Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R.

Abejo RN,MAN

LAYERS A. Epidermis Avascular outermost layer Stratified squamous epithelium Composed of keratinocytes (produce keratin responsible for formation of hair and nails) and melanocytes (produce melanin). Form the appendages (hair and nails) and glands Epidermis Stratum basale Stratum granulosum Stratum spinosum Stratum lucidum Stratum corneum B. Dermis Layer beneath the epidermis composed of connective tissues. Contains lymphatics, nerves and blood vessels. Elasticity of the skin results from presence of collagen, elastin and reticular fibers. Responsible for nourishing the epidermis. C. Subcutaneous layer Layer beneath the dermis. Composed of loose connective tissues and adipose cells. Stores fat. Important for thermoregulation. APPENDAGES Hair 2. Regulation Maintains normal body temperature by regulating sweat secretion and regulating the flow of blood close to the body surface. Evaporation of sweat from the body surface Radiation of heat at the body surface due to the dilation of blood vessels close to the skin Excessive heat loss causes shivering (contraction of skeletal muscle) increasing heat production and goosebumps (contraction of arrector pili muscle) pulling hair shaft vertical, creating an insulated air space over the skin. 3. Absorption Absorbs oxygen and carbon dioxide and UV rays Steroids (hydrocortisone) and fat-soluble vitamins (ie D) are readily absorbed Topical medications motion sickness patch etc 4. Synthesis Skin produces melanin, keratin, vitamin D Melanin protects the skin from UV rays; determines skin color Keratin helps waterproof the skin and protects from abrasions and bacteria Vitamin D stimulated by UV light. Enters blood and helps develop strong healthy bones. Vitamin D deficiency causes Rickets 5. Sensory Sensory nerve endings tell about environment They respond to heat, cold, pressure, touch, vibration, pain Nails Covers most of the body surface (except the palms, soles, lips, nipples and parts of the external genitalia). Hair follicles: tube-like structures, derived from the epidermis, from which hair grows. Functions as protection from external elements and from trauma. Protects scalp from ultraviolet rays and cushions blows. Eyelashes, hair in nostrils and in ears keep particles from entering organ. Hair growth controlled by hormonal influences and by blood supply. Scalp hair grows for 2 to 5 years. Approximately 50 hairs are lost each day. Sustained hair loss of more than 100 hairs each day usually indicates that something is wrong Dense layer of flat, dead cells, filled with keratin. Systemic illnesses may be reflected by changes in the nail or its bed: Clubbing Beaus line

MEDICAL AND SURGICAL NURSING Integumentary System Lecturer: Mark Fredderick R. Abejo RN,MAN ________________________________________________ Integument Skin The skin is the largest organ of the body As the external covering of the body, the skin performs the vital function of protecting internal body structures from harmful microorganisms and substances. FUNCTIONS: 1. Protection Covers and protects the entire body from microorganisms Protects from UV rays melanin (pigment in the skin) Keratin a protein in the outermost layer of the skin waterproofs and toughens skin and protects from excessive water loss, resists harmful chemicals, and protects against physical tears

Glands Eccrine sweat glands are located all over the body and produce inorganic sweat which participate in heat regulation. Apocrine sweat glands are odiferous glands, found primarily in the axillary, areolar, anal and pubic areas; the bacterial decomposition of organic sweat causes body odor. Sebaceous glands are located all over the body except for the palms and soles; produce sebum.

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

ASSESSMENT Health History Presenting problem Changes in the color and texture of the skin, hair and nails. Pruritus Infections Tumors and other lesions Dermatitis Ecchymoses Dryness Lifestyle practices Hygienic practices Skin exposure Nutrition / diet Intake of vitamins and essential nutrients Water and Food allergies Use of medications Steroids Antibiotics Vitamins Hormones Chemotherapeutic drugs Past medical history Renal and hepatic disease Collagen and other connective tissue diseases Trauma or previous surgery Food, drug or contact allergies Family medical history Diabetes mellitus Allergic disorders Blood dyscrasias Specific dermatologic problems Cancer Physical Examination Color Areas of uniform color Pigmentation Redness Jaundice Cyanosis Vascular changes Purpuric lesions Ecchymoses Petechiae Vascular lesions Angiomas Hemangiomas Venous stars Lesions Color Type Size Distribution Location Consistency Grouping Annular Linear Circular Clustered Edema (pitting or non-pitting) Moisture content Temperature (increased or decreased; distribution of temperature changes) Texture Mobility / Turgor Effects of Aging in the Skin Skin vascularity and the number of sweat and sebaceous glands decrease, affecting thermoregulation. Inflammatory response and pain perception diminish. Thinning epidermis and prolonged wound healing make elderly more prone to injury and skin infections. Skin cancer more common.

