Integumentary System

The integumentary system consists of the Skin Appendages Hair Nails Cutaneous glands

Skin

Integument - Covering The largest organ in the human body". It weighs more than any single internal organ

Skin

The most obvious function- the protection that the skin gives to underlying tissues Keeps most harmful substances out (it plays the most important role in protecting against pathogens) Prevents the loss of fluids Regulates body's temperature It is useful in Vitamin D absorption

Skin- Epidermis

Epidermis - Stratified squamous cells - Has 5 layers: - Corneum - Lucideum - Granulosum - Spinosum - Basale - Avascular part - It contains melanocytes

Skin- Dermis

Dermis - Middle layer - contains a number of structures including blood vessels, nerves, hair follicles, smooth muscle, glands and lymphatic tissue.

Skin- Hypodermis

Innermost layer Serves as padding and insulation for the body Clinical Application: The patch drug delivery system. The transdermal patch is an increasingly popular drug delivery system. These patches are designed so that the drug molecules diffuse through the epidermis to the blood vessels in the dermis layer.

Appendages
HAIR Lanugo

the fine, unpigmented hair that covers nearly the entire body of a fetus the short, downy, "peach fuzz" body hair (also unpigmented) that grows in most places on the human body.

Vellus hair

Terminal hair

the fully developed hair, which is generally longer, coarser, thicker, and darker than vellus hair, and often is found in regions such as the axillary, male beard, and pubic.

Hair

Hair on the scalp provides insulation from cold for the head The hair of eyelashes and eyebrows helps keep dust and perspiration out of the eyes Hair in our nostrils helps keep dust out of the nasal cavities Any other hair on our bodies no longer serves a function, but is an evolutionary remnant.

Pathological Impacts on Hair

Drugs used in cancer chemotherapy frequently cause a temporary loss of hair, noticeable on the head and eyebrows, because they kill all rapidly dividing cells, not just the cancerous ones. Other diseases and traumas can cause temporary or permanent loss of hair, either generally or in patches.

Nails

It serves as a protective plate and enhances sensation of the fingertip. Protect the tips of fingers and toes from mechanical injury Give the fingers greater ability to pick up small objects.

Cutaneous Glands

Sebaceous Gland - Oil gland - Sebum - Keeps the skin soft and moist - Contains chemicals that kills bacteria - Increase activity during adolescence

Sweat glands

Eccrine sweat glands

are exocrine glands distributed over the entire body surface but are particularly abundant on the palms of hands, soles of feet, and on the forehead.

Apocrine sweat glands

only develop during early- to mid-puberty (approximately age 15) are mainly present in the armpits and around the genital area, areola, perineum

Assessment

Health History
-

Skin allergies Allergic reactions to food, medication, chemicals Previous skin problems Skin cancer

Cosmetics being used

-

Soaps, shampoo, personal hygiene products

Look for:

Onset Signs and Symptoms Location Duration Other discomfort

Terminologies:

Alopecia Dermatosis Erythema Hirsutism Hyperpigmentation Hypopigmentation Lichenification Petechiae Striae Telangiectases

Assessing General Appearance

Observe the color, texture, moisture, vascularity, mobility, condition of hair and nails Pallor Cyanosis Jaundice Rash

Primary Lesions

Macule/ Patch Macule= <1cm, Patch= >1cm

Papule, Plaque Papule= <0.5 cm, Plaque= >0.5 cm

Primary Lesions

Nodule, Tumor

Primary Lesions

Vesicle, Bulla Vesicle= <0.5 cm, Bulla= >0.5 cm

Primary Lesions

Pustule
Secondary

lesion

Ulcer Keloid Scar Lichenification

Diagnostic Tests

Skin biopsy
is a biopsy technique in which a skin lesion is removed and sent to the pathologist to render a microscopic diagnosis CA cells

There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy Patient consent and anesthesia (usually lidocaine injected into the skin) are prerequisites.

Skin biopsy
Shave Biopsy

With either a small scalpel blade, a curved razor blade, or a broken piece of "safety" razor. Will shave only a small fragment of protruding tumor and leaving the skin relatively flat after the procedure

Skin biopsy

Punch Biopsy With a round shaped knife ranging in size from 1mm to 8 mm. Some punch biopsies are shaped like an ellipse, although one can accomplish the same desired shape with a standard scalpel. Incisional and Excisional Biopsy Cut is made through the entire dermis down to the subcutaneous fat Cut is made plus some normal part of the skin

Description: Interventions Preprocedure: a. Obtain an informed consent b. Cleanse site as prescribed. Interventions Post procedure: a. Place specimen when obtained by physician in the appropriate container and send to pathology laboratory for analysis b. Use surgically aseptic technique for biopsy site dressings

Skin Biopsy

Skin biopsy
c. Assess the biopsy site for bleeding and infection d. Instruct the client to keep dressing in place for at least 8 hours, and then clean daily as prescribed, use antibiotic ointment as prescribed.

