INTEGUMENTARY SYSTEM

1. INTEGUMENTARY SYSTEM

3. Review cont�. Collagen Protein that gives strength and resilience to skin Loss of collagen results in wrinkles Desquamation Loss of skin

4. Dermatology-study of skin diseases Dermatologist-physician who specializes in this field See Box 74-1 Abrasion Laceration Purpura** Discolored skin d/t blood in the tissue outside the blood

5. 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

6. 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

7. Pruritis (Itching) Sx of skin disease Can also be caused by systemic disorders, such as liver disease and dry skin Scratching is inevitable, and causes skin breaks which can result in scarring and infections Tx: divert attention, hypnosis Administer medications: antianxiety (Ataraz, Vistaril), antihistamines (Benadryl, Tavist), topical corticosteroids Prevention: Cotton clothing, apply lotion to dry skin, skin testing, cool or lukewarm baths, soothing baths (colloidal oatmeal, starch)

8. Therapeutic Bath Purposes: *Cleanse body and soothe skin *Promotes wound healing *Relieves itching Aids in the removal of eschar Aids in prevention of infection After the bath, you can apply medication to the body Give this type of bath in a WP or bathtub, disinfect after each pt. Use Oatmeal, cereals, starch, tars and baking soda can also be added to the bath Don�t use soap (dries the skin), use medicated bath oil **Tepid water (heat makes one itch)-no more than 100 degrees F Pat the skin dry, rubbing increases pruritis *Use lotion if the MD allows

9. 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

10. Moist Dressings Moist packs-reduce edema and weeping in acute dermatitis -soften and remove exudate and crusts Relieve pruritus and discomfort -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 -Explain procedure -Proper disposal -DOCUMENT -MD will order the type of dressing or medication to use

11. Wound Debridement Physician or Surgeon will remove loose skin, crusts, eschar or denuded (protective) tissue Sterile procedure often done when changing moist packs (change moist packs q2hours!!)

12. Surgical Treatments Plastic or Reconstructive Surgery-improves disfigurement, may be performed for cosmetic effects, to repair congenital defects or repair trauma tissue

13. Skin and Tissue Grafts Assess the skin: -report any changes -color -turgor Document: size, color, texture, location or distinct characteristics of the skin Fluid and Electrolyte Balance Encourage the client to drink and eat Provide high Kcal, high protein meals Observe and document I & O

14. 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-involves deeper dermal and Subq. Tissues. Affects the lips, eyelids, skin, GI tract, hands, feet, genitalia, tongue, and larynx TX: removal of cause, tepid baths, antipruritic lotions, antihistamines, epinephrine for severe cases

15. Vitiligo Occurs when areas of skin lack in pigmentation Results in patches of pale or white looking skin Cause unknown Tx: methoxsalen after exposure to sunlight can temporarily darken the affected area Surgical tx: grafting and melanocyte transplantation Melanin-gives skin color Albinos cannot make melanin Can also use cosmetics to cover birthmarks

17. 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

18. Eczema (atopic dermatitis) Tx: prevent dry skin, cracking and itching Apply moisturizing creams, corticosteroid ointments, or wet dressings Use lanolin free lotions Meds: Topical corticosteriods-exert localized anti-inflammatory activity, reduce swelling, redness, itching, antihistamines-may relieve itching! Potency depends on drug concentration and the vehicle (lotion, cream, etc.) Adverse Reactions: Burning, itching, irritation, redness, dryness of the skin, secondary infections

21. Psoriasis Chronic, noncontagious disorder that affects young adults and middle aged adults Cause is unknown but hereditary, environmental, metabolic or immune factors contribute to breakouts Stress and anxiety precede exacerbations of the disorder

22. 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 Therapeutic baths, wet dressings, or lubricating ointments

23. Psoriasis Meds: Topical antipsoriatics-help remove the plaques associated with this disorder Ex: calcipotriene (Dovonex) Anthralin (Anthra-Derm) Antihistamines Methotrexate & oral retinoids are useful in treating severe, extensive psoriasis Adverse Reactions: Burning, itching and skin irritation Anthralin may cause temporary discoloration of the hair and fingernails

25. 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

26. Warts

27. Warts Cryosurgery-application of liquid nitrogen Keratolytic agents-removes excess growth of the epidermis. Used to remove warts, callusues, and corns Ex. Salicylic acid, masoprocol (Actinex) Adv. Rxns: burning sensation, rash, dry skin, scaling or flu-like syndrome Contraindicated: for use on moles, birthmarks or warts with hair growing from them, genital or facial warts, warts on mucous membranes Salicylate acid may cause salicylate toxicity

