Transcript integumentary ppt

Integumentary System
RESPONSE TO ALTERED INTEGUMENTARY FUNCTION
Unit Outcomes: Upon completion of this unit of study
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the student will be able to:
Safe Effective Care Environment:
1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
2 . Perform thorough dermatological assessment throughout the life span.
Health Promotion and Maintenance:
3. Identify healthy behaviors by the client and family ( screening exams, limiting risk taking behaviors).
Psychosocial Integrity:
4. Discuss psychosocial impact of client’s altered dermatological condition ( acne, burns, rashes, tumors).
Physiologic Integrity:
5. Discuss nursing implications for medications prescribed for clients with dermatologic disorders.
6. Develop plan of care for client with impaired skin integrity.
7. Explain the eight parameters of assessing a lesion.
8. Describe common lesions and rashes utilizing proper terminology.
9. Describe pre-op and post care of clients receiving dermatological surgical procedures.
10. Select nursing diagnoses most likely to be utilized with clients with integumentary problems.
11. Discuss etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and parasitic skin
disorders.
Introduction: Skin in our Culture
• Defining ‘beauty’
• Language
• Costs
Functions:
• Protective Barrier
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– Injury
– Microbial Invasion
– Fluid & Electrolyte Balance
– Temperature control
Excretion
Sensation
Vitamin D
Identity
Topics:
• Assessment
• Safety and preventive measures
• Nursing Implications for Pharmacologic
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Management
Nursing Implications for Nonpharmacologic
Management
Nursing Implications for Surgical Management
Nursing Management of Clients with Alterations
- Integument
KP’s
• Assessment
• A. Parameters of General Skin Assessment
• B. Lesions
• C. Cultural/Ethnic variations
• D. Diagnostic Testing
Thorough History
• Dx & Tx – realm of practice
– Difficult due to similarities in lesions and sx
• Differential dx requires clues
Assessment: Subjective Data
– Past Medical History
• Trauma
• Surgery
• Prior skin disease
• Jaundice
• Delayed wound healing
• Allergies
• Sun exposure
• Radiation treatments
Assessment: History
Medications
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Prescription
OTC
Herbals
Name
Length of usage
Assessment: History
• Surgery
– Cosmetic
– Biopsy
• Diet
• Health Practices
– Hygiene, products
– Sunscreen, SPF
– Complementary &
alternative medicine
• C/O symptoms
• Known exposure to
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carcinogens, chemical
irritants, allergens
Family
– Alopecia (bald)
– Psoriasis
– Skin cancer
Assessment: History
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Changes
– Skin condition
– Hair condition
– Nail condition
– Mucous membranes
Assessment
• Privacy
• Carefully describe:
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Obvious changes in color and vascularity
Presence or absence of moisture
Edema
Skin Lesions
Skin integrity
• Document properly
Parameters of General Skin Assessment
• color, temperature, moisture, elasticity,
turgor, texture, and odor.
Assessment: Inspection
• Consider Cultural and Ethnic variations
– Dark skin
• rates - skin cancer
• Difficult to assess flushing; cyanosis; jaundice
• Rashes difficult to observe
• Pseudofolliculitis
• Keloids
• Mongolian spots
Assessment: Inspection
• Inspection of hair
– Distribution
– Texture
– Quantity
• Inspection of nails
• Iggy page 474-475; Wilkinson 370
– Grooves
– Pitting
– Ridges
– Curvature
– Shape
Malnutrition
Anorexia nervosa
Anxiety
Hygiene
Depression
Hormones
Living conditions
Circulatory status
Chronic disease
Lesion Description
• Size
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– Metric
Shape
– Circumscribed
– Irregular
– Round
Texture
– Rough
– smooth
• Configuration
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– Annular
• “relating to, or
forming a ring”
– Linear
– Concentric rings
– Clustered
– Diffuse
Effect of pressure
Lesion Description
• Distribution
– Asymmetric vs. Symmetric
– Confluent
• “flowing or coming together; also : run together”
– Diffuse
– Localized
– Solitary
– Zosteriform
• “resembling shingles”
– Satellite
Assessment: Palpation
– Edema
– Moisture
– Temperature
– Turgor
– Texture
Fever
C-V status
Respiratory status
Hormones
Hydration
Rash/ Lesion
Nutritional status
Skin cancer - most common cancer!
