Nursing Integumentary System

Integumentary system Ruby Ruth Roces, R.N., M.D.

Anatomy and Physiology  Epidermis B-asale S-pinosum G-ranulosum L-ucidum-found in regions w/ thick corneum C-orneum

- Cells of the epidermis are composed of keratinocytes, melanocytes, langerhans cell, merkels cells  Dermis  Hypodermis-fastens skin to underlying structures

 B. C.

D.

Cutaneous appendages Eccrine sweat glands-not viscous, controlled by cholinergic Appocrine sweat glandsvicous,odor-producing, controlled by adrenergic, do not function till puberty Sebaceous glands- functions for lubrication of hair and skin, hormonal contol

 Hairs  Nails

History and Assessment  C-haracter  L-ocation  I-ntensity  T-ime  A-asso.

factors  A-ggravating factors

Macule-flat, circumscribed ,different color  Patch- macule>2 cm  Papule-elevated, circumscribed,<1 cm  Nodule->1 cm  plaque,-elevated, flat topped,>1 cm  Vesicle-sharply marginated,elevated,w/ fluid, <1 cm  Bullae- vesicular lesion > 1cm 

 Scale-

flaky accumulation of excess keratin  Crust- collection of inflammatory cells and dried serum  Excoriations- linear, angular erosions,2 to scratching, loss of epidermis  Ulcer- deeper erosion, loss of epidermis and papillary dermis  Lichenification-thickening of skin 2 to chronic rubbing

Diagnostic Tests 1) Skin Biopsy  Punch, excisional, incisional & shave Nursing Interventions Preprocedure - Secure consent - clean site

 Postprocedure

– place specimen in a clean container & send to pathology laboratory – use aseptic technique for biopsy site dressing, assess site for bleeding & infection – instruct px to keep dressing in place for 8hrs & clean site daily

Diagnostic Tests 2) Skin Culture  Used for microbial study  Viral culture is immediately placed on ice  Obtain prior to antibiotic administration

3) Wood’s Light Examination  Skin is viewed through a Wood’s glass under UV Nursing Interventions Preprocedure – darken room Postprocedure – assist px in adjusting to light

Diagnostic Test 1) 

Skin Testing Administration of an allergen by patch, scratch, or ID techniques

Nursing Interventions Preprocedure – d/c systemic steroids or antihistamines 48º prior, consent, ready resuscitation equipments

Postprocedure – keep skin-patch area dry – instruct to avoid activities which can increase sweating if doing a patch test – record site, date, time of test, ff-up & reading

INTEGUMENTARY DISORDERS

Skin cancer Etiology : – chronic friction, irritation & exposure to UV Types: 1. basal cell – most common 2. squamous cell 3. malignant melanoma – most fatal

Squamous cell Carcinoma Risk factors:  UV rays  Radiation  Actinic keratosis  Immunosuppression  Industrial carcinogens

Squamous cell Carcinoma History and Assessment:  Slowly evolving  Assymptomatic  Occassionaly bleeding and pain  Exophytic nodules w/ varying degree of scaling or crusting

Squamous cell Carcinoma Diagnosis:  Biopsy- irregular masses of anaplastic epidermal celss proliferating down to the dermis

Squamous cell Carcinoma Treatment  Surgical excision  Mohr’s micrographic surgery  Radiation  prevention-

Basal Cell Carcinoma Risk factors:  UV rays  May take several forms: nodular, ulcerative, pigmented ad superficial

Basal Cell Carcinoma Hx and Assessment:  Usually asymptomatic unless secondarily infected in advanced disease  Pearly-colored PAPULE  External surface - fine telangiectasia and is translucent

Basal Cell Carcinoma Diagnosis:  Biopsy- basophilic palisading cells

Basal Cell Carcinoma Treatment:  Curettage  Surgical  Cryosurgery  Radiation  prevention  Mohr’s micrographic surgery

Melanoma Risk factors:  Sun exposure  Fair skin  Positive family history  Presence of dysplastic nevi

