Transcript SKIN

IN THE
NAME OF GOD
SKIN AND ORAL
MUCOUS MEMBRANE
GOALS
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Students can explain the anatomy and
physiology of skin and oral cavity
They can demonestrate the key point of
assessment
They know current disease of skin and oral mucous
membrane
They can explain about pressure sore and its
treatment
They know apropriate nursing diagnosis and
outcoms
ANATOMIC AND
PHYSIOLOGIC OVERVIEW
THE LARGEST ORGAN SYSTEM OF THE BODY ,
 THE SKIN,IS ESSENTIAL FOR HUMAN LIFE .
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ANATOMY OF THE
SKIN,HAIR ,NAILS AND
GLANDS OF THE SKIN
I
Skin
The Integumentary
System
THE SKIN IS COMPOSED OF THREE LAYER :
1-EPIDERMIS
2-DERMIS
3-SUBCUTANEOUS TISSUE OR HYPODERMIS
Three Layers of skin:
Epidermis:
Stratified squamous
epithelium; outer
layer is "keratinized" or
"cornified"
Dermis:
Dense irregular
connective tissue
Hypodermis:
Adipose connective
tissue
Epidermis: Avascular.
Depends on blood vessels in underlying
dermis for its nutrition
Cells formed by
mitosis in deepest,
or basal, layer, then
get pushed into
more superficial
layers
Primary cell type in epidermis = keratinocytes which
produce large amounts of protein keratin
Other cell types:
Melanocytes produce
pigment melanin & transfer
it to keratinocytes
Langerhans cells (really
macrophages) clean up
debris
Merkel cells detect touch
and pressure; transfer this
information to sensory
receptors in the dermis
Dermis:
Dense irregular connective tissue
Separated from epidermis (stratified squamous epithelium) by
basement membrane
Highly vascular
Highly innervated
Two Layers:
Papillary layer just
below epidermis
Reticular layer forms
deep 80%
SUBCUTANEOUS TISSUE (HYPODERMIS)
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Subcutaneous tissue (hypodermis) is deep to dermis
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Anchors skin to underlying organs, bones and muscles
Contains half of the body’s fat; acts as padding and
insulation.
Appendages of the skin
Hair follicles and hair
Sweat glands
Sebaceous (oil) glands
Nails on fingers and toes
Hair
- Distribuled over all skin except: palms of hands
soles of feet
nipples
glans of penis & clitoris
minor labia
- Formed in follicles located deep in dermis
Shaft
Root
Bulb
Each hair is associated with:
One or more sebacious
(oil) glands
An arrector pili muscle
A plexus of nerves around
the root
Nails:
- Tips of fingers and toes
- Thick layer of densely packed
keratinocytes
- Produced by nail matrix at
proximal end
Deeper layers of
epidermis = nail bed
Average growth:
0.5 mm per week
Sebaceous (oil) glands:
- Branched tubular glands
- Duct opens into opening
of hair follicle
- Secretes sebum,
consisting of lipids,
proteins, ions,
carbohydrates,
Sweat Glands
- 2 to 3 million
- Two types:
Merocrine: Distributed over all skin except nipples
(Eccrine) Simple coiled glands in dermis
Duct leads to sweat pore on surface
Secreted watery sweat for cooling
Apocrine: Located only in axillary, pubic, anal regions
Larger than eccrine glands
Duct opens into opening of hair follicle
Secretes thicker sweat, high content of
proteins and fats.
SKIN FUNCTIONS
Mechanical/Chemical damage – keratin
toughens cells; fats cells cushion blows; and
pressure receptors to measure possible
damage
 Bacterial damage – skin secretions are acidic
and inhibit bacteria.
 Ultraviolet radiation – melanin produced to
protect from UV damage
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SKIN FUNCTIONS
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Thermal control – regulates body temperature
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Heat loss: sweat to cool the skin
Heat retention: prevents blood to rush into capillary beds
Waterproofing – contains lipids to prevent drying out
Excretion of waste – urea and uric acid secreted in
sweat
Makes vitamin D – modifies cholesterol molecules in
skin and converts it to vitamin D
SKIN FUNCTIONS
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Covers the internal structures of body
Senses temperature, pain, touch, pressure
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Promotes wound repair-cell replacement
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OLDER ADULT SKIN
Skin atrophies - dec. sebum, dec. sweat
 Skin drier, flattens - paperlike
 Elasticity decreases and wrinkles develop’
 Dec. melanocyte function-grey hair, pale, age
spots.