• Risk factors
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Fair skin
Blue/green eyes
Blond/red hair
History chronic sun exposure
Family history
Living near the equator
Very high/low altitudes
Working outdoors
Age > 60 (damage is cumulative)
Non-melanoma Skin Cancers
• Basal Cell Carcinoma
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Most common type of skin cancer
Easily treated
Doesn’t metastasize
Middle age to older adults
Symptoms
• Small slow growing papule
• Semi translucent or “pearly”
• Erosion/ulceration of center
Basal Cell Carcinoma
Medical Tx
• Excision
• Cryosurgery
• Radiation
• Topical chemotherapy
Non-Melanoma Skin Cancer
• Squamous cell
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Less common than BCC
High cure rate with early detection
Can be aggressive, metastasize & be fatal
Common on lips, mouth, face and hands
• Pipe, cigar, & cigarette smoking
– Symptoms
• Firm nodule
• Scaling/ulceration
• Opaque
Squamous cell carcinoma
Medical Tx
• Excision
• Radiation
• Moh’s surgery
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(see slide #33)
• 5 FU or methotrexate intralesional
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Diagnostic & Surgical Therapy
• Simple Excision
• Excision
– Moh’s micrographic surgery
• Microscopically controlled removal of lesion
• Removes tissue in thin layers
• Can see all margins of specimen
• Preserves normal tissue
• Produces smallest wound
Drug Therapy: Topical Fluorouracil (5-FU)
– Selective toxicity for sun damaged cells (cytotoxic)
– Indications
• Premalignant skin disease (esp. actinic keratosis)
• Systemic absorption minimal
It causes painful eroded area within 4 days and must
use 1-2 times daily 2-4 weeks.
Healing up to 3 weeks after med stopped
Is photosensitizing - avoid sunlight during treatment
Will look worse before it gets better
Non-Melanoma Skin Cancers
• Actinic Keratosis (AKA Solar keratosis)
– Most common precancerous lesion
– Premalignant form of squamous cell carcinoma
– Symptoms
• Hyperkeratotoc papules/plaques on sun exposed areas
• Varied appearance
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Irregular shape
Flat
Indistinct borders
Overlying scale
Actinic Keratosis
(AKA Solar keratosis)
Medical Tx:
• Cryosurgery
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(see slide #37)
• 5 FU
• Surgical removal
• Retin A
• Chemical peels
Cryosurgery
– Subfreezing temps for surgery (liquid nitrogen)
• Lesion becomes red & swollen, blisters, then scabs; falls off
in 1-3 weeks
• Minimal scarring
– Indications
• Genital warts
• Seborrheic keratosis
• Actinic keratosis
Malignant Melanoma
• 1/3 of all melanoma occur in existing nevi
or moles
– Any sudden or progressive change in size,
color or shape of a mole should be checked
Malignant Melanoma
• Can metastasize anywhere
• Most deadly of skin cancers
• Causes
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UV radiation
Skin sensitivity
Genetic
Hormonal
Sun exposure
Mutation of gene (B-RAF) 70%
A B C D’s of Melanoma
Asymmetry
Border irregular, edges ragged
Color varied pigmentation
• Tan, brown, black, red
Diameter > 6mm
Melanoma
Medical Tx
Depends on site, stage, age and
general health of client
– Surgery
– Chemotherapy
– Biologic Therapy
• Interferon, interleukin
– Radiation therapy
Prevention/Education
• Sunscreen
• Limit exposure
• Hat/clothes/sunglasses
• Shade
• Inspect skin regularly
Sunburn: Education
(Protect, Protect, Protect)
• Same precautions as for skin cancer.
• Don’t let clouds or cool air fool you –
Florida sun is damaging then too.
• Get out of the sun before you turn red!
• Cool skin off. Immediately!
• Hydrate!
Sunburn
• Superficial burn
• Excessive exposure to ultraviolet rays injures
dermis.
• Dilated capillaries = red, tender, edema,
blisters
• Large area = nausea, fever
Sunburn
• Redness & pain begin within a few Hours.
• Intensity may increase before subsiding.