Melanoma Hx and Assessment:  Usually asymptomatic until late  Pruritus or mild discomfort  Recent changed in a previous skin lesion  A- asymetry  B- border irregularity  C- color variation  D- diameter(large)

Melanoma Diagnosis:  Biopsy- melanocytes w/ marked cellular atypia and melanocytic invasion of the dermis

Melanoma  Treatment:  Surgical

excision  Chemotherapy- metastasis

Skin Cancer Interventions: a. b. c. d. e. f.

preventive measures monitoring of any lesion have moles or lesions removed if they are subject to chronic irritation avoid contact with chemical irritants use of sunscreen avoid too much sun exposure

Actinic Keratosis Risk Factor:  Sun exposure Hx and assessment:  Asymptomatic unless irritated  Discrete, rough scaling patches and papules

Actinic Keratosis Diagnosis:  Biopsy- dysplastic squamous epithelium w/o invasion

Treatment:  Topical 5-Fu  Cryosurgery  Curettage  Chemical peel  prevention

Contact dermatitis Etiology: – inflammatory response to contact of an allergen - any substance w/c the patient has been previously sensitized

Contact Dermatitis Hx and Assessment: a. Pruritus b. Burning c. Edema d. Erythema e. signs of infection f. vesicles with drainage

Contact Dermatitis  2. 3. 4.

Diagnosis: Hx and PE Biopsy- eosinophils Patch test

Contact Dermatitis  Treatment: 2. Antihistamines 3. Prophylactic

antibiotics 4. Topical steroids

Interventions: a. elevate to reduce edema b. Cold compress c. prevent scratching d. assist in skin testing e. use hypoallergenic materials f. administer antibiotics, antipruritics, steroids

psoriasis Etiology: – chronic, non-infectious inflammation involving keratin synthesis caused by stress, trauma & infection Koebner’s phenomenon – development of a lesion at a site of injury e.g. scratch

Psoriasis Assessment: a. Pruritus b. silvery white scales on a round reddened plaque usually affecting scalp, knees, elbows, extensor surfaces of arms & legs & sacral regions c. Joint inflammation with Psoriatic arthritis

psoriasis Management: • Topical pharma therapy (tar,anthralin, salicylic acid, retinoid compound, corticosteroid) • Intralesional therapy (triamcinolone acetonide) • Systemic therapy (methotrexate, cephalosporins) • Photochemotherapy (psoralens + UV light)

Bacterial Viral Fungal parasitic

Lyme Disease Etiology: – spirochete Borrelia burgdorferi (tick bite) Assessment: 1st stage - Small red pimple - Ring shaped - Flu-like symptoms

Interventions: a. daily soaks & tepid H20 compress b. remove scales c. use of emolients d. instruct px not to scratch area e. check s/sxs of infection f. use light cotton clothing g. Assist in ways to reduce stress

2nd stage - Neuro complications - Cardiac complications - Joint pain 3rd stage - Large joints involved - Arthritis progress

 Diagnosis: -

-

Hx and PE Antibody test Treatment: Penicillin

Impetigo  -

Etiology: Staphylococcus or B-hemolytic streptococcus

Impetigo  Assessment: -

papule---pustule---vesicles---crust Characteristic honey colored crusts fever

Impetigo Treatment:  topical antibiotics  Oral antibiotics

Interventions  Keep area clean  Implement contact precaution  Administer meds as prescribed

Erysipelas & Cellulitis Erysipelas – inflammation, acute, superficial, rapidly spreading caused by B-hemolytic Streptococcus Cellulitis – inflammation/infecton of deeper dermis usually caused by Streptococcus & Staphylococcus

 Assessment: -

Swelling or edema Redness Pain or tenderness Fever

 Treatment: -

IV antibiotics ( penicillin, cloxacillin) antipyretics Elevate affected area

Staphylococcal infections  Folliculitis Furuncle  Carbuncle

infection of hair follicle

Staphylococcal infections  Assessment:

-

Papule, pustule, nodule, node, cyst Fever Pain and tenderness

Staphylococcal infections Treatment: - Incision and drainage - Antibiotics - antipyretics