 Dec. axil, pubic,scalp hair
 Inc. facial hair; men - ears, nose
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VARIATIONS ACROSS THE LIFESPAN: ELDERLY
CHANGES R/T AGING
Physiological change
↓ SQ tissue
Loss of collagen and elastic
fibers
↑ Capillary fragility
↓ sweat gland activity
Over exposure to sun
Loss of or inefficiency of
melanocytes
INTEGUMENTARY SYSTEMHEALTH HISTORY
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skin colour change
any past skin problems
temperature changes
texture changes
sweating
any masses including warts or moles (nevi)
INTEGUMENTARY SYSTEMHEALTH HISTORY
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changes in masses, warts, nevi – also, cosmetic
concerns and physical discomfort
rashes or eruptions
changes in hair texture or oiliness, hair loss, dandruff,
hair bleaching, dyeing
management of any problems with hair or scalp
medications
INTEGUMENTARY SYSTEMHEALTH HISTORY
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complaints of tenderness, flakiness, itchiness,
lumps, sores on scalp, bleeding
problems with nails including breaking, ingrown
nails, nail biting
Self-care behaviours
REVIEW OF SYSTEMS
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A series of questions : pt’s current and past
health including health promotion practices
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Inquires about signs and symptoms as well as
diseases related to each body system
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HEALTH HISTORY: SKIN
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How?When? did the changes occur?
Is it a skin rash or lesion?
One area or has it spread?
Bleeding or drainiage from the area?
Does the area itch?
How much time do you spend in the sun?
How do you protect from the UV rays?
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(continued)
HEALTH HISTORY: SKIN
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Allergies?
Family hx of skin cancer or significant
disease?
Fever or joint pain, or weight loss?
Recent insect bite?
Do you take medications or herbal
preparations?
What changes in your skin have you observed
in the past few years?
HEALTH HISTORY: HAIR
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When did first notice loss (gain)? Sudden
or gradual?
Few spots or all over body?
What was happening in your life?
Any dyes, medications or herbal
preparations?
Did you experience itching pain,
discharge, fever, weight loss?
Any serious illness?
HEALTH HISTORY: NAILS
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When did you first notice?
What type of changes have you noticed?
Sudden or gradual?
Other signs - bleeding,or discharge?
What is normal condition of your nails?
PHYSICAL
ASSESSMENT
WHAT ARE THE GENERAL
CHARACTERISTICS OF THE SKIN
THAT SHOULD ALWAYS BE NOTED?
Inspection and Palpation of the skin
SKIN
Inspect:
Color
Integrity
Lesions
Primary
Secondary
Vascular
Palpate 
Moisture 
Temperature 
Texture 
Turgor/elasticity 
Tenting 
INSPECTION
Color: 
Depositions of abnormal pigments 
Jaundice from bilirubin 
Carotenemia from carotene
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excess ingestion of yellow
vegetables (carrots)
Gray from heavy metals (Au-gold, Ag- 
silver,Bi-bismuth)
INSPECTION
natural lighting preferred, need 
complete exposure of all skin
surfaces.
remember to scan nails, hair, mucous
membranes
Location and Distribution
exact, measure, symmetry?
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INSPECTION
Color:
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variation common, even within same person.
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Melanin 
maybe diffuse or localized 
increased: Addison’s Disease, hyperthyroidism,
pregnancy, sunlight exposure
decrease: albinism 
Erythema 
appearance of increased amounts of 
oxygenated blood in dermal vasculature
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INSPECTION
Color: 
Cyanosis 
blue tint from venous blood (deoxygenated 
hemoglobin) seen associated with congestive
heart failure, pneumonia
Chapter 4
ecchymosis, petechiae 
Extravasation of blood products
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Pallor 
decrease hemoglobin in vessels close to skin
secondary to anemia, shock
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INSPECTION
Morphological structure 
primary lesions 
flat 
elevated 
-- serous filled 
-- pus filled 
-- solid 
INSPECTION
Morphological structure
secondary lesions 
loss of skin 
-- erosion 
-- ulcer 
-- fissure 
build-up of skin 
-- crust 
-- lichenification 
-- scar 
HOW DO YOU EXAMINE A LESION?
 Palpate,
wear gloves
 Roll nodule between thumb and forefinger
to assess depth
 Does it blanche with pressure or when
stretched?
SKIN LESIONS
SKIN LESIONS
SKIN LESIONS
PALPATION
Temperature 
localized hyperthermia from increased blood 
flow due to cellulitis or injury
generalized hyperthermia due to fever of 
systemic infection, hyperthyroidism
localized hypothermia caused by peripheral 
arteriosclerosis, Raynaud’s disease
generalized hypothermai due to shock
PALPATION
Moisture 
Dryness(hypothyroidism), lubricity(acne)
Texture 
quality 
character 
rough 
smooth (hyperthermia) 
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PALPATION
Elasticity 
decreases with age 
Decreased skin turgor - dehydration 
edema - accumulation of fluid in interstitial spaces 
under the skin. 
