18 Chapter 08 – Lecture Unit 8: Integumentary

Integumentary

Link to visit the Integumentary Chapter

This will be the last of our chapters that utilizes your pathophysiology text – and will utilize it just regarding a few select few areas. The self-assessment activities embedded in the pathophysiology text and within this chapter will provide you with a helpful means of studying and checking your knowledge.

Thus far we have discussed the integumentary system as it relates to pressure ulcers.  However, there are three other types of ulcers that need to be discussed: The venous insufficiency ulcer, the arterial insufficiency ulcer and the neuropathic ulcer.

NEUROPATHIC ULCERS:

These ulcers fall under the umbrella of pressure ulcers in that they are caused due to ischemia of the tissues from prolonged pressure. To explain more fully:  A neuropathic ulcer develops because the individual does not feel discomfort (due to sensory loss: neuropathy) from (prolonged) pressure. Consequently, they do not know to relieves the pressure by re-positioning.

Patients at risk would be those with a neuropathy due to diabetes, a peripheral nerve impairment (which can occur because of compression on the spinal nerves) or following a spinal cord injury.

The most common area for development of these ulcers are on the plantar surface of the foot or on boney prominences.

VENOUS INSUFFICIENCY ULCERS:

Please read 12.3.5.2 Peripheral Venous Insufficiency (PVI)

Risk factors for Venous insufficiency ulcers:

• Damaged valves in the veins or thrombus formation: either cause pooling of blood and fluid retention in the legs and feet.
• This results in a darkening of the skin (Induration)
• This lack of blood flow (venous stasis), can lead to venous stasis ulcers.

Key Characteristics of Venous Insufficiency Ulcers:

• Irregular in shape ulcers in lower legs and feet
• Dorsal pedal and posterior tibial pulses are palpable as this is a condition of the veins not arteries.
• Venous stasis ulcers can become infected and lead to cellulitis, osteomyelitis
• LE elevation and compression bandaging are part of the treatment

ARTERIAL INSUFFICIENCY ULCERS:

Please read 12.3.5.3 Peripheral Artery Disease (PAD).

Risk factors for Peripheral Artery Disease

• Smoking, diabetes
• HTN
• High cholesterol.

Key Characteristics:

• Damaged arteries lead to plaque buildup which leads to…
• Weak or absent pulses and pale/ cold LEs
• Ulcers: Circular, red and deep.
• Pain is present event at rest
• Do not elevate LE for these types of ulcers as it makes it worse (decreases blood flow even more)

RELATED INTEGUMENTARY TOPICS

KELOIDS:  A small number of your patients will have an unfavorable scarring response following surgery or trauma.  Our PowerPoint has a nice visual for a keloid.

Key Characteristics:

• Excessive amounts of collagen are deposited by fibroblasts relative to the amount of collagen-lysis that Occurs during the final (maturation) phase of wound healing.
• May impair mobility of the area depending on severity.
• Scar tissue massage may reduce the risk for development.

INFLAMMATORY RESPONSE:

First phase of wound healing that includes vascular and cellular responses.  Care must be taken to support the healing process at this time and not cause any further damage to the area.  Patient education in this regard is essential. So too is proper positioning of the impacted body part.

MATURATION PHASE

This phase of healing is often referred to as the remodeling phase.  This point the body part is active in movement – and that movement is helping to facilitate a mobile scar.

BURNS:

Please read your Patho text: 12.03.  While you will cover burns in greater detail next year, it is important you understand that burns are assessed:

1. Their depth
2. The size: percentage of total body surface area

Please review: The levels of pain associated with the type of burn.

Pain:

Most Painful:

1st and second degree: Superficial partial thickness

Painful, but less painful:

Second degree: Deep partial thickness

Not painful:

3rd and 4th degree burns

RULE OF NINES. (TOTAL BODY SURFACE AREA percentage):

This is an assessment tool that is used following a burn event to estimate the total body surface area that was injured.  Knowing the total body surface area, along with the depth and severity of the burn, is key to planning treatment for the patient.

After reviewing the body chart for the Rule of Nines in your patho text as well as PowerPoint for this chapter, please answer the following.

Practice:

Click on the best choice.