• 3-5 days to heal
• Tx: cool bath; soothing lotions; topical
corticosteroids; fluids
Insects/Pests/Parasites
• Spiders
• Fire Ants
• Lice/Scabies
• Mosquitoes
• Scorpions
• “Sand fleas”
Infestations: Pediculosis
– Head, body or pubic lice (“crabs”)
– Parasite excrement and eggs on skin
– Nits in hair
• Waxy, don’t fall off easily
• Symptoms
• Tiny red points to papular wheal-like lesions
• Pruritis – check hairline
• Secondary excoriation
Pediculosis
Medical tx
• Pyrethrins (Rid), Permethrin (Nix) or if all other
agents fail…Benzene hexachloride (Kwell)
• Contact screening
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Infestations: Scabies
– Skin reactions due to eggs, feces, & mite parts
– Transmitted by direct contact
• Symptoms
– Severe itching especially at HS
– Usually not on face
– Presence of burrows esp. interdigital webs & flexor
surface of wrists
– Redness, swelling, vesiculation
Scabies
Medical tx
– Topical Scabicide
– Antibiotics for 2ndary
infection
– Treat those in close
proximity
– Clothing & linens – hot
water and detergent
Drug Therapy: Antiparasitics
– Pediculicides
• Pyrethrins (RID)
• Permethrin (NIX)
– Scabicide & Pediculicide
• Lindane (Kwell, Scabene)
– Cream, lotion
– Shampoo
 nit comb
– Adverse effects
 Rash, rare CNS toxicity
Plants in FL that irritate skin
• Poinsettia, Croton
• Milky sap can cause skin irritation
• Oleander
– Touching the plant is not dangerous, but prolonged contact can
irritate the skin.
• Poison Ivy , Brazilian Pepper
– Touching the leaves or oil from the plant can cause an itchy rash
with blisters.
Brazilian Pepper
Virginia Creeper
Poison Ivy:
Drug Therapy
• Topical Corticosteroids
– Anti-inflammatory, antipruritic
• Low potency (hydrocortisone)
– Slower acting
– Can be used longer without serious side effects
– Ointment most efficient
– Higher potency, long term, systemic use is different tx
Corticosteroids
Triamcinolone (Kenalog)
– Intralesional
• Reservoir of med effects lasts several weeks to months
• Indications
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Psoriasis
Alopecia
Cystic acne
Hypertrophic scars and keloids
– Systemic
• Undesirable adverse effects – Lilley 6 ed. Page 869
• Short term therapy – poison ivy
• Long term therapy – chronic bullous diseases
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Bases for Topical Medications
• Powder
– Promotes dryness
– Good for antifungals
• Lotion
– Cooling and drying with residual powder film
– Good for pruritic eruptions
• Cream
– Emulsion of oil and water
– Lubrication and protections
• Ointment
– Oil with water in suspension
– Lubrication
– Most efficient delivery system
• Paste
– Mixture of powder and ointment
– Drying
– Moisture absorption
Nursing Management:
RN as skin “symptomologist”
• Dry skin
– Elderly; Infants
• Itchy skin
• Broken skin
• Prevention of secondary infections
Nursing Management: Dry skin
• Manifestations
• Interventions:
– Elder –
• Fewer total baths
• Lotions & Mild soaps
• Hydrate!
Nursing Management: Itchy skin
• Control of pruritis
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Keep cool
No rubbing
Moisturize
Systemic antihistamines
Wet dressing
Topical steroids
Menthol, Camphor, Phenol numb itch receptors
Oatmeal baths
Nursing Management: itch
• Baths
– For large body areas
– Has sedating and antipruritic effect
– Oilated oatmeal (Aveeno), potassium permangenate,
sodium bicarb
– Temp comfortable to client
– Soak 15-20 mins 3-4 times daily
– Pat dry, no rubbing
– apply moisturizers or meds after baths
Nursing Management
• Wet dressings
– Indications
• Skin weepy from infection/inflammation
• Relieves itching
• Debrides wound
• Increases penetration of topical meds
• Relieves discomfort
• Enhances removal of scabs, crusts, and exudate
Wet dressings
Procedure
• Clean solution and gauze
• Squeeze until not dripping
• Apply to affected area, avoid normal tissue
• Leave in place 10-30 minutes 2-4 times a
day
• Discontinue if skin macerates (“to soften”)
Nursing Management: Protect
• Protect intact skin!