28. Wart Cryosurgery

29. Warts 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

30. Veneral Warts

31. 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 Bacteria transfers from infected client to another person through touch** Meds: mupirocin (Bactroban) Adv. Rxns: burning, stinging, pain, itching, rash, nausea, dry skin

33. Impetigo

34. 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

35. Folliculitis

36. Bacterial skin infections 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

37. Furuncle

38. 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: 5% permethrin cream (Elimite) lindane (Kwell) Leave medication on for 8-24 hours and then bathe thoroughly, repeat tx. In one week

39. Scabies

40. Scabies

41. 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!!

42. Lice-Pediculosis 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

43. 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, erupts where there is a large concentration of sebacous glands-scalp, eyebrows, eyelashes 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 oily scales and crusts on a red base Tx: Shampoo frequently with selenium sulfide suspension (Selsun Blue) and leave on for 5-10 minutes, coal tar** If lotions or solutions contain steroids, use sparingly

44. Burns Result in tissue loss or damage and are traumatic

45. 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

46. Burns Severity of injury is related to the burn�s depth, extent, location and length of exposure Inhalation injuries occur in closed areas with fire and smoke s/s: singed nasal hairs, facial burns, and soot � stained sputum

47. 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

48. �Rule of Nine� 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% See page 1104 for child �Rule of Nines� classification Phases of Burn Injury Management Immediately � apply cold packs or cold water

49. Resuscitative phase: Initial hours after burn, stabilize immediate health concerns!! Burn care unit Always wash hands, use sterile gloves V/S NEVER apply ointments to an extensive burn!!!! Monitor respiratory status-rate and depth of repirations Suspect inhalation injury if client was in a closed in area with fire and smoke 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

50. Fluid and Electrolyte Balance: Lose body fluids from capillary leaks and open wounds, require large amounts of IV fluids particularly containing sodium Record I&O Assess electrolytes: potassium, sodium

51. Renal Function: Monitor urine output hourly, decrease could show shock If u/o is less than 30mls/hr. dialysis may be needed.

52. Infection: Leading cause of death for burn clients May be placed in protective isolation to prevent exposure to pathogens

53. 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

54. 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 Impregnated antibiotic gauze may also be used Wounds heal better when moist

55. Acute Phase: Tight occlusive dressings may be used as they prevent keloid (scar) tissue Tropical agents: Mafenide Acetate (Sulfamylon) Silver sulfadiazine (Sivadene) Bacitracin ointment Used for superficial and facial burns applied as a thin layer 2-3 times/day Silver Nitrate

56. 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

57. Acute Phase: Enzymatic Debridement using a proteolytics substance digests necrotic tissue

58. 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

59. 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.

60. Grafts DO NOT DISTURB SKIN GRAFTS! They need to attach to the live tissue underneath and grow

61. Other Considerations Diet high in calories, nitrogen, and protein Monitor wound drainage Administer LR (per MD order) STRICT I & O

62. 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.

63. 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

64. 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

65. 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

66. 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

67. Skin Cancer Basal cell carcinoma Found in areas exposed to sunlight or UV light Most common form of skin cancer

68. 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

69. Topical Drugs Antiviral Acyclovir Antiseptic and Germicides (kill bacteria) Chlorhexidine Povidone-iodine Corticosteroids (apply sparingly) exert localized anti-inflammatory activity Amcinonide Betamethasone dexamethasone

70. Topical Drugs Anti-psoriatic calcipotriene Selenium sulfide Collagenase Keratolytic (removes excess growth of the epidermis) Diclofenac Salicyclic acid Local anesthetics Benzocaine lidocaine

71. Nursing Process: Implementation Topical Anti-infectives-clean area with soap and warm water prior to applying medicine Topical corticosteroids-applied sparingly, clean area prior to applying Topical enzymes Topical antipsoriatics - apply only to the psoriatic lesions Topical anesthetics � when using lidocaine viscous for oral anesthesia for pain control, instruct client not to eat food for 1 hour after use, anesthetic may impair swallowing

72. Nursing Process: Education patient and family Keep topical meds away from the eyes (unless ordered by PCP) If product is accidentally spilled or sprayed in the eyes, wash the eyes with copious amounts of water.

73. 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