LABORATORY / DIAGNOSTIC STUDIES Blood chemistry / electrolytes: calcium, chloride, magnesium, potassium, sodium Hematologic studies Biopsy Removal of a small piece of skin for examination to determine diagnosis 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 instruct the patient to keep biopsied area dry until healing occur Skin Culture Used for microbial study Viral culture is immediately placed on ice Obtain prior to antibiotic administration Woods Light Examination Skin is viewed through a Woods glass under UV Nursing Interventions Preprocedure darken room Postprocedure assist px in adjusting to light Skin testing Administration of allergens or antigens on the surface of or into the dermis to determine hypersensitivity Types: Patch Prick Intradermal

DIAGNOSIS Impaired skin integrity Pain Body image disturbance Risk for infection Ineffective airway clearance Altered peripheral tissue perfusion

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

PLANNING AND IMPLEMENTATION Goals

Restoration of skin integrity. The patient will experience relief of pain. The patient will adapt to changes in appearance. The patient will be free from infection. Maintenance of effective airway clearance. Maintenance of adequate peripheral tissue perfusion.

Protecting grafted skin from direct sunlight for at least 6 months. Protecting graft from physical injury. Need to report changes in graft. Possible alteration in pigmentation and hair growth; ability to sweat lost in most grafts. Sensation may or may not return.

Interventions: Skin Grafts Replacement of damaged skin with healthy skin to provide protection of underlying structures or to reconstruct areas for cosmetic or functional purposes. Sources: Autograft patients own skin Isograft skin from a genetically identical person Homograft or allograft cadaver of same species Heterograft or xenograft skin from another species Nursing care: Preoperative Donor site: Cleanse with antiseptic soap the night before and morning of surgery as ordered. Recipient site: Apply warm compresses and topical antibiotics as ordered. Nursing care: Postoperative Donor site: Keep area covered for 24 to 48 hours. Use bed cradle to prevent pressure and provide greater air circulation. Outer dressing may be removed 24 to 72 hours postsurgery; maintain fine mesh gauze until it falls of spontaneously. Trim loose edges of gauze as it loosens with healing. Administer analgesic as ordered (more painful than recipient site). Recipient site: Elevate site when possible. Protect from pressure through the use of a bed cradle. Apply warm compresses as ordered. Assess for hematoma, fluid accumulation under graft. Monitor circulation distal to the graft. Provide emotional support and monitor behavioral adjustments; refer for counseling if needed. Provide client teaching and discharge planning concerning: Applying lubricating lotion to maintain moisture on the surface of healed graft for at least 6 to 12 months.

EVALUATION Healing of burned areas; absence of drainage, edema and pain. Relaxed facial expression/body posture. Changes into self-concept without negating selfesteem Achieves wound healing Lungs clear to auscultation Palpable peripheral pulses of equal quality

Disorders of the Integumentary System Primary Lesions of the Skin Macule is a small spot that is not palpable and is less than 1 cm in diameter Patch is a large spot that is not palpable & that is > 1 cm. Papule is a small superficial bump that is elevated & that is < 1 cm. Plaque is a large superficial bump that is elevated & > 1 cm. Nodule is a small bump with a significant deep component & is < 1 cm. Tumor is a large bump with a significant deep component & is > 1 cm. Cyst is a sac containing fluid or semisolid material, ie. cell or cell products. Vesicle is a small fluid-filled bubble that is usually superficial & that is < 0.5 cm. Bulla is a large fluid-filled bubble that is superficial or deep & that is > 0.5 cm. Pustule is pus containing bubble often categorized according to whether or not they are related to hair follicles: follicular - generally indicative of local infection folliculitis - superficial, generally multiple furuncle - deeper form of folliculitis carbuncle - deeper, multiple follicles coalescing Secondary lesions of the Skin Scale is the accumulation or excess shedding of the stratum corneum. Scale is very important in the differential diagnosis since its presence indicates that the epidermis is involved. Scale is typically present where there is epidermal inflammation, ie. psoriasis, tinea, eczema Crust is dried exudate (ie. blood, serum, pus) on the skin surface. Excoriation is a loss of skin due to scratching or picking. Lichenification is an increase in skin lines & creases from chronic rubbing. Maceration is raw, wet tissue.