– Turn at least q2h
– Reposition frequently
– Alleviate pressure
– Hydration
– Mechanical intervention
– Rx
Nursing Management:
Psychological support
• Chronic skin conditions
– Emotional stress
– Self concept alterations
– Body image changes
Nursing Interventions:
Psychological support:
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Support client
Allow verbalizations of frustrations
Reinforce treatment
Support groups
Help with camouflage
Diagnostic Testing
Biopsy
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Punch
Incisional
Excisional
Shave
RN Responsibilities
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Informed Consent
Prep site
Assist with procedure
Apply dressing
Post-op instructions
Properly ID specimen
Diagnostic Testing
• Cultures
– Diagnose fungal, bacteria, viral infections
– KOH (Potassium Hydroxide)
• Fungus
• Sample collection
– Skin scraping
– Swabbing
– Meticulous labeling
Diagnostic Testing
• Woods Light
– Organisms fluoresce
• Pseudomonas
• Fungus
• Vitiligo
• Mineral oil slides
– Infestations
• Patch test
– Allergen testing
Dermatological Interventions
• Phototherapy
– UVA & UVB (UVL)
– Ultraviolet wavelengths cause erythema,
desquamation, and pigmentation
– Enhance with psoralem (photosensitizing)
• Treatment for
• Psoriasis
• Atopic dermatitis
• Vitiligo
Phototherapy
• Adverse effects
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Basal or squamous cell Ca
Burns
Erythema
Teach patients to avoid further sun exposure &
photosensitizing drugs
– Wear eye protections as psoralem absorbed by lens of eye
Dermatological Interventions
• Radiation Therapy
– Indications
• Cutaneous malignancies
– Advantages
• Produces minimal damage to surrounding tissues
– Adverse effects
• Permanent hair loss (alopecia) to irradiated areas
• Telangiectasia
• Atrophy
• Hyperpigmentation / depigmentation
• Ulceration
• BCC and SCC
y.
Dermatological Interventions
• Laser Therapy (CO2, Argon)
– Cuts, coagulates, & vaporizes tissue
– No cumulative tissue damage
• Indications
– Coagulation of vascular lesions
– Skin resurfacing
– Removal birthmarks
– BCC
– Keloids
– Plantar warts
Diagnostic & Surgical Therapy
• Skin Scraping
– Scalpel
– Surface cells for microscopic inspection
• Electrodesication & electrocoagulation
– Electrical energy converted to heat
– Destroys tissue by burning
• Coagulates bleeding vessels
• Curettage
– Remove tissue with circular cutting edge
– Small skin tumors
• warts, seborrheic keratosis, BCC, SCC
Allergic Conditions
• Contact Dermatitis
– Delayed hypersensitivity
– Lesions 2-7 days after antigen exposure
• Manifestations
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Red, hive-like papules and plaques
Sharply circumscribed
Vesicles
Pruritic
Contact Dermatitis
Medical Tx
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Topical corticosteroids
Antihistamines
Skin lubrication
Elimination of allergen
Systemic steroids if
severe
http://dermatology.cdlib.org/DOJvol7num1/NYUcases/contact/joe.html
Drug Therapy: Antihistamines
• Compete with histamine receptor site
– Oral or Topical
• Cetitizine (Zyrtec)
– PO tabs, syrup QD
– Non-sedating
• Diphenahydramine (Benadryl)
– PO, IM, topical
• Indications
– Urticaria
– Pruritis
– Allergic reactions
Drug Therapy: Antihistamines
• Adverse effects
– Anticholinergic
– Sedation (Benadryl)
– Use with caution in older adults
• Indications
– Urticaria
– Pruritis
– Allergic reactions
• Adverse effects
– Anticholinergic
– Sedation (Benadryl)
– Use with caution in older adults
Allergic Conditions: Drug Reaction
• Manifestations
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Rash of any morphology
Red, macular, papular
Generalized rash with sudden onset
Pruritic
Can occur as late as 14 days after drug is stopped
Drug Reaction
Medical Treatment
– Discontinue drug
– Antihistamines, local or
systemic
– Corticosteroids if needed
Allergic Conditions: Atopic Dermatitis
– Cause unknown
– Begins in infancy and declines with age
• Manifestations
– Scaly, red to re-brown, circumscribed lesions
