Transcript integumentary system

INTEGUMENTARY SYSTEM
 Dermatology-study of skin diseases
 Dermatologist-physician who
specializes in this field
Dx Tests:
 Direct observation
 Diagnostic tests can be used to determine the origin of
the skin disorder
 Wood’s light-use of UV rays to Dx pigment
abnormalities, can also detect superficial fungal and
bacterial infections
 Tzanck’s smear-examination of cells and fluids found in
vesicles (ex. Herpes zoster and Varicella), they are
applied to a glass slide and examined using a
microscope
Dx Tests:
 Biopsy-removal of skin-tissue specimen for
microscopic exam to determine malignancy or to Dx
a skin disorder
 Scabies scraping-shave off the top of a suspected
lesion, place on a glass slide covered with immersion
oil and examine the slide under a microscope
Pruritis (Itching)
 Sx of skin disease
 Can also be caused by systemic disorders, dry
skin
 Scratching is inevitable, and causes skin breaks
which can result in scarring and infections
 Tx: divert attention, hypnosis
 Administer medications: antianxiety
(hydroxyzine-Ataraz, Vistaril), antihistamines
(diphenydramine-Benadryl, fexofenadineAllegra), topical corticosteroids
Pruritis prevention
 Rinse clothes in clear ater
 Use soothing baths (colloidal oatmeal, starch)
 Apply lotion to dry skin
 Keep fingernails short, wear cotton gloves or cotton socks at
night
 Lightly slap, rather than scratch the itching area
Pruritis (Itching)
 Therapeutic baths
Purposes:
 Cleanse body and soothe skin
 Promotes wound healing
 Relieves itching
 Aids in the removal of eschar
 Aids in prevention of infection
 Monitor for infection
Give this type of bath in a WP or bathtub, disinfect after each pt.
Use
Don’t use soap (dries the skin), use medicated bath oil
Tepid water-temp 100F (heat makes one itch)
Pat the skin dry, rubbing increases pruritis





Moist Dressings
 Moist packs
reduce edema and weeping in acute dermatitis
 -soften and remove exudate and crusts
 -clean or sterile
 -closed dressing-covered with plastic or a firm material
 open dressing-not covered, tissues need O2 to prevent
necrosis
-requires frequent dressing changes or resoaking q2 hours
 MD will order the type of dressing or medication to use

Skin infections
 Contact dermatitis
Caused by allergic reaction
 Mediated by IgE

 Cellulitis
Skin infection
 s/s include red, warm, painful area

Wound Debridement
 Physician or Surgeon will remove loose skin, crusts,
eschar or denuded (protective) tissue
 Sterile procedure that is often performed when changing
moist packs
 Autolysis

Uses bodys own enzymes to rehydrate wound and dissolve slough
 Enzymatic debridement

Using commercially prepared chemical enzymes to the necrotic
tissue
 Surgical debridement

Uses a scalpel or scissors to remove slough and eschar
 Mechanical debridement

Utilizes wet to moist or wet to dry dressings
Surgical Treatments
 Plastic or Reconstructive Surgery-
improves disfigurement, may be
performed for cosmetic effects, to
repair congenital defects or repair
trauma tissue
Skin and Tissue Grafts
 Skin grafts are used to cover areas of skin lost from burns,





infections or wounds
Graft-transplant of skin that is placed on viable tissue
-very painful -may take months to heal, depending on
success
Free graft-skin completely removed from its original site
and grafted on to the recipient site
Pedicle graft-one end of the graft remains attached to the
donor site so that new circulation is established
Nursing Considerations:
 Explain procedure
 Can expect postop edema, ecchymosis
 Protect sites, grafts
 Provide emotional support
Nursing Process
 Data Collection

Assess the skin: report any changes in color or turgor
 Fluid and Electrolyte Balance
 Encourage the client to drink and eat
 Provide high Kcal, high protein meals
 Observe and document I & O
 Emotional Support
 Allergies
 Known food or drug allergies may aggravate skin
conditions
Acute and Chronic Skin Conditions
 Urticaria (hives)
 S/S: edematous, raised pink areas called wheals
 Wheals itch and burn
 May disappear quickly or stay for days
 Most commonly caused by an allergic reaction to meds, foods,
spores or pollens
 Chronic urticaria
 lasts longer than 6 weeks, cause is unknown in 80-90% of adults
 Angioedema
 May be life threatening: extreme swelling of the lips, around the
eyes and dyspnea
 TX: removal of cause, tepid baths, antipruritic lotions,
epinephrine for severe cases
Vitiligo
 Occurs when areas of skin lack in pigmentation
 Results in patches of pale or white looking skin
 Cause unknown
 Can also use cosmetics to cover birthmarks
 Surgical tx: grafting and melanocyte
transplantation
 Albinos are unable to produce melanin
Vitiligo