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

Fissure is a linear crack in the skin; often very painful. Erosion is a superficial open wound with loss of epidermis or mucosa only Ulcer is a deep open wound with partial or complete loss of the dermis or submucosa Distinct Lesions of the Skin Wheal or hive describes a short lived (< 24 hours), edematous, well circumscribed papule or plaque seen in urticaria. Burrow is a small threadlike curvilinear papule that is virtually pathognomonic of scabies. Comedone is a small, pinpoint lesion, typically referred to as whiteheads or blackheads. Atrophy is a thinning of the epidermal and/or dermal tissue. Keloid overgrows the original wound boundaries and is chronic in nature. Hypertrophic scar on the other hand does not overgrow the wound boundaries. Fibrosis or sclerosis describes dermal scarring/thickening reactions. Milium is a small superficial cyst containing keratin (usually <1-2 mm in size Vascular Skin Lesions Petechiae is a round or purple macule, associated with bleeding tendencies or emboli to skin Ecchymosis a round or irregular macular lesion larger than petechiae, color varies and changes from black, yellow and green hues. Associated with trauma and bleeding tendencies. Cherry Angioma, popular and round, red or purple, may blanch with pressure and a normal age-related skin alteration. Spider Angioma is a red, arteriole lesion, central body with radiating branches. Commonly seen on face,neck,arms and trunk. Associated with liver disease, pregnancy and vitB deficiency. Telangiectasia , shaped varies: spider-like or linear, bluish in color or sometimes red. Does not blanch when pressure applied. Secondary to superficial dilation of venous vessels and capillaries. Pruritus General itching Scratching the itchy area causes the inflamed cells and nerve endings to release histamine, which produces more generating itching. Usually more severe at night and less frequently reported during waking hours., probably because the person is distracted by daily activities Occurs frequently in elderly as a result of dry skin Treatment: Topical corticosteroid as antiinflammatory agent to reduce itching. Oral antihistamines - Diphenhydramine (Benadryl) - Hydroxyzine (Atarax) Nursing Management: Tepid bath as prescribed Avoid vigorous rubbing of towel to the affected parts Avoid situations that causes vasodilation: - overly warm environment - ingestion of alcohol or hot foods/liquids

Activities causes much perspiration should be avoided. Advise wearing cotton clothing at night Avoid vigorous scratching and nails kept trimmed to prevent skin damage and infection

SECRETORY DISORDERS Hydradenitis Suppurativa Abnormal blockage of sweat gland causes recurring inflammation. Seborrheic Dermatoses Excessive production of sebum Two forms: - Oily form appears moist or greasy, There may be patches of sallow, greasy skin with slightly redness - Dry form, consisting of flaky desquamation of the scalp ( Dandruff ) Nursing Management: Avoid secondary candidal infection by cleaning carefully the affected areas . Dandruff Treatment: - Frequent shampooing with medicated shampoo - Two or three different type of shampoo should be used in rotation to prevent the seborrhea from becoming resistance to a particular shampoo. - The shampoo is left at least 5-10 min. Avoid external irritants, excessive heat and perspiration; rubbing and scratching prolong the disease Ance Vulgaris Associated with increased production of sebum from sebaceous glands at puberty. Lesions include pustules, papules and comedones. Primary lesions of acne are comedones: - Close Comedones (whiteheads), formed from impacted lipids or oil and keratin that plug the dilated follicle. - Open Comedones (blackheads), the content of ducts are in open communication with the external environment. The color result not from dirt, but from an accumulation of lipid, bacterial and epithelial debris. Majority of adolescents experience some degree of acne, mild to severe. Lesions occur mostly on face, neck, shoulders and back. Caused by variety of interrelated factors including increased activity of the sebaceous glands, emotional stress, certain medications, menstrual cycle. The inflammatory response may result from the action of certain skin bacteria such as: Propionibacterium Acnes.

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

Assessment findings: Appearance of lesions is variable and fluctuating. Systemic symptoms absent. Psychologic problems such as social withdrawal, low self-esteem, feelings of being ugly. Pharmacologic Therapy Benzoly Peroxide Oral Antibiotics: Tetracycline, Doxycycline, Minocycline Oral Retinoids: Isotretinion (Accutane) Note: commone side effect, is cheilitis inflammation of lips Hormone Therapy: Estrogen-progesterone preparation. Nursing Management: Elimination of food products associated with a flare-up of acne such as chocolate, cola and fried foods Milk products should be promoted Advise the client to wash face at least twice a day with mild soap. Provide positive reassurance, listening actively and being sensitive the feelings of the patient. Discuss over-the-counter products and their effects. Patients are instructed to avoid manipulation of pimples or blackheads. Squeezing merely worsens the problem.