– Pruritic
– Symmetric eruptions
Atopic Dermatitis
Medical Treatment
– Topical corticosteroids
– Phototherapy
– Coal tar
corticosteroids
– Lubrication of dry skin
– Antibiotics for secondary infections
Dysplastic Nevus Syndrome
• Abnormal mole pattern
• Increased risk for melanoma
– Doubles with dysplastic nevi
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Atypical moles larger than usual (>5mm)
Irregular borders, possibly notched
Various variegated colors
Most common on back
Infections of the skin
• Risk factors
– Imbalance between host and microorganism
– Broken or damaged skin; Trauma
– Systemic disease such as Diabetes
– Moisture
– Obesity
– Systemic corticosteroids, antibiotics
• Prevention
– Proper hygiene
– Good health
Infections: Herpes Simplex Virus, Type I
(AKA “cold sores/fever blisters”)
• Contagious
• Dormant – Exacerbation
• Triggers
• Symptoms -- 1st episode 3-7 days after exposure
– Painful local reaction
– Vesicles on erythematous base
– Fever, malaise
Herpes Simplex Virus, Type I
Medical Tx
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Symptom management
Moist compresses
Petrolatum to lesions
Antiviral agents (Zovirax,
Famvir, Valtrex)
www.treatmentsforhealth.com/.../cold-sores/
Infections: Herpes Simplex Virus, Type II
– Genital
Iggy page 1742-1743
“Most genital herpes is caused by HSV-2.”
– Recurrence more common than oral
• Does not mean re-infection
• Symptoms
– Same as Type I
• Treatment
– Same as Type I
(n.l.m.-n.i.h./ Medline plus)
Infections: Herpes Varicella Virus
(chicken pox)
** Highly contagious
• No chicken pox or vaccination
• Keep those w/active lesions separated until crusted
• Symptoms
– Vesicular lesions in successive crops
• Face , scalp, spreading to trunk and extremities
Protect eyes
 Do not squeeze pustules or crusts
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• Vesicles > pustules > crusts > scars
• Postherpetic neuralgia
• Self limiting in children
Herpes Varicella Virus
Medical Tx
– Antivirals
– Symptomatic relief
Infections: Herpes Zoster
(shingles)
– Activation of varicella zoster virus
– Frequent occurrence in immunocompromised
– Potentially contagious to immunocompromised
• Symptoms
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Grouped vesicles on erythematous base
Unilateral on trunk
Burning pain and neuralgia
Herpes Zoster
Medical Tx
– Symptomatic
• Wet compresses
• White petrolatum to lesions
– Antiviral agents
Drug Therapy: Antivirals
– Acyclovir (Zovirax)
• Suppresses chicken pox, herpes simplex 1 & 2, shingles
• Po, IV, topical
– Valacyclovir (Valtrex)
• Herpes zoster (shingles) & genital herpes
– Vaccines
• Varivax
– Prevention of chicken pox
– Given to children > 12 mo.
• Zostivax
– HZU vaccine for adults > 60 y/o
Infections: Verruca Vulgaris
– Human papillomavirus
– Mildly contagious
• Symptoms
– Circumscribed hypertrophic flesh colored papule
• Treatment
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Scoop removal
Liquid nitrogen therapy
Keratolytic agents
CO2 laser therapy
Infections: Plantar Warts
(Human papillomavirus)
• Symptoms
– Wart on “Plantar” surface (bottom) of foot –
– Cone shaped with black dots (“seeds”)
Plantar Warts
Medical Tx
– Liquid nitrogen
– Frequent paring with chemical patches
– Duct tape??????
Infections: Candidiasis (moniliasis)
– Candida albicans (Fungus)
– 50% are symptom free carriers
– Immunocompromised >> pathogenic
– Likes warm moist areas
• Mouth, vagina, skin
An opportunistic
infection
Infections: Candidiasis
– Symptoms
• Mouth
– White, cheesy plaque (milk curds)
• Vagina
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Vaginitis
Red edematous painful vaginal wall
White patches
Vaginal discharge
Pruritis
Painful urination & intercourse
• Skin
– Diffuse papular erythematous rash
– Pinpoint satellite lesions around edges
Physiologic Integrity: 5. Discuss nursing implications for medications prescribed for clients with dermatologic disorders. 6. Develop plan of care for client with impaired skin integrity.