Skin Cultures
Description: a. A non invasive procedure b. A small skin culture sample is obtained using a sterile applicator and appropriate type of culture tube (bacterial vs. viral) c. Culture is placed immediately on ice d. Sample is sent to laboratory to identify an existing organism

Skin Culture
Interventions Preprocedure a. Obtain skin culture samples before instituting antibiotic therapy Intervention Postprocedure a. Send skin culture sample to the laboratory

Wood's Light Examination

Description: a. Skin is viewed under ultraviolet light through a special glass (Wood's Glass) to identify superficial infections of the skin. Interventions Preprocedure: a. Darken the room before examination Interventions Postprocedure: a. Assist the client during adjustment from the darkened room

Description: a. Administration of an allergen to the surface of the skin or into the dermis b. Administered by patch, scratch or intradermal technique

Skin Testing

Skin Testing
Intervention Preprocedure: a. Discontinue systemic corticosteroids or antihistamine therapy 5 days before the tests as prescribed. b. Obtain informed consent c. Have resuscitation equipment available if a scratch test is performed, for it may induced an anaphylactic reaction

Skin Testing
Interventions Postprocedure: a. Instruct the client to keep skin testing area dry. . instruct the client to avoid activities that may produce sweating if a patch test was performed. c. Record the site, date and time of the tests. d. Record the date and the time for follow up site reading. e. Inspect the site for papules, vesicles, erythema, edema and induration

Patients with Dermatologic Disorders

Pruritus
first indication of systemic disease (hepatic/ renal disease) - Scratching - Release of histamine

Medical Management: - No soap and hot water (use tepid) - Preferably bath oils - Cold compress, ice cube or cool agents with menthol or camphor to relieve pruritus

Pruritus

Blot the area with a towel Lubricate the skin after bathing No to overly warm environment No ingestion of alcohol, hot foods or hot fluids Use humidifier Limit activities that causes perspiration Wear cotton clothing Keep the nails trimmed

Pruritus

Oral antihistamines Topical corticosteroids

Perineal and Perianal Itching

Management

Proper hygiene measures Discontinue home and over the counter remedies Rinse with lukewarm water, blot dry Moistened tissues must be used Cornstarch may be applied in the skin fold areas No hot water, bubble baths, sodium bicarbonate and detergent soaps

Perianal Itching

No synthetic fabrics No vasodilating agents and stimulants Adequate fiber diet

Secretory Disorders
HYDRADENITIS SUPPURATIVA Is an infection of the skin on the areas of the body where apocrine sweat glands exist. These areas are the armpits, groin, skin around the nipples and around the anus.

Hydradenitis Suppurativa
Pathophysiology Sweat is thicker containing more fat and less watery- - Abnormal blockage of the sweat glands -Inflammation, nodules - Hypertrophic bands of scar tissue

Hydradenitis Suppurativa
Clinical Manifestations Usually in the axilla, inguinal folds, mons pubis and around the buttocks Multiple suppurative lesions Appear after puberty Has no genetic basis, cause is unknown

Hydradenitis Suppurativa
Management Hot compress Oral antibiotics I & D with gauze packs

Seborrheic Dermatoses

Is excessive production of sebum in areas where sebaceous glands are normally found in large numbers such as face, scalp, axilla, under the breasts, etc. Is a chronic inflammatory disease of the skin that are well supplied with sebaceous glands

Seborrheic Dermatoses
Clinical Manifestations May start in childhood and continue throughout life Oily form or dry form Oily form appears moist and greasy Slight erythema Small pustules resembling acne may appear on the trunk

Seborrheic Dermatoses
Dry form consist of flaky desquamation of the scalp with amounts of fine, powdery scales (dandruff) Causes: Genes Nutritional status Infection Emotional stress Remissions and Exacerbations should be explained to the client

Seborrheic Dermatoses
Medical Management Topical corticosteroids (Dandruff)= proper and frequent use of medicated shampoo (daily or 3x weekly)

Seborrheic Dermatoses
Nursing Management Avoid external irritants Avoid excessive heat and perspiration Avoid rubbing and scratching Keep skin folds clean and dry, air the skin

Acne Vulgaris

Is a common follicular disorders affecting the hair follicles and sebaceous glands. Most commonly found on the face, neck and upper trunk. Exacerbations coincide with the menstrual cycle from hormonal activity. Pustules result as the inflammatory progresses