Eczema (atopic dermatitis)
 Sx: small vesicles appear along with red
and pruritic skin, when the vesicles burst
and ooze, crusts form
 Viral, bacterial or fungal skin infection may
develop
 Cause unknown but heredity, allergy, and
emotional stress can contribute
 Most commonly found in the folds of the
elbow, back of the knees, on the face, neck,
wrists, hands and feet
Eczema

Eczema

Eczema (atopic dermatitis)
 Tx: prevent dry skin, cracking and itching
 Apply moisturizing creams-Eucerin, corticosteroid
ointments, or wet dressings
 Use lanolin free lotions
 Meds: Topical corticosteriods-exert localized antiinflammatory activity, reduce swelling, redness,
itching
Psoriasis
 Chronic, noncontagious disorder that affects young
adults and middle aged adults
 Epidermal cells proliferate and form small, scaly
patches of skin
 Cause is unknown but hereditary, environmental,
metabolic or immune factors contribute to
breakouts
 Stress and anxiety precede exacerbations of the
disorder
Psoriasis
 S/S: red papules covered with silvery,
yellow-white scales that the client sheds
 Patches appear on the elbows, knees, scalp
and lower back, the nails may loosen at the
fingertips (onycholysis)
 Tx: reduce scaling and itching,
corticosteroids and methotrexate
Psoriasis

Psoriasis

Infections
 Warts (verrucae)
 Small, flesh-colored, brown or yellow papules caused by
HPV
 Common warts-found on the hands (esp.
children), or on other sites subjected to trauma
 Filiform warts-slender, soft, thin, finger-like
growths seen on the face and neck
 Plantar/palmar warts-firm, elevated or flat
lesions occurring on the soles or palms
 Tx: electrodessication-short duration of high
frequency electrical current or curettage-scraping
or suctioning is the treatment for filiform warts
Warts

Infections
 Condylomata acuminate-venereal warts
 Grow in warm, moist body areas, skinfolds
 Usually develop in clusters
 Found on the foreskin and the penis or on
vaginal and labial mocosa and the urethral
meatus or perianal area
 Spread by sexual contact

Infections
 TX-WARTS (cont.)
 Cryosurgery-application of liquid nitrogen
 Keratolytic agents-removes excess growth of the
epidermis. Used to remove warts, callusues, and
corns
 Ex. Salicylic acid

may cause salicylate toxicity
Wart Cryosurgery

Bacterial skin infections
 Impetigo-contagious among infants and young





children
Caused by strept or staph
Vesicles ooze a clear exudates that develops into
golden-yellow crust that causes discomfort and pruritis
Tx: systemic antibiotics
Good handwashing
Wear gloves when bathing the client or treating lesions
 Meds: mupirocin (Bactroban)

Adv. Rxns: burning, stinging, pain, itching, rash, nausea, dry skin
Impetigo

Impetigo

Bacterial skin infections
 Folliculitis-white pustules or follicular nodules
 A staph infection starting around the hair follicle
 Moisture, trauma and poor hygiene can contribute
 Deep folliculitis-on face
 Superficial folliculitis-responds to antibacterial soap
cleansing or topical antibiotics
 Furuncle (boil) –firm, red, tender nodule
 May drain pus and finally extrude the core
 Core is dead tissue that can drain by itself or be
reabsorbed into the skin
 Can also be I & D
Bacterial skin infections
 Furuncle
 Found
in areas of hair-bearing skin, esp. the face, scalp,
buttocks and axillae
 Furunculosis-recurrent boils on people who have the staph
organism
 Carbuncle-interconnecting boils in a cluster
 Drains at multiple sites
 Mostly located on the back of the neck, the back and the
thighs
 Tx: warm, wt dressings or soaks to localize the boil and
carbuncle infections to one spot
 I & D large boils
 Oral antibiotics after a sensitivity test
Furuncle

Parasitic Infections
 Scabies (mites that burrow under the outer layer of the
host’s skin)-intense itching, red spots appear with rows
of blackish dots with tiny vesicles and depressions
 Mostly found between the fingers
 Mites can live for months or years in people if left
untreated
 Infection can be transmitted through clothing, linens, or
towels
 Meds:
 lindane (Kwell)
 Leave medication on for 8-24 hours and then bathe
thoroughly, repeat tx. In one week
Scabies