Candidiasis
Medical Tx: Anti-fungals
• Nystatin
– Vaginal suppository
– Oral lozenge
• Mycostatin powder, cream
• Keep skin clean dry
• Diagnosis
culture
Microscopic exam (KOH)
Infections: Fungal
• Tinea Corporis
– AKA ringworm
– Symptoms
• Annular
• well defined margins
• erythematous
Tinea Corporis
AKA ringworm
Medical Tx
• Cool compresses
• Topical antifungals
– Miconazole, clotrimazole, butenafine
Infections: Fungal
• Tinea Cruris
– AKA jock itch
– Symptoms
• Self-defined border
• In groin
– Treatment topical antifungal cream or solution
Infections: Fungal
• Tinea Pedis
– AKA athletes foot
– Symptoms
• Interdigital scaling
• Erythema
• Blistering
• Pruritis
• Pain
Tinea Pedis
AKA athletes foot
Medical Tx
• Topical antifungals
• Keep dry
Infections: Fungal
• Tinea Unguium
– Symptoms
• Brittle thickened nails
• White/yellow discoloration
Tinea Unguium
Medical Tx
• Topical antifungal cream
or solutions
• Griseofulvin (fingernails)
• Lamisil
• Debride toenails
Drug Therapy: Antifungals
– Clotrimazole (Mycelex, Lotrimin)
• Lozenges- thrush
• Cream, solution, lotion- athletes foot
• Intravaginal creams, tablets
– Miconazole (Monistat, Micotin)
• Athletes foot
• Jock itch
• Ringworm
• Yeast infections
Drug Therapy: Antifungals
– Fluconazole (Diflucan)
• PO & IV
• Excellent bioavailability
• Vaginal or systemic candidiasis
– Ketaconazole (Nizoral)
– Nystatin (Mycostatin)
– Tervinafine (Lamisil) for onychomycosis
– Tolnaftate (Tinactin)
Infections, Bacterial
• Impetigo
– Group A beta hemolytic strept or staph
– Associated with poor hygiene and low socioeconomic status
• Symptoms
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Vesiculopustular lesions
Thick honey colored crust
Surrounded by erythema
Pruritic
Contagious
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Systemic antibiotics
Saline or aluminum acetate soaks
Soap & water
Removal of crusts
Topical antibiotic cream
• Treatment
• Strept can cause glonerulonephritis if untreated
Infections: Bacterial
• Cellulitis
– Staph aureus or strept
– Can be primary or secondary infection
– Symptoms
• Hot
• Tender
• Erythematous
• Edematous
• Diffuse borders maybe malaise and fever
– Treatment
• Moist heat
• Immobilization
• Elevation
• Systemic antibiotics
• Hospitalize if severe
– Can progress to gangrene if untreated
Drug Therapy: Antibiotics
– Topical - apply lightly
• OTC
– bacitracin
– Polymixin B
• Prescription
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Mupirocin (staph)
gentamycin (staph),
erythromycin (staph & strept)
clindamycin (Cleocin) (acne)
– Systemic - culture & sensitivity guides selection
• Penicillin
• Erythromycin
• Tetracycline
Benign Skin Conditions: Acne
Inflammatory disorder of sebaceous glands
• Symptoms
comedones, inflammatory lesions, papules, pustules face,
neck, upper back
• Treatment
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Comedo extraction
Topical Benzoyl Peroxide
Peeling and irritating agents (retinoic acid)
Antibiotic therapy - long term
Phototherapy
Sun exposure
If severe - isotretinoin (Accutane) CAUTION! Teratogenic
Drug Therapy: Acne Preparations
– Benzoyl peroxide (Benzac, Desquam-X,
PanOxyl, etc)
• Apply 1-4x day
• Effects seen 4-6 weeks
• Adverse effects
– Erythema, tenderness, dryness, pruritis, burning
– Erythromycin (Eryderm, T-Stat, Erygel)
• Macrolide antibiotic
• Adverse effects
– Erythema, tenderness, pruritis, burning
Drug Therapy: Acne Preparations
– Isotretinoin (Accutane)
• Pregnancy Category X
– Proven teratogen
– 2 contraceptive methods
– Tretinoin (Retinoic acid, Vitamin A acid, Retin-A)
• Stimulates epidermal cell turnover -> skin peeling
• Adverse effects
– Red edematous blisters, crusted skin, altered skin
pigmentation
• Avoid sun, use sunscreen
• Apply to dry skin
Benign Skin Conditions: Moles
Grouping of normal cells
• Manifestations
– Hyperpigmented areas
– Varying form and color
• Treatment
– None necessary