Non-infected members of the household should pay special attention to areas of the skin that have been injured, such as cuts, scrapes, bug bites, areas of eczema, and rashes. These areas should be kept clean and covered to prevent infection. In addition, anyone with impetigo should cover the impetigo sores with gauze and tape. All members of the household should wash their hands thoroughly with soap on a regular basis. It is also a good idea for everyone to keep their fingernails cut short to make hand washing more effective. Contact with the infected person and his or her belongings should be avoided, and the infected person should use separate towels for bathing and hand washing. If necessary, paper towels can be used in place of cloth towels for hand drying. The infected person's bed linens, towels, and clothing should be separated from those of other family members, as well. While suffering from impetigo it is best to stay indoors for a few days to stop any bacteria getting into the blisters and making the infections worse.

FOLLICULAR DISEASES Folliculitis Is the inflammation of one or more hair follicles. Folliculitis starts when hair follicles are damaged by friction from clothing, an insect bite, blockage of the follicle, shaving or too tight braids too close to the scalp traction folliculitis. In most cases of folliculitis, the damaged follicles are then infected with the bacteria Staphylococcus Symptoms: rash (reddened skin area) pimples or pustules located around a hair follicle o may crust over o typically occur on neck, axilla, or groin area o may be present as genital lesions itching skin spreading from leg to arm to body through improper treatment of antibiotics

BACTERIAL INFECTIONS Impetigo Is a superficial bacterial skin infection most common among children 2 to 6 years old. It is primarily caused by Staphylococcus aureus, and sometimes by Streptococcus pyogenes Impetigo generally appears as honey-colored scabs formed from dried serum, and is often found on the arms, legs, or face. The infection is spread by direct contact with lesions or with nasal carriers. The incubation period is 13 days. Dried streptococci in the air are not infectious to intact skin. Scratching may spread the lesions. The lesions begin as small, red macules which quickly become discrete, thin-walled vesicles that soon ruptured and become coved with a loosely adherent honey-yellow crust. Medical Management: Topical or oral antibiotics are usually prescribed: - Benzathine penicillin - Penicillinase-Resistant- cloxacillin - Penicillin-Allergic- erythromycin Treatment may involve washing with soap and water and letting the impetigo dry in the air. Mild cases may be treated with bactericidal ointment, such as fusidic acid, mupirocin, chloramphenicol or neosporin, which in some countries may be available over-the-counter. Nursing Management: Good hygiene practices can help prevent impetigo from spreading. Those who are infected should use soap and water to clean their skin and take baths or showers regularly.

Furuncles (Boils) Is a skin disease caused by the infection of hair follicles, resulting in the localize accumulation of pus and dead tissue. The symptoms of boils are red, pus-filled lumps that are tender, warm, and extremely painful. A yellow or white point at the center of the lump can be seen when the boil is ready to drain or discharge pus. In a severe infection, multiple boils may develop and the patient may experience fever and swollen lymph nodes. A recurring boil is called chronic furunculosis. In some people, itching may develop before the lumps begin to form. Boils are most often found on the back, stomach, underarms, shoulders, face, lip, eyes, nose, thighs and buttocks, but may also be found elsewhere.

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

Sometimes boils will exude an unpleasant smell, particularly when drained or when discharge is present, due to the presence of bacteria in the discharge. The cause are bacteria such as staphylococci. Bacterial colonization begins in the hair follicles and can lead to local cellulitis and abscess formation.

VIRAL SKIN INFECTION Herpes Zoster (Shingles) Commonly known as shingles, is a viral disease characterized by a painful skin rash with blisters in a limited area on one side of the body, often in a stripe. The infection is caused by varicella zoster virus. Symptoms The earliest symptoms of herpes zoster, which include headache, fever, and malaise. These symptoms are commonly followed by sensations of burning pain, itching, hyperesthesia (oversensitivity), or paresthesia ("pins and needles": tingling, pricking, or numbness). The pain may be extreme in the affected dermatome, with sensations that are often described as stinging, tingling, aching, numbing or throbbing, and can be interspersed with quick stabs of agonizing pain. After 12 days (but sometimes as long as 3 weeks) the initial phase is followed by the appearance of the characteristic skin rash. Later, the rash becomes vesicular, forming small blisters filled with a serous exudate, as the fever and general malaise continue. The painful vesicles eventually become cloudy or darkened as they fill with blood, crust over within seven to ten days, and usually the crusts fall off and the skin heals: but sometimes after severe blistering, scarring and discolored skin remain. Medical management: Analgesics Corticosteroids Acetic acid compresses Acyclovir (Zovirax) Nursing interventions: Apply acetic acid compresses or white petrolatum to lesions Administer medications as ordered. Analgesics for pain Systemic corticosteroids: monitor for side effects of steroid therapy. Acyclovir: antiviral agent which reduces the severity when given early in illness.