Acne Vulgaris
Clinical Manifestations Primary lesions are comedones Closed comedones (white heads)are obstructive lesions formed from impacted lipids or oils and keratin that plug the dilated follicle. Small, whitish papules with minute follicular openings that generally cannot be seen Open comedones (black heads)- ducts are in open communication with the external environment

Acne Vulgaris
Pathophysiology Androgens stimulate the sebaceous glands- - glands enlarge and secretes sebum In adolescent, glands androgenic stimulation produces a heightened response - plugging of the glands

Acne Vulgaris
Medical Management Nutrition and hygiene therapy Topical pharmacologic therapy
Benzoyl peroxide Topical antibiotics

Systemic pharmacologic therapy

Antibiotics Oral retinoids Hormone therapy

Surgical Management

Acne Vulgaris
Nursing Management Prevent Scarring Prevent infection Educate that heat and perpiration may exacerbate acne Uncleanliness, dietary indiscretions, menstrual cycle and other myths are not responsible for acne

Acne Vulgaris

Wash the face gently with mild soap twice daily. Do not scrub Do not squeeze blackheads, not to prop hands on or rub face, to wash hair daily and keep it off face, and use cosmetics cautiously

Tinea

A fungal skin disorder Tinea= ringworm Tinea pedis= athletes foot Tinea corporis= body (face, neck, trunk, and extremities) Tinea capitis= scalp Tinea cruris= groin (jock itch) Tinea unguium= toenails/ fingernails

Tinea Pedis
Management Administer fungal foot sprays Keep the feet as dry as possible
Using cotton socks Using cotton balls Apply talcum/ antifungal powder Alternate the use of shoes

Tinea Corporis
Management Use clean towel and washcloth daily Dry all skin areas and skin folds Wear clean cotton clothing next to the skin Tinea Capitis Use separate comb and brushes and to avoid exchanging hats and other headgear

Tinea Cruris
Management Avoid excessive heat and humidity as much as possible Avoid wearing nylon underwear, tight fitting clothes and wet bathing suits Clean, and dry the groin area and dust with topical antifungal agent

Pediculosis
Infestation by lice Pediculosis capitis Pediculosis corporis Pediculosis pubis S/Sx Itching Excoriation from scratching Tiny, gray white nits on hair shafts

Pediculosis
Management Wash all bedding and clothing in hot water and dry on hot cycle of clothes dryer Never share hair brushes, combs, or hats Remove nits with a fine- toothed comb

Skin Disorders- Skin Cancer

Description: a. is a malignant lesion of the skin which may or may not metastasize b. skin cancer causes include chronic friction and irritation to a skin area and exposure to ultraviolet rays. c. diagnosis is confirmed by a skin biopsy.

Skin Cancer
chemicals, viruses, tobacco smoke or too much sunlight. -damaged DNA - repair the DNA - cell dies Assessment a. change in color, size or shape of preexisting lesions b. pruritus c. local soreness

Skin Cancer
Interventions: Instruct... a. monitor for lesions that do not heal or that change characteristics b. have moles or lesions removed that are subject to chronic irritation c. avoid contact with chemical irritants d. wear layered clothing and use sunscreen lotions when outdoors e. avoid sun exposure between 11AM- 3PM f. assist in surgical excision of the lesion as prescribed

Contact Dermatitis
Description: a. an inflammatory response of the skin that produces skin changes after contact with specific antigens Assessment: a. pruritus and burning b. edema c. erythema at the point of contact d. vesicles with drainage e. signs of infection

Contact Dermatitis
Interventions: a. elevate the extremity to reduce edema b. apply cool, wet dressings and tepid baths as prescribed. c. maintain a cool environment d. protect the affected area from trauma e. prevent scratching and rubbing of the affected area f. assist with skin testing as prescribed to determine allergens g. instruct the client to avoid harsh soaps

Contact Dermatitis
h. avoid using heating pads or blankets i. administer antibiotic for infection, antihistamine or antipruritic for itching and corticosteroids for inflammation as prescribed.

Lyme Disease
Description: a. is an infection caused by spirochete borrelia burgdorferi from a tick bite Pathophysiology Enters the skin- remain localized but viable/ may disseminate via lymphatic system or blood - travel to other parts of the skin, the heart, joints, the CNS, and other parts of the body.