Scabies

Lice-Pediculosis
 Pediculosis humanus capitis head lice
 Pediculosis humanus corporis-body lice
 Phthirus pubis, pediculosis pubis-pubic lice
 Survival depends on sucking blood
 Difficult to get rid of
 Nits (eggs) can live for a long time on clothes, bedding, furniture
 S/S: presence of nits, extreme pruritis
 Tx: permethrin (Elimite, Nix) and pyrethrings (RID), apply to
hair for 5-10 minutes, rinse with water. Remove the nits by
combing the hair with a fine-toothed comb, apply petroleum to
the eyelashes and eyebrows to remove nits
 ALL LIVE LICE AND NITS MUST BE DESTROYED
TO PREVENT RE-INFESTATION!!
Bedbugs-Cimex lectularius
 4-5 millimeters and can survive up to 1 year
without food
 Live in clothing or bedding and are difficult to get
rid of
 Bites appear as red macules that develop into
nodules
 Bites often appear in groups of three, and bite the
legs and feet resulting in itching and burning
 Tx: lotions containing menthol, phenol, or 0.5%
hydrocortisione cream
 Spray all crevices in furniture with an insecticide
Sebaceous Gland Disorders
 Sebaceous Cysts-secrete oil and when plugged with oil, small
nodules form called cysts
 Usually not treated unless they become large and then they
are I & D
 Seborrhea, Seborrheic Dermatitis and Dandruff
 Seborrhea-sebaceous discharge that forms large scales or
cheeselike plugs on the body
 Seborrheic dermatitis causes scaling, primarily of the scalp that
itches
Sebaceous gland disorders
 Dandruff-dry form of seborrheic dermatitis
 Scales range from small and dry to thick and powdery
 Oily form of seborrheic dermatitis is characterized by
greasy or ily scales and crusts on a red base
 Tx: Shampoo frequently with selenium sulfide
suspension (Selsun Blue) and leave on for 5-10 minutes
 If lotions or solutions contain steroids, use sparingly
Burn depth and size
 Partial-thickness-superficial, moderate and deep-
dermal burns
 1st degree and 2nd degree
 Full thickness (3rd degree)-includes all the
characteristics of 1st and 2nd degree burns along with
subq. Fat, connective tissue, muscle and even bone.
 See table 74-2 in book
Classification:
 Thermal-most common, caused by steam, hot water,
flames and direct contact with heat sources.
 Electrical – Caused by electric shocks due to
exposure to lightning or electricity
 Chemical – caused by exposure to acids, alkalis or
other organic substances.
 Radiation – exposure to the radiation, sun
First aid for minor burns
 Box 75-2
 Cool area
 Cover burn with sterile gauze
 Relieve pain
 Monitor
“Rule of Nines”
 Used in determining% of body burned
 Adults:
 Head=9%
 Each arm = 9%, front 4.5%; back 4.5%
 Each leg = 18%
 Front or back = 18%
 Genitals = 1%
 Phases of Burn Injury Management
 Immediately – apply cold packs or cold water
Resuscitative phase:







Initial hours after burn, stabilize immediate health concerns!!
Burn care unit
Goal of this phase is to achieve physiologic stability!!
Always wash hands, use sterile gloves
V/S
NEVER apply ointments to an extensive burn!!!!
Monitor respiratory status-rate and depth of respirations
 Suspect inhalation injury if client was in a closed in area
with fire and smoke
 Observe for singed nasal hairs
 Report cough immediately!! Note amount and character of
sputum-black/gray indicates smoke inhalation
 May need O2, keep an ET tube or trach tube at bedside
 Prevent pneumonia
Fluid and Electrolyte Balance:
 Lose body fluids from capillary leaks and open
wounds, require large amounts of IV fluids
particularly containing sodium (replace fluids)
 Record I&O!!
 Assess electrolytes: potassium, sodium
Renal Function:
 Monitor urine output hourly, decrease could show
shock
 If u/o is less than 30mls/hr. dialysis may be needed.
Infection:
 Leading cause of death for burn clients
 May be placed in protective isolation to prevent
exposure to pathogens
Pain Management
 Assess pain level, location
 Superficial burns have more pain that full-thickness