Carbuncles Is an abscess larger than a boil. It is usually caused by bacterial infection, most commonly Staphylococcus aureus. The infection is contagious and may spread to other areas of the body or other people. A carbuncle is made up of several skin boils. The infected mass is filled with fluid, pus, and dead tissue. Fluid may drain out of the carbuncle, but sometimes the mass is so deep that it cannot drain on its own. Carbuncles may develop anywhere, but they are most common on the back and the nape of the neck. Men get carbuncles more often than women. Things that make carbuncle infections more likely include friction from clothing or shaving, generally poor hygiene and weakening of immunity. Nursing Management Carbuncles usually must drain before they will heal. This most often occurs on its own in less than 2 weeks. Placing a warm moist cloth on the carbuncle helps it to drain, which speeds healing. The affected area should be soaked with a warm, moist cloth several times each day. The carbuncle should not be squeezed, or cut open without medical supervision, as this can spread and worsen the infection. Treatment is needed if the carbuncle lasts longer than 2 weeks, returns frequently, is located on the spine or the middle of the face, or occurs along with a fever or other symptoms. A doctor may prescribe antibacterial soaps and antibiotics applied to the skin or taken by mouth. Deep or large lesions may need to be drained by a health professional. Proper excision under strict aseptic conditions will treat the condition effectively. Proper hygiene is very important to prevent the spread of infection. Hands should always be washed thoroughly, preferably with antibacterial soap, after touching a carbuncle. Washcloths and towels should not be shared or reused. Clothing, washcloths, towels, and sheets or other items that contact infected areas should be washed in very hot (preferably boiling) water. Bandages should be changed frequently and thrown away in a tightly-closed bag. If boils/carbuncles recur frequently, daily use of an antibacterial soap or cleanser containing triclosan, triclocarban or chlorhexidine, can suppress staph bacteria on the skin.

Herpes Simplex Virus Assessment findings: Clusters of vesicles, may ulcerate or crust Burning, itching, tingling Usually appears on lip or cheek. Nursing interventions: Keep lesions dry. Apply topical antibiotics or anesthetic as ordered.

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

Condition

Description

Illustration

Tinea Pedis athletes foot

- soles of feet have scaling and mild redness with maceration in toe webs

Infection occurs when the virus comes into Herpes labialis contact with oral mucosa or abraded skin.

- Soak feet in vinegar and water solution. - Resistant infection: griseofulvin or terbinafine - Lamisil daily for 3 months

Tinea Ungum (toenails)

Herpes genitalis

When symptomatic, the typical manifestation of a primary HSV-1 or HSV-2 genital infection is clusters of inflamed papules and vesicles on the outer surface of the genitals resembling cold sores.

- Nails thicken, crumble easily and luck cluster - whole nail maybe destroyed

- Itraconazole (sporanox)

Nursing Management Keep feet dry as much as possible, including area between the toes. Wear clothing and socks should be made of cotton Anti-fungal powder may applied twice a day to keep feet dry. Instruct the patient to always use a clean towel and washcloth daily Each person should have separate comb and hairbrush to prevent spread of tinea capitis.. Household pets should be examined.

PEDICULOSIS Parasitic infestation Adult lice are spread by close physical contact such as sharing combs, clips, caps, hats, etc. Occurs in school-age children particularly those with long hair. Medical management: Special medicated shampoos (Lindane). Use of fine-tooth comb to remove nits. Assessment findings: White eggs (nits) firmly attached to base of hair shafts. Pruritus of scalp. Nursing interventions: Institute skin isolation precautions. Use special shampoo and comb the hair. Provide client teaching and discharge planning concerning: How to check self and other family members and how to treat them. Washing of clothes, bed linens, etc.; discouraging sharing of brushes, combs and hats.

FUNGAL INFECTION Types and Location Clinical Manifestation Treatment

Tinea Capitis ( Head) - Oval, scaling, erythematous patches - small papules or pustules in scalp - brittle hair - Griseofulvin for 6 weeks - Shampoo hair 2 or 3 times with Nizoral or Selenium sulfide shampoo

Tinea Corporis (Body)

- Begins with red macule, which spreads to a ring of papules - lesions found in cluster - very pruritic

- Mild condition: Topical antifungal creams -Severe condition: Griseofulvin or Terbinafine

Contact Dermatitis Irritation of the skin from a specific substance which came in contact with the skin. Usually caused by irritants and allergens Contact dermatitis is a localized rash or irritation of the skin caused by contact with a foreign substance. Only the superficial regions of the skin are affected in contact dermatitis. Inflammation of the affected tissue is present in the epidermis (the outermost