– Cosmetic
– Biopsy for diagnosis
Benign Skin Conditions
• Psoriasis
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Chronic dermatitis due to rapid turnover of epidermal cells
Family predisposition
Manifestations
Sharply demarcated scaling plaques of
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Scalp
Elbows
Knees
Palms, soles, and fingernails possible
• Treatment
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Retard growth of epidermal cells
Topical corticosteroids
Tar
Anthralin topical
Sunlight, UV light
Alefacept (Amevive) injection
Antimetabolites (methotrexate) or systemic retinoids for difficult
cases
Benign Skin Conditions
• Seborrheic Keratoses
– Irregularly shaped flat topped papules or
plaques
– Warty surface
– Appearance of being stuck on
– Increase in pigmentation
– No association with sun exposure
– Treatment
• Removal
– Curettage
– cryosurgery
Benign Skin Conditions: Lipoma
Encapsulated tumor of adipose tissue
Most common 40-60 years of age
• Manifestations
– Rubbery, compressible, round mass
– Variable in size
– Most common on trunk, back of neck, forearms
• Treatment
– Biopsy
– Excision if indicated
Benign Skin Conditions: Vitiligo
–
–
–
–
Unknown cause
Genetic connection
Complete absence of melanocytes
Non-contagious
• Manifestations
– Complete loss of pigment
– Variation in size an location
– Symmetric and permanent
• Treatment
– Exposure to UVA and psoralens
– Depigmentation of pigmented skin in extensive
disease
– Cosmetics and stains
Benign Skin Conditions: Lentigo
•
(see fig. 26-7, Iggy page 465)
– AKA liver spots
– Increased number of melanocytes
– Related to aging and sun exposure
• Manifestations
– Hyperpigmented brown to black flat lesion
– Usually in sun exposed areas
• Treatment
– Liquid nitrogen
• Possible reoccurrence in 1-2 years
– Cosmetics
Primary Lesions
• Macule (freckles, petecchia, measles)
– Flat
– Change in color
– < 1cm
• Papule (wart, mole)
– elevated,
– Solid
– <1cm
• Vesicle (chicken pox, herpes zoster, 2nd burns)
– Elevated
– Fluid filled
– <1cm
Primary Lesions
• Bulla
– > 1cm
– Elevated
– Serous fluid filled
• Plaque (psoriasis, keratosis)
– Elevated
– Solid lesion
– >1cm
Primary Lesions
• Wheal (insect bite)
–
–
–
–
Firm
Edematous
Irregular shape
Diameter variable
• Pustule (acne, impetigo)
– Elevated
– Purulent fluid
– Varied size
Secondary Lesions
• Fissure (athletes foot)
– Linear crack from epidermis to dermis
• Scale (excess dead & flaking of skin)
– Drug eruption
– Scarlet fever
• Scar
– Increased connective tissue
– Surgical incision
– Healed wound
Secondary Lesions
• Ulcer
– Crater
– Loss of epidermis, dermis
– Pressure ulcers, chancre
• Atrophy
– Thinning of epidermis/dermis
– Ages skin, striae
• Excoriation
– Missing epidermis
– Scabies, abrasion, scratch
References:
• Chickenpox in Pregnancy. (2009). March of Dimes Foundation. Retrieved 9/25/09 from
•
•
•
http://www.marchofdimes.com/professionals/14332_1185.asp
Common Poisonous Plants of Florida (Florida Poison Information Center/Tampa) @
http://www.poisoncentertampa.org/poisonous-plants.aspx
Culbert, D. (April 14, 2005). Florida scorpions. UF/IFAS Okeechobee County Extension Service. Retrieved 6/17/09 from
http://okeechobee.ifas.ufl.edu/News%20columns/Florida.Scorpions.htm
Groch, J. (August 23, 2006). Guidelines for Preventing Pressure Ulcers Seen as Suboptimal. MedPage Today. Retrieved 6/12/09
from http://www.medpagetoday.com/Dermatology/GeneralDermatology/3982
References:
• Hembree, D. (July 21, 2008) 10 Poisonous Plants in Florida and Safety Precautions @
•
•
•
http://www.associatedcontent.com/article/875395/10_poisonous_plants_in_florida_and_pg2.html?cat=11
“Herpes simplex” (May, 2009). Medline Plus Medical Encyclopedia. Retrieved 6/15/09 from
http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001324.htm
Lilly, L.L., Harrington, S, & Snyder, J. (2005) Pharmacology and the Nursing Process. (4th ed.) Mosby Elsevier.