burns because the nerve endings have been
destroyed
PCA may be used
Morphine – Monitor RR!!
Imagery, distraction may also be used
Some cultures may not use drugs to relieve pain
Acute Phase:
 Client remains ill and requires continuous
assessment, focus on the burn wound Dressings such
as OpSite, DuoDerm (synthetic) promote healing
and cover the wound
 Tight occlusive dressings help to prevent keloid
(scar) tissue
Acute Phase:
 Topical agents:
 Mafenide Acetate (Sulfamylon)
 Associated with c/o burning after application
 Silver sulfadiazine (Sivadene)
 Bacitracin ointment
 Used for superficial and facial burns applied as a thin layer 2-3
times/day
 Silver Nitrate
Acute Phase:
 Topical proteolytics (enzymes) may be used to
remove dead tissue
 Debridement-removing eschar, exposing living tissue
 WP is used, more comfortable
 MD’s can use laser scalpels or scalpels to excise
eschar
Burns
 Skin grafting-replaces tissue that does not heal or can be
used for cosmetic reasons
 Autograft-uses the client’s own skin, MD cuts slices of
skin from an unaffected part of the client’s body and
places these graft on the affected areas
 Homograft/Allograft – cadaver skin

Take immunosuppressive meds to prevent rejection
Burns
 Heterograft/Xenograft – using pigskin
 **The client’s body will reject in 1 week but the
pigskin will aid the body in fluid retention, promote
healing and prevent infection
 CEA – cultured epithelial autografts

Biopsy is performed on unburned skin and grows new skin,
used to cover extensive burns
Pedicle graft-skin remains attached on one end
Grafts
DO NOT DISTURB SKIN GRAFTS!
They need to attach to the live tissue underneath and
grow
Other Considerations
 Diet high in calories, nitrogen, and protein
 Monitor wound drainage
 Administer LR (per MD order)
 STRICT
I&O
Rehabilitative Phase
 Lasts months to years
 May need PT Service for WP tx’s
 Financial assistance
 Complications:
 anemia
 Infections, GI disturbances, pneumonia, kidney failure,
anemia, skin ulcers, contractures (ROM)
 Escharotomy may need to be performed to relieve
tension on skin.
Rehabilitative Phase
 Curling’s ulcers-may develop 1 week after the
injury causing a GI bleed
Occurs when gastric mucosa becomes ischemic, excess
hydrogen ions, inadequate mucosal cell proliferation
 Monitor GI pH, internal feedings, medications that
reduce stomach acid

 Provide emotional support
 Teach: wound care, meds, s/s infection
 Neoplasms: New growths, tumors
 Malignant
 Benign
NEOPLASMS
 Nonmalignant tumors are warts, angiomas,
keloids, cysts and nevi (moles)
 Moles may become malignant
 Angiomas can be difficult to remove, or they may
often go unnoticed.
Birthmarks or vascular skin tumors involving underlying
tissues and blood vessels
 Port-wine angioma-difficult to remove
 Most angiomas are not noticeable or dangerous

 Keloids – benign overgrowths that develop at scar
sites
Skin Cancer
 Most common
 Most curable
 Caused by sun exposure
 Light skinned, light-eyed people or those that burn vs.
tan are at the highest risk
 A deeply pigmented mole should be checked
 American Cancer Society rules for mole evaluation:




Asymmetry
Border
Color
Diameter
Skin Cancer
 Tx: curettage, electrodessication, cryosurgery, or
wide excision
 Pathologist examines the tissue
 Basal cell carcinoma-small, fleshy bump or nodule


Found in UV exposed tissues, head and neck
Most common type
Skin Cancer
 Basal cell carcinoma
 Found in areas exposed to sunlight or UV light
 Most common form of skin cancer
Skin Cancer
 Squamous cell carcinoma – appears as a nodule or
red, scaly patch



Found on rim of ear, face, lips, or mouth
May metastasize, increases in size and develops into large
mass
95% cure rate with surgery!
 Malignant melanoma – darkly pigmented mole or
skin tumor


Most virulent of all skin cancers
May metastasize to the skin, bone, brain, and lung
Skin cancer prevention
 Box 75-3
 Avoid midday sun
 SPF of 15 or higher
 Avoid sunlamps and tanning beds
 Premature aging of skin and subsequent skin cancer
is associated with UVA rays of the sun and tanning
bed bulbs (d/t loss of collagen)
Miscellaneous skin problems
 Closed comedones-whiteheads
 Fungal infection
 Tinea
corporis
Ringworm-passed from human to human
Shingles
 Herpes Zoster
 Incubation period is 14-21 days
 Rash appears on the face and trunk and then
develops into blisters surrounded by a red ring
Herpes Zoster/Shingles