Tinea Cruris (Groin)

- Begins with small, red scaling patches which spread to form circular elevated plaques. - very pruritic

- Mild condition: Topical antifungal creams -Severe condition: Griseofulvin or Terbinafine

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

layer of skin) and the outer dermis (the layer beneath the epidermis) Symptoms of both forms include the following: Red rash. This is the usual reaction. The rash appears immediately in irritant contact dermatitis; in allergic contact dermatitis, the rash sometimes does not appear until 2472 hours after exposure to the allergen. Blisters or wheals. Blisters, wheals (welts), and urticaria (hives) often form in a pattern where skin was directly exposed to the allergen or irritant. Itchy, burning skin. Irritant contact dermatitis tends to be more painful than itchy, while allergic contact dermatitis often itches. Nursing Interventions: Apply wet dressings of Burrows solution for 20 minutes, 4 times a day to help clear oozing lesions. Provide relief from pruritus. Administer topical steroids and antibiotics as ordered. Allowing crusts and scales to drop off skin naturally as healing occurs. Avoidance of wool, nylon, or fur fibers on sensitive skin. Need to use gloves if handling irritant or allergenic substances. Provide client teaching and discharge planning concerning: Avoidance of causative agent. Preventing skin dryness: Use mild soaps. Soak in plain water for 20 to 30 minutes. Apply prescribed steroid cream immediately after bath. Avoid extremes of heat and cold.

Nursing Interventions: Apply occlusive wraps over prescribed topical steroids. Protect areas treated with coal tar preparation from direct sunlight for 24 hours. Administer methotrexate as ordered, assess for side effects. Provide client teaching and discharge planning concerning: Feelings about changes in appearance of skin (encourage client to cover arms and legs with clothing if sensitive about appearance). Importance of adhering to prescribed treatment and avoidance of commercially advertised products.

Vitiligo Is a chronic disorder that causes depigmentation in patches of skin. It occurs when the melanocytes, the cells responsible for skin pigmentation which are derived from the neural crest, die or are unable to function. Unknown caused, but there is some evidence suggesting it is caused by a combination of autoimmune, genetic, and environmental factors. Symptom of vitiligo is depigmentation of patches of skin that occurs on the extremities. Although patches are initially small, they often enlarge and change shape. When skin lesions occur, they are most prominent on the face, hands and wrists. Depigmentation is particularly noticeable around body orifices, such as the mouth, eyes, nostrils, genitalia and umbilicus

Psoriasis Skin Cancer Is a chronic, non-contagious autoimmune disease which affects the skin and joints. It commonly causes red scaly patches to appear on the skin. The scaly patches caused by psoriasis, called psoriatic plaques, are areas of inflammation and excessive skin production. Skin rapidly accumulates at these sites and takes on a silvery-white appearance. Plaques frequently occur on the skin of the elbows and knees, but can affect any area including the scalp and genitals. Predisposing factors: Stress Trauma Infection Changes in climate Excessive alcohol consumption Smoking Familial factors Medical management: Topical corticosteroids Coal tar preparations Ultraviolet light Antimetabolites (methotrexate) Types of skin cancers: Basal cell epithelioma most common type of skin cancer; locally invasive and rarely metastasizes; most frequently located between the hairline and upper lip. Risk factors: UV rays May take several forms: nodular, ulcerative, pigmented ad superficial Hx and Assessment: Usually asymptomatic unless secondarily infected in advanced disease Pearly-colored PAPULE External surface - fine telangiectasia and is translucent Treatment: Curettage Surgical Cryosurgery Radiation prevention Mohrs micrographic surgery

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

Squamous cell carcinoma (epidermoid) grows more rapidly than basal cell carcinoma and can metastasize; frequently seen on mucous membranes, lower lip, neck and dorsum of the hands. Risk factors: UV rays Radiation Actinic keratosis Immunosuppression Industrial carcinogens History and Assessment: Slowly evolving Assymptomatic Occassionaly bleeding and pain Exophytic nodules w/ varying degree of scaling or crusting Diagnosis: Biopsy- irregular masses of anaplastic epidermal celss proliferating down to the dermis Treatment Surgical excision Mohrs micrographic surgery Radiation Malignant melanoma least frequent of skin cancers, but most serious; capable of invasion and metastasis to other organs. Risk factors: Sun exposure Fair skin Positive family history Presence of dysplastic nevi Hx and Assessment: Usually asymptomatic until late Pruritus or mild discomfort Recent changed in a previous skin lesion asymetry border irregularity color variation diameter(large) Diagnosis: Biopsy- melanocytes w/ marked cellular atypia and melanocytic invasion of the dermis Treatment: Surgical excision Chemotherapy- metastasis

