
 Tachycardia
 Tachypnea

11. Nursing Interventions: Fever
 Promote cool environment
 Encourage fluids
 Antipyretic medications
 Reassess temperature frequently

12. Drugs Acting on Thermal
Regulation
 acetylsalicylic acid (Aspirin)
 acetaminophen (Tylenol)
 ibufrofen (Advil, Motrin)

13. Hypothermia
 Prolonged exposure to cold
 Body temp lower than normal: mild to
profound
 Cell function in all body cells declines

14. Signs of Hypothermia
 Decrease in vital signs, shivering, chills
 Waxy, pale cool skin
 Decreased urinary output
 Decreased muscle coordination
 Disorientation
 Drowsiness progressing to coma

15. Nursing Interventions
Hypothermia
 Warm environment
 Warm blankets, dry clothing
 Warm oral/intravenous fluids
 Keep limbs close to body

16. Application of Heat and Cold
 Physician’s order needed

17. Assessment Prior to Therapy
Warm or Cold
 Temperature tolerance
 Circulatory state
 Neurological response
 Medication decreasing sensitivity
 Age
 New tissue (skin)

18. Application of Heat
 HEAT

VASODILATION (Increasing blood flow),
MUSCLE RELAXATION, PAIN RELIEF,
INCREASES ROM, REDUCES JOINT
STIFFNESS

MAY BE MOIST OR DRY FORMAT

19. Application of Cold
 COLD: VASOCONSTRICTION (reduces
blood flow)
 REDUCES PAIN, DECREASES
BLEEDING, LOCAL ANESTHETIC
EFFECT, DECREASES INFLAMMATION
 MOIST OR DRY FORMATS

20. Skin Assessment
 Inspect the skin for:

Color
 Texture
 Thickness

Turgor
 Temperature

Hydration

21. Common Nursing Diagnoses
 Risk for Impaired Skin Integrity
 Impaired Skin Integrity
 Disturbed body image
 Risk for imbalanced Body temperature
 Hyperthermia
 Hypothermia
 Ineffective Thermoregulation

22. Health Teaching
 Monitor skin daily
 Report alterations/changes
 Keep well moisturized
 Use sunscreen
 Avoid direct sunlight between 10AM and
2PM
 Know your family history of skin cancer

23. Thank You!
 Questions/comments?