St. Louis, MS.
Medical Dictionary (2009) Merrium – Webster Inc. Retrieved 6/15/09 from
http://www.nlm.nih.gov/medlineplus/mplusdictionary.html
References:
• The Medical News. Brain eating amoeba in lake kills sixth victim. (October 2007). Retrieved 6/16/09 from
•
•
http://www.news-medical.net/news/2007/10/07/30863.aspx
The US Market for Skin Care Products. (May, 2005). Retrieved 6/12/09 from
http://www.mindbranch.com/Skincare-Products-R567-0199/
Scorpion Sting Treatments. (2008). Orkin. Retrieved 6/17/09 from
http://www.orkin.com/other/scorpions/scorpion-sting-treatments
Burns
• Thermal burns
– Flame, flash, scald
• Chemical burns
– Necrotizing substances
• Acids
• Alkali
– Cleaning agents, drain cleaners, lye
• Electrical burns
– Intense heat from electrical current
The
Following
Content –
Burns –
will be
covered in
future
classes!
Save this
information for
future use.
Classification: Depth of Burn
See page 522 in Iggy text
• ABA by depth of destruction
– Partial thickness burn
• Epidermis and dermis involved
– Full thickness burn
• “burns reach through the entire dermis and sometimes into
the subcutaneous fat.” (Iggy, page 522)
• Possibly involves muscles, tendons, and bones
• *Skin cannot heal on its own.
Classification: Extent of Burn
• Total Body Surface Area (TBSF)
– (Iggy page 531)
• Berkow method
– http://www.umobile.edu/main/notes/Burn.pdf
• Rule of 9’s
– (Iggy page 531)
Classification: Location of Burns
• Severity related to location
• Complication risks related to location
• Face, neck, chest
– Respiratory complications
• Hands, feet, joints, and eyes
– Compromise ADLs
• Circumferential burns of extremities
– Circulatory compromise
Emergent Care
• A,B,C’s
• Fluid Therapy
• Wound Care
• Pain management
• Prevention of infection
Burns
What happens….
Complications of Emergent Phase
• Cardiovascular
– Arrhythmias
– Hypovolemic shock
– Impaired circulation
• Respiratory
– Upper airway burns
– Inhalation injuries
• Urinary
– Acute tubular necrosis
Acute Phase
• Fluid therapy
– Lactated Ringers per Parkland (Baxter) formula
• Wound care
– Topical silvadene, sulfamylon, bacitracin, or bactroban
– PREVENT INFECTION
• Excision and grafting
– Remove necrotic tissue
– Apply split thickness auto graft skin
• Porcine skin, cadaver skin, clients own skin, skin culture
• Nutritional therapy
– Increased fluids, proteins, vitamins A, C, E.
– Zinc, iron, folate
• Physical therapy
– Prevent contractures
• Physical and psychological comfort
Drug Therapy: Antibiotics
• Silver Sulfadiazine (Slivadene)
– Burn treatment
– QD or BID
– “frosting”
– Adverse effects
• Pain
• Itching
• Burning
Rehabilitation Phase
• Prevent and minimize contractures and
scarring!
• Cosmetic / reconstructive therapy
• Psychological support if needed