BURNS Direct tissue injury due to: o Thermal: scald, hot grease, sunburn, contact with flames o Electrical o Chemical o Smoke inhalation: fumes, gasses, smoke I. TYPES A. Full thickness 1. First degree burns (superficial) Epidermis Common cause is thermal burn (+) blanching upon pressure and erythema (+) pain 2. Second degree burns (deep burn) Chemical (+) very painful (+) erythema or fluid filled blisters B. Partial thickness 1. Third to fourth degree burns Affect all layers of skin, muscle and bones Electrical burns Less painful than 1st and 2nd degree burns Dry, thick, leathery texture Eschar devitalized tissue A description of the traditional and current classifications of burns.

Nomenclature

Traditional nomenclature

Depth

Clinical findings

Superficial thickness

First-degree

Epidermis involvement

Erythema, minor pain, lack of blisters

Partial thickness superficial

Superficial Second-degree (papillary) dermis

Blisters, clear fluid, and pain

Precancerous lesions: Leukoplakia white shiny patches in the mouth or on the lip. Nevi (moles) junctional nevus may become malignant; compound and dermal nevi unlikely to become cancerous. Senile keratoses brown, scale-like spots on older individuals. Partial thickness deep Deep Second-degree (reticular) dermis

Whiter appearance

Nursing interventions: Limitation of contact with chemical irritants. Need to report lesions that change characteristics and/or those that do not heal. Protection against UV rays from the sun Wear thin layer of clothing. Use sunblock or lotion containing PABA.

Full thickness

Third- or Fourthdegree*

Dermis and underlying tissue and possibly fascia, bone, or muscle

Hard, leather-like eschar, purple fluid, no sensation (insensate)

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

10

C.

STAGES 1. Emergent removal of client from source of burn Thermal smother burn beginning with the head. Smoke inhalation ensure patent airway. Chemical remove clothing that contains chemical; lavage are with copious amounts of water. Electrical note victim position, identify entry and exit routes; maintain airway. Wrap in dry, clean sheet or blanket to prevent further contamination of wound and to provide warmth. Assess how and when burn occurred. Provide IV route if possible. Transport immediately. 2. Shock phase (24-48 hours) shifting of fluids from intravascular to interstitial hypovolemia Elevated HCT Tachycardia Metabolic acidosis Low serum sodium Low serum potassium Hypotension Diuresis Phase/Fluid remobilization phase characterized by the return of fluids from interstitial to intravascular Assessment findings: Elevated blood pressure, increased urine output. Hypokalemia, hyponatremia, metabolic acidosis Convalescent/Recovery phase characterized by continuous wound healing Healing starts immediately after injury Assessment findings: Elevated blood pressure, increased urine output. Hypokalemia, hyponatremia, metabolic acidosis

2.

3.

4. F.

Wound care: Hydrotherapy Debridement (enzymatic or surgical) Drug therapy: Topical antibiotics Systemic antibiotics Tetanus toxoid or hyperimmune human tetanus globulin Analgesics Surgery: excision and grafting

NURSING MANAGEMENT 1. Administer medications as ordered Tetanus toxoid Burn surface area is a good source of microbial growth CLOSTRIDIUM TETANY Tetanospain Tatanolysin Narcotic analgesics morphine Systemic antibiotics Cephalosporins Penicillin Tetracyclines Topical antibiotics Silver sulfadiazide Silver nitrate Povidone iodine Provide relief/control of pain: Administer morphine sulfate and monitor vital signs closely. Administer analgesics/narcotics 30 minutes before wound care. Position burned areas in proper alignment. Monitor alterations in fluid and electrolyte balance: Assess for fluid shifts and electrolyte alterations. Administer IV fluids as ordered. Monitor Foley catheter output hourly (30 ml/hr desired). Monitor balance: alterations in fluid and electrolyte Weigh daily. Monitor circulation status regularly. Administer/monitor crystalloids/colloids/water solutions.

3.

2.

4.

3.

4.

D.

ASSESSMENT FINDINGS 1. Rule of 9s Head and neck = 9 Anterior chest = 18 Posterior chest = 18 Upper extremity = 9 x 2 Lower extremity = 18 x 2 Genital = 1 2. Severity of burns: Major: partial thickness greater than 25%; full thickness greater than or equal to 10%. Moderate: partial thickness 15%-25%; full thickness less than 10%. Minor: partial thickness less than 15%; full thickness less than 2%.

5.