Lyme Disease
Assessment: First Stage: a. symptoms can occur several days to months following the bite b. a small red pimple develops that spread into a ring- shaped rash c. rash maybe large or small or may not occur at all d. flulike symptoms such ad headaches, stiff neck, muscle aches, and fatigue

Lyme Disease
Second Stage: a. several weeks following the bite b. joint pain occurs c. neurological complications d. cardiac complications Third Stage: a. large joint become involve b. arthritis progresses

Lyme Disease
Interventions: a. gently remove the tick with tweezers, wash skin with antiseptic, and dispose the tick by flushing it down to the toilet b. obtain a blood test 4-6 weeks after a bite to detect the presence of the disease c. administer antibiotics as prescribed if the disease is confirmed.

Lyme Disease
d. instruct the client to avoid areas that contain ticks, such as wooded grassy areas, especially in summer months. e. wear long- sleeved tops, long pants, closed shoes and hats while outside. f. spray the body with tick repellant before going outside g. examine the body when returning inside.

Cellulitis
Description: a. is a skin infection into the deeper dermis and subcutaneous fat, and the causative organisms is usually streptococcus pyogenes Pathophysiology fissure, cut, laceration, insect bite, or puncture wound - organisms will multiply - be buried deeper to the dermis

Assessment: a. pain b. itching c. swelling d. redness and warmth Interventions: a. promote rest b. apply warm compress as prescribed c. administer antibiotics as prescribed for infection following a culture of the area. d. clean skin daily with an antibacterial type of soap as prescribed.

Cellulitis

Psoriasis
Description: a. is a chronic noninfectious skin disorder due to excessive epidermal proliferation b. possible causes of the disorder include stress, trauma, infection and changes in climate. d. maybe exacerbated by the use of certain medications

Psoriasis
Pathophysiology hyperplasia of epidermis, vascular hyperplasia, infiltration of T lymphocytes, neutrophils, and other types of leukocyte in affected skin. Assessment: a. pruritus b. shedding, silvery white scales on a raised reddened, round plaque that usually affects the scalp, knees, elbows, and sacral regions

Psoriasis
Interventions: a. administer daily soaks and tepid, wet compresses to the affected areas to remove scales, oil or coal tar preparations maybe added to the bath water. b. assist the client to remove the scales using a washcloth. Emollient creams or salicylic acid maybe applied to affected areas after the bath c. occlusive dressings may be applied following application of corticosteroid to increase its effectiveness

Psoriasis
Intralesional Therapy - it is an injection of medication to isolated patches of psoriasis Systemic Therapy - to treat extensive psoriasis Photochemotherapy - a combination of psoralens and ultraviolet light therapy to decrease cellular proliferation

Psoriasis
Client Education a. not to scratch the affected areas and to keep the skin lubricated to minimize itching b. monitor and recognize the S/Sx of infection c. wear light cotton clothing over affected areas. d. avoid over the counter medications e. assist the client to identify ways to reduce stress.

Paronychia
Description: - an infection of the tissue around the nail plate that most commonly occurs in middle aged woman and in the client with DM. Assessment: a. redness and swelling around the nailbed b. soreness at the nailbed

Paronychia
Interventions: a. monitor for infection around the nails b. monitor for cellulitis in the affected area c. assist the client with warm soaks as prescribed d. prepare to assist with I&D of the infected area if prescribed. e. administer antibiotic or fungicidal ointment as prescribed.

Boils
Description: - are deep bacterial inflammation of hair follicles caused by staphylococcus. Assessment: a. redness on skin b. tender and painful furuncle c. skin swelling at the site d. a yellow or white center at the furuncle

Boils
Interventions: a. have a good handwashing technique to prevent infection b. apply hot moist compress c. assist in I&D d. instruct about daily cleanliness, use of seperate bath linens, and administration of antibiotics.

Description: a. damage to tissues and blood vessels as a result of prolonged exposure to cold. b. fingers, toes, nose and ears often are affected.

Frostbite

Assessment: a. numbness b. paresthesia c. pallor d. severe pain, erythema, swelling and blistering once in warm environment e. necrosis and gangrene may develop

Frostbite
Interventions: a. handle the tissues gently b. rewarm the affected part rapidly for 15-20 minutes until skin flushing occurs c. avoid slow thawing, interrupted periods of warmth d. do not debride blisters e. apply bulky dressings as prescribed to provide protection

Decubitus Ulcer
Description a. is impairment of skin integrity b. localized areas of necrosis of the skin and subcutaneous tissue are caused by pressure. Risk factors: a. malnutrition b. incontinence c. immobility d. skin shearing e. decreased sensory perception

Decubitus Ulcer
Pathophysiology external force such as a mattress, wheelchair pad, or bed rail, shear forces and friction - cause microcirculatory occlusion -ischemia -leads to inflammation and tissue anoxia. -cell death, necrosis, and ulceration.