ASSESSING SKIN TURGOR
EDEMA
Edema is defined as a clinically apparent
increase in the interstitial fluid volume
 Weight gain precedes overt edema
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EDEMA
Pitting edema
Non-pitting edema
PITTING EDEMA SCALE
Return to
baseline
2-5 minutes
Depth of
indentation
8mm
description
severe
+4
1-2 minutes
6mm
moderate
+3
10-15
seconds
4mm
mild
+2
Disappears
rapidly
2mm
trace
+1
scale
HAIR
Inspect
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Color 
Quantity 
Distribution 
Condition of scalp 
Lesions or pediculosis
Palpate
Texture
Scalp 
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NAILS
Inspect
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Color 
Condition 
Angle of attachment
Abnormalities 
Palpate
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Texture 
Consistency 
Thickness 
Adherence to nailbed
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INTEGUMENTARY ASSESSMENT:
DIAGNOSTIC EVALUATION
Skin Biopsy
 Patch testing
 Scabies scrapings
 Tzanck Smear
 Wood’s Light Examination
 Skin culture
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What is wood’s light? Give two uses for it
and what are the findings?
TYPES OF WOUNDS
AND LOCATION
 Pressure:
 Venous:
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sacrum, heels, trochanter
Inside the leg -Medial
-Lateral
 Diabetic:
neuropathic areas
 Traumatic:
anywhere
WOUNDS
Abrasion – skin is rubbed or
scraped off
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Lacerations – torn, ragged,
irregular edges made by blunt
objects
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Avulsions – the tearing away of
tissue from a body part
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Incisions – cuts made by sharp
cutting instruments
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Punctures – caused by objects
that penetrate tissue while leaving
a small surface opening
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Amputations – traumatic is the
nonsurgical removal of a limb
from the body
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BURNS
Leading cause of accidental death
 Classified by depth of tissue involvement
 1st degree—involves epidermis only
 2nd degree—involves epidermis and some dermis
 3rd degree—involves epidermis, dermis and some
deeper tissue are destroyed
 1st and 2nd degree burns are considered partial
thickness burns, and 3rd degree is a full thickness
burn
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BURNS
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1st degree – partialthickness
(superficial)
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2nd degree – partialthickness (deep)
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3rd degree – fullthickness
NURSING DIAGNOSIS
AND
INTERVENTIONS
IMPAIRED SKIN INTEGRITY RELATED TO;
Inflammation of dermal-epidermal junctions
 Decreased blood and nutrients to tissues
 Imposed immobolity
 Mechanical irritants or pressure
 Chemical trauma
 Environmental irritants
 Dry , thin skin and decreased dermal
vascularity
 Poor hygiene
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INTERVENTIONS
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Identify causative
factors
Example; hard,supporting
sleep or sitting tissue
Removal of adhesives
Profuse diaphoresis
Pressure dressing
Fixation devices
Bladder and bowel
incontinence
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Ng tubes
Prolonged sitting or lying in
same position
Sensory,motor deficits
REDUCE CAUSATIVE
FACTORS IF POSSIBLE
MECHANICAL IRRITANTS OR PRESSURE
Encourage highest degree of mobility to avoid
prolonged periods of pressure
 Change position at least every 2h
 Frequently supplement full-body turns with
minor shifts in body weight
 Reduce environmental source of
pressure(drains, tubes, dressings)
 Use lift sheet to reposition client
 Keep client clean and dry
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MECHANICAL IRRITANTS OR PRESSURE
Keep cast edges smooth and away from skin
surfaces
 Apply padding over bony prominence
 Protect skin around feeding tubes with a
protective barrier
 Instruct to report discomforts
Teach client/significant other appropriate
measures to prevent pressure or friction
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DECREASED BLOOD AND NUTRIENTS TO TISSUES
Increased portein-carbohydrate intake
sufficient to prevent negative nitrogen balance,
hypoalbuminemia , and weight loss .
 Increased daily intake of vitamins and minerals
 Adequate oxygen supply and the blood volume
 and ability to transport it
 Consult a dietitian
 Weigh the person daily
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POOR HYGIENE
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patients sheets be dry and clean
Remove any discharges from patients skin as soon as
possible
Don’t share personal tools such as towel with other
patients
Wash linens and clothes with hot water if possible
Bath patient by tepid water and mild soap daily
Lubricate the patients skin with lotions if there isnt
any contraindicate
QUESTIONS?
REFRENCE
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Potter-pory-2009-fundamentals of nursing –page12781342
Morton,patricia and k.fontaine -2009-critical care
nursing a holistic approach page610-613,1313-1349
Hokanson.jane-2009-medical surgical nursing clinical
management for positive outcoms-page2208-2210
Brunner suddarth’s-2010-text book of medical-surgical
page1658-1751
Moyet-lynda jula-2009-health assessment for nursing
practice-page111-148
PRODUCED BY;
Zahra
Abbas Ali Madadi
and
Maryam Sharifi
The students of M.S in
C.C.N