Formula in IVF administration: Evans Formula: Colloids: 1 ml x wt (kg) x % BSA burned Electrolytes (saline): 1 ml x wt (kg) x % BSA burned Glucose (D5W): 2000 ml for insensible loss. Day 1: half to be given in 1st 8 hours; remaining half over next 16 hours. Day 2: half of previous days colloids and electrolytes; all of insensible fluid replacement. Maximum of 10 L over 24 hours.

E.

MEDICAL MANAGEMENT: 1. Supportive therapy: IV fluid management, catheterization

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

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Second and third-degree burns exceeding 50% BSA calculated on basis of 50% BSA Brooke Army Formula: Colloids: 0.5 ml x wt (kg) x % BSA burned Electrolytes (lactated Ringers): 1.5 ml x wt (kg) x % BSA burned Glucose (D5W): 2000 ml for insensible loss Day 1: Half to be given in first 8 hours, remaining half over next 16 hours. Day 2: Half of colloids, half of electrolytes, all of insensible fluid replacement. Second and third-degree burns exceeding 50% BSA calculated on basis of 50% BSA Parkland/Baxter Formula: Lactated Ringers: 4 ml x wt (kg) x % BSA burned Day 1: Half to be given in first 8 hours; half to be given over next 16 hours. Day 2: Varies; colloid is added. Consensus Formula: Lactated Ringers: 2-4 ml x wt (kg) x % BSA burned Half to be given in first 8 hours after burn; remaining fluid to be given over next 16 hours. 6. Prevent wound infection. Place the patient in a controlled sterile environment. Maintain strict aseptic technique Use hydrotherapy for no more than 30 minutes to prevent electrolyte loss. Observe wound for separation of eschar and cellulitis. Apply mafenide (sulfamylon) as ordered: Administer analgesics 30 minutes before application. Monitor acid-base status and renal function studies. Provide daily tubbing for removal of previously applied cream. Apply silver sulfadiazine as ordered. Administer analgesics 30 minutes before application. Observe and report hypersensitivity reactions. Store drug away from heat. Apply silver nitrate as ordered. Handle carefully: solution leaves gray or black stain on skin, clothing and utensils. Administer analgesics 30 minutes before application. Keep dressings wet with solution; dryness increases the concentration and causes precipitation of silver salts in the wound. Apply povidone-iodone ordered. solution as

Administer analgesics before application. Assess for metabolic acidosis/renal function studies. Administer gentamicin as ordered: assess vestibular/auditory and renal functions at regularly intervals.

7.

Promote maximal nutritional status: Diet high in CHO, CHON, VIT C Monitor tube feedings/TPN if ordered. When oral intake permitted, provide highcalorie, high-protein, high carbohydrate diet with vitamin and mineral supplements. Serve small portions. Schedule wound care and other treatments at least 1 hour before meals. Prevent GI complications: Assess for signs and symptoms of paralytic ileus. Assist with insertion of NGT to prevent/control Curlings/stress ulcer; monitor patency/drainage. Administer prophylactic antacids through NGT and/or IV cimetidine or ranitidine. Monitor bowel sounds. Test stools for occult blood. If (+) to burn of the head and neck and face Assist in intubation Assist in hydrotherapy Assist in surgical wound debridement Analgesics before debridement Prevent complications Infections Septicemia Paralytic ileus Curlings ulcers (H2 receptor antagonists) Assist in surgical procedure

8.

9. 10. 11. 12.

13.

14. Provide client teaching and discharge planning concerning: Care of healed burn wound Assess daily for changes. Wash hands frequently during dressing change. Wash area with prescribed solution or mild soap and rinse well with water; dry with clean towel. Apply sterile dressing. Prevention of injury to burn wound. Avoid trauma to area. Avoid use of fabric softeners or harsh detergents (might cause irritation). Avoid constrictive clothing over burn wound. Adherence to prescribed diet. Importance of reporting formation of local trophic changes. Methods of coping and resocialization.

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

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Wound Healing Process

Wound healing, or wound repair, is an intricate process in which the skin (or some other organ) repairs itself after injury. In normal skin, the epidermis (outermost layer) and dermis (inner or deeper layer) exists in a steadystated equilibrium, forming a protective barrier against the external environment. Once the protective barrier is broken, the normal (physiologic) process of wound healing is immediately set in motion The classic model of wound healing is divided into three or four sequential, yet overlapping, phases: (1) hemostasis (2) inflammatory, (3) proliferative and (4) remodeling

C. Proliferative Phase Fibroblasts begin to enter the wound site, marking the onset of the proliferative phase even before the inflammatory phase has ended. Angