UNIT 4 BUILDING CLINICAL COMPETENCE Responses to...
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UNIT 4 BUILDING CLINICAL COMPETENCE Responses to Altered Integumentary Structure and Function FUNCTIONAL HEALTH PATTERN: Nutritional—Metabolic Think about clients with altered nutrition or metabolic function for whom you have cared in your clinical experiences. ■ What were the clients’ major medical diagnoses (e.g., psoriasis, cysts, folliculitis, cellulitis, candidiasis, pediculosis, herpes zoster, seborrheic dermatitis, acne vulgaris, nonmelanoma skin cancer, malignant melanoma, basal cell carcinoma, pressure ulcers, or burn trauma)? ■ What manifestations did each of these clients have? Were these manifestations similar or different? ■ How did the clients’ nutritional and metabolic status affect their integumentary system? What was their daily intake of foods and fluids? Were they gaining or losing weight? What medications or dietary supplements were they taking? What was the condition of their skin, hair, and nails? Did they complain of dry skin, itching, rashes, bruising, or hair loss? Did they note any changes in moles or warts? Did they have any pressure areas on the sacrum, hips, or ankles? Did they have any previous skin disorders and how were they treated? Did they use preventive measures to protect against temperature extremes? The Nutritional-Metabolic Pattern includes food and fluid intake to maintain the nutritional and metabolic needs of the integumentary system. Breakdown of skin and its accessory structures leads to decreased protection between internal and external environments. Integumentary disorders are affected by nutritional and metabolic status in three primary ways: ■ Lack of proper nutrients lowers the body’s resistance to illness and can result in integumentary disorders such as infection (e.g., viral, bacterial) or skin breakdown (e.g., pressure ulcers). ■ Exposure to extremes of cold or heat can result in trauma to the skin and accessory structures (e.g., frostbite, burn trauma). ■ Use of certain medications, trauma, and medical disorders can result in hair distribution changes (e.g., hirsutism, alopecia). Nutrients are used by the body to promote maintenance and repair of cells and tissues. Improper intake of nutrients affects the integumentary system’s ability to maintain protection, regulate body temperature, and maintain fluid and electrolyte balance. Exposure to environ- mental extremes may alter the integrity of the skin, increasing the risk for infection and alter- ations of fluid/electrolye balance. Due to these factors, the client can develop skin, hair, and nail disorders, leading to manifestations such as: ■ Skin ulcerations (external pressure impairs the flow of blood and lymph or friction and shearing from sliding tears and injures vessels tissue ischemia and hypoxia occur resulting in tissue death and necrosis) ■ Infection (microorganisms invade tissue and replicate toxic by-products of microorganism metabolism, cell lysis, and immune response occur resulting in inflammation and tissue damage) ■ Alopecia (scarring from trauma, infection, radiation, medications affects rapidly growing cells in hair follicles affected hair follicle cells slow down hair production resulting in loss of hair). Priority nursing diagnoses within the Nutritional-Metabolic Pattern that may be appropriate for clients with integumentary disorders include: ■ Impaired Skin Integrity as evidenced by open skin lesions, edema, delayed wound healing, itching, rashes ■ Risk for Infection related to altered skin integrity, moisture, altered sensation, and obesity ■ Deficient Fluid Volume as evidenced by dry skin and mucous membranes, decreased urine output, and elevated hemotocrit ■ Disturbed Body Image as evidenced by verbalizations of altered body appearance and burn scars on face and arms. Two nursing diagnoses from other functional health patterns often are of high priority for the client with integumentary disorders because the physiologic responses to these problems interfere with proper nutrition and metabolic functioning: ■ Acute Pain (Cognitive-Perceptual) ■ Ineffective Protection (Activity-Exercise)
Transcript of UNIT 4 BUILDING CLINICAL COMPETENCE Responses to...
UNIT 4 BUILDING CLINICAL COMPETENCEResponses to Altered IntegumentaryStructure and FunctionFUNCTIONAL HEALTH PATTERN: Nutritional—Metabolic
Think about clients with altered nutrition or metabolic function for whom you have cared in yourclinical experiences.
■ What were the clients’ major medical diagnoses (e.g., psoriasis, cysts, folliculitis, cellulitis,candidiasis, pediculosis, herpes zoster, seborrheic dermatitis, acne vulgaris, nonmelanomaskin cancer, malignant melanoma, basal cell carcinoma, pressure ulcers, or burn trauma)?
■ What manifestations did each of these clients have? Were these manifestations similar ordifferent?
■ How did the clients’ nutritional and metabolic status affect their integumentary system?What was their daily intake of foods and fluids? Were they gaining or losing weight? Whatmedications or dietary supplements were they taking? What was the condition of theirskin, hair, and nails? Did they complain of dry skin, itching, rashes, bruising, or hair loss?Did they note any changes in moles or warts? Did they have any pressure areas on thesacrum, hips, or ankles? Did they have any previous skin disorders and how were theytreated? Did they use preventive measures to protect against temperature extremes?
The Nutritional-Metabolic Pattern includes food and fluid intake to maintain the nutritional andmetabolic needs of the integumentary system. Breakdown of skin and its accessory structuresleads to decreased protection between internal and external environments. Integumentarydisorders are affected by nutritional and metabolic status in three primary ways:
■ Lack of proper nutrients lowers the body’s resistance to illness and can result inintegumentary disorders such as infection (e.g., viral, bacterial) or skin breakdown (e.g., pressure ulcers).
■ Exposure to extremes of cold or heat can result in trauma to the skin and accessorystructures (e.g., frostbite, burn trauma).
■ Use of certain medications, trauma, and medical disorders can result in hair distributionchanges (e.g., hirsutism, alopecia).
Nutrients are used by the body to promote maintenance and repair of cells and tissues.Improper intake of nutrients affects the integumentary system’s ability to maintain protection,regulate body temperature, and maintain fluid and electrolyte balance. Exposure to environ-mental extremes may alter the integrity of the skin, increasing the risk for infection and alter-ations of fluid/electrolye balance. Due to these factors, the client can develop skin, hair, and naildisorders, leading to manifestations such as:
■ Skin ulcerations (external pressure impairs the flow of blood and lymph or friction andshearing from sliding tears and injures vessels � tissue ischemia and hypoxia occur �resulting in tissue death and necrosis)
■ Infection (microorganisms invade tissue and replicate � toxic by-products ofmicroorganism metabolism, cell lysis, and immune response occur � resulting ininflammation and tissue damage)
■ Alopecia (scarring from trauma, infection, radiation, medications � affects rapidly growingcells in hair follicles � affected hair follicle cells slow down hair production � resulting inloss of hair).
Priority nursing diagnoses within the Nutritional-Metabolic Pattern that may be appropriate forclients with integumentary disorders include:
■ Impaired Skin Integrity as evidenced by open skin lesions, edema, delayed woundhealing, itching, rashes
■ Risk for Infection related to altered skin integrity, moisture, altered sensation, and obesity■ Deficient Fluid Volume as evidenced by dry skin and mucous membranes, decreased
urine output, and elevated hemotocrit■ Disturbed Body Image as evidenced by verbalizations of altered body appearance and
burn scars on face and arms.
Two nursing diagnoses from other functional health patterns often are of high priority for theclient with integumentary disorders because the physiologic responses to these problemsinterfere with proper nutrition and metabolic functioning:
■ Acute Pain (Cognitive-Perceptual)■ Ineffective Protection (Activity-Exercise)
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