Acne vulgaris Etiology: - Propiniobacterium acne Assessment: - Papule - Pustule - nodule

Acne vulgaris Management:  Topical - Benzoyl peroxide - Retinol  Intralesional therapy  systemic - Tetracycline - clindamycin

Chickenpox Etiology  VZV  Mode of transmission- droplet or skin lesion contact  Incubation- 10-20 days

Chickenpox  Hx

and Assessment  Hx of exposure  Prodrome of malaise, fever, HA and myalgia- 24 hrs before onset of rsh  Pruritic lesions in crops  Pink-red macules---central vesicles---crusting

Chickenpox  Treatment:  Self-limited

in healthy children  Adults- uncomplicated- oral acyclovir  Immunocompromised- IV acyclovir  Vaccine- prevention

HZ (Shingles) Etiology: – VZV, reactivation of VZV from the dorsal root ganglia

HZ (shingles) Assessment: a. dermatomal distribution of vesicles b. Neuralgia c. Fever

HZ (shingles) Diagnosis: Culture Interventions: a. Isolate b. assess neurovascular status c. Keep area clean and dry d. Give analgesics as ordered

Herpes Simplex Etiology  Oral form- HSV 1  Cenital form- HSV 2

Herpes simplex Hx and Assessment:  1 Eruption- more severe, longerlasting - Acccompanied by LAD, fever, malaise and edema  Recurrent- limited to mucocutaneous are innervated by involved nerve - Tingling, burning sensation precedes the lesion

Herpes simplex 

Grouped vesicle on an erythematous bases

Herpes simplex Diagnosis:  Culture- definitive  tzanck smear- multinucleated giant cells Treatment:  Topical  Oral/IV acyclovir

Molluscum Contangiosum Etiology:  Poxvirus  Common in young children and in AIDS patients

Molluscum Contangiosum HX and Assessment:  Asymptomatic unless inflamed  Discrete dome-shaped, shiny pauples w/ central umbilication  2-5 mm in diameter  In children- trunk  In adults- perianal and perigenital areas

Molluscum Contangiosum Diagnosis:  Giemsa or wright’s stain- large inclusion or molluscum bodies  Ask Hx of AIDS

Molluscum Contangiosum Treatment:  Curettage  Liquid nitrogen cryotherapy  Tricloroacetic acid

Tinea Etiology: - dermatophytes, yeasts Tinea capitis- fungal infection of scalp Tinea corporis- fungal infection of the body Tinea cruris- fungal infection of the inguinal area Tinea pedis- foot Tinea inguinum- nails

 Assessment: -

Circular, annular, plaques, hypo/hyperpigmented Scaling and erythematous plaques pruritic

Tinea  Diagnosis: -

-

KOH smear Woods light exam Treatment: Topical/oral antifungals

Interventions  Keep area clean and dry  Do not scratch  Proper hygiene  Cut off nails or trim nails (onychomycosis)

Candidal Intertrigo Predisposing factors:  Obesity  DM  Recent antibiotic therapy  Warm, moist environment

Candidal Intertrigo Hx and Assessment:  Pruritus  Pain  Well-demarcated, beefy-red, erythematous patches surrounded by satellite pustules  Restricted to intertriginous areas  In infants- diaper rash

Candidal Intertrigo Diagnosis:  KOH smear of scrapingspseudohyphae and yeasts forms

Candidal Intertrigo Treatment:  Topical antifungal +/- low- potency steroid  Reduce moisture  Reduce friction through weight loss

Pityriasis versicolor  Etiology:  Malassezia

furfur

Pityriasis versicolor Hx and assessment  Usually asymptomatic  Mild itching  Small, scaling Macules that enlarges and coalesce  Pinkish, lightly pigmented, hypopigmented

Pityriasis Versicolor Diagnosis  KOH- short, blunt hyphae and small spores  Wood’s light exam

Pityriasis versicolor  Treatment:  Topical

antifungal- resolution in 2-3

wks  Seleniium sulfide shampoo- 1-3x/wk; leave for 10 mins and scrub off  Systemic antifungals- sever cases