Decubitus Ulcer
Assessment: Stage I: a. skin is intact b. reddened area that returns to normal skin after 15- 20 minutes of pressure relief Stage II: a. top layer of the skin is missing b. skin is shallow with a pink to red base and a white or yellow eschar maybe present.

Decubitus Ulcer
Stage III: a. deep ulcer that extends into the dermis and subcutaneous tissues b. white, gray, or yellow eschar usually is present at the bottom of the ulcer c. purulent drainage is common Stage IV: a. deep ulcer that extends into muscle and bone b. foul smelling c. brown or black eschar is present d. purulent drainage is common

Decubitus Ulcer
Interventions: a. assess the nutritional status of the client b. remove pressure on the skin c. reposition immobile client every 2 hours. d. provide active and passive exercises every 8 hours e. keep the skin clean and dry and the sheets wrinkle free f. apply medications as prescribed.

Burn Injuries
Description: - cell destruction of the layers on the skin and the resultant depletion of fluids and electrolytes

Burn Injuries
Burn Depth Superficial/ 1st Degree a. mild to severe erythema (pink to red) b. no blisters c. burn is painful, with tingling sensation d. pain is eased by cooling e. discomfort lasts about 48 hours, healing is 3-7 days

Burn Injuries
Partial Thickness/ 2nd Degree a. large blisters cover an extensive area b. edema is present c. broken epidermis, with wet, shiny and weeping surface d. painful e. heals in 2-3 weeks

Burn Injuries
Full Thickness/ 3rd Degree a. deep red, black, white, yellow or brown area b. appears dry c. edema is present d. with little or no pain e. burn requires removal of eschar f. scarring and wound contractures are likely to develop without preventive measures

Burn Injuries
Deep Full Thickness/ 4th Degree a. involves muscle and bone b. injured area appears black c. edema is absent d. pain is absent e. no blisters f. eschar is hard and inelastic g. grafts are required

Burn Injuries
Types of Burns: a. thermal- exposure to flames, hot liquids, steam, hot objects b. electrical- heat generated by an electrical energy as it passes through the body c. chemical- contact with strong acids or chemicals d. radiation- exposure to ultraviolet rays

Burn
Pathophysiology trauma- general body edema- decreased circulation of intravascular blood volume - decreased organ perfusion- hypoTT, decreased cardiac output- hyponatremia and hyperkalemia- increased hct- oliguria - GI dysfunction and intestinal ileus- immunosupression- hypovolemic/ septic shock- death

Burn Injuries
Management: Emergent Phase: a. from time of injury up to restoration of capillary permeability (Fluid resuscitation) usually 48- 72 hours b. it includes prehospital and emergency room care Goal: Prevent hypovolemic shock and preserve vital organ functioning

Burn Injuries
Prehospital care a. remove the victim from the source of burn b. assess ABC c. assess for associated trauma d. conserve body heat e. cover burns with sterile or clean cloths f. remove constricting jewelry or clothing g. assess the need for IVF h. transport

Burn Injuries
Emergency Room Care a. ensure patent airway and administer 100% O2 b. initiate IV access c. assess for hypovolemia and the need for IVF d. insert foley catheter and maintain urine output of 30-60 NPO status f. administer tetanus prophylaxis as prescribed. g. administer pain medications as prescribed h. prepare the client for an escharotomy as prescribed

Burn Injuries
Resuscitative Phase a. from the initiation of IVF up to capillary integrity returns to near normal levels b. fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital Parkland Formula 4ml (lactated ringers solution) per kg per percent of burn injury

Burn Injuries
a. successful fluid resuscitation is evaluated by stable vital signs, adequate urine output, palpable peripheral pulses and a clear sensorium b. urinary output is the most common and most sensitive noninvasive assessment parameter for cardiac output and tissue perfusion

Burn Injuries
Interventions: a. elevate the head of the bed 30% b. initiate ECG monitoring c. assess for S/Sx of infection d. initiate protective isolation techniques e. monitor daily weights

Medications for Skin Disorders

Antimicrobial drugs
Treat infections caused by pathogenic microorganisms Before administering the first dose, assess for presence of allergies Assess for allergies, presence of superinfection/ phlebitis, monitor WBC

Corticosteroids
Antiinflammatory Monitor for S/Sx of infection Taper the drug May cause reportable cushingoid effects

Medications for Skin Disorders

Analgesics
Relieve pain Assess first the pain Institute safety measures Evaluate the effectiveness of the medication after 30 minutes

Topical vitamin A
Seeds cellular turnover Skin redness and peeling are common Avoid sun exposure