Scabies Etiology: – caused by parasite Sarcoptes scabiei – there is 1 mos delay from exposure to onset of pruritus

Scabies Assessment: • Erythematous papules & pustules • Threadlike brownish linear burrows • 2ndary lesions (crust, vesicles, nodules & excoriations) • Intense pruritus that worsens at night

Interventions: • Antihistamines • Topical antiscabies (Lindane) – not to be used on <2y/o (neurotoxic) • Treat close contact • All beddings & clothes should be washed in very hot water

Frostbite Assessment: a. Numbness b. Paresthesia c. Pallor d. severe pain e. necrosis & gangrene may develop

Interventions: a. rewarm rapidly & continuously for 15 to 20 mins or until skin flushing occurs b. Avoid slow thawing, interrupted periods of warmth or massage c. Do not debride blisters

Burns types: thermal chemical electrical radiation

Classification: • Superficial – mild to moderate erythema, no blisters, pain eased by cooling • Partial thickness – (+) blisters, edema, painful, injured are sensitive to cold air • Full thickness – injured space appears dry, fat exposed, little or no pain

Disorders Methods of estimating extent of injury Rule of 9’s  Head & Neck 9%  Anterior trunk 18%  Posterior trunk 18%  Arms 18%  Legs 36%  Perineum 1%

Management: • Emergent phase – time of injury  restoration of capillary permeability (48% – 72%) 1º goal is prevent hypovolemic shock Prehospital care 1. remove victim from source 2. ABC 3. Assess for trauma 4. Cover wounds with clean cloth 5. Remove jewelries 6. Need for IV ? 7. Transport ER care - continuation of care

• Resuscitative phase – initiation of fluids  capillary integrity near normal - Fluid resuscitation - pain management - escharotomy - fasciotomy - nutrition

a. Acute phase – hemodynamically stable  restored capillary permeability - wound care - debridement - wound closure - PT

Autografting care of graft site a.Elevate & immobilize b.Keep free from pressure c. Check for infection d.Instruct client to protect affected area from sunlight e.Use splints & support garment

a. Rehabilitative phase goals – promote wound healing – minimize deformities – increase strength & function – provide psychological & emotional support

Lichen planus Etiology: - unknown, idiopathic, drugs(gold), HLA asso predisposition - acute, chronic involving skin & mucous memb.

Assessment: 4 Ps Purple  Polygonal  Pruritic  Papule Treatment:  cyclosporine  steroids

Erythema multiforme  EM

minor- no mucus involvement, extensor surfaces  EM major SJS and TEN-necrotizing tracheobronchitis, renal tubular necrosis, meningitis

Erythema Multiforme Etiology: Immune mediated reaction due to  Drugs  Infection  Vaccination  pregnancy

Erythema Multiforme Hx and assessment:  Mild prodrome- malaise and myalgia  Lesions mat be asso. w/ pain and fever  Mucosal involvement-dysphagia and dysuria  Pink to red macules, papules, erythematous plaques, target lesions and bullae

Erythema Multiforme  Diagnosis:  Clinical

Hx of exposure  Elevated eosinophils

Erythema Multiforme  Treatment:

mild cases- resolve spontaneously  Identify the cause  Severe forms- corticosteroids and analgesia  SJS- rehydration 

3. Steven johnsons syndrome is managed thru b. Antibiotics c. Steroids d. Identifying the cause e. All of the above

4.A 15 y.o. patient was diagnosed w/ lichen planus. This disorder is characterized by except b. A purple papule c. Pruritus d. Polygonal lesion e. patch

5. A patient was involved in a fire accident and sustained burns. Half of her anterior face and neck, whole left arm and anterior chest was involved. Compute for the estimated burn area using rule of nines.

6. Scabies is caused by a b. Parasite c. Protozoan d. Bacteria e. fungi

8. Management of frostbite includes all of the ff except: b. rewarm rapidly & continuously for 15 to 20 mins or until skin flushing occurs c. Avoid slow thawing, interrupted periods of warmth d. debride blisters e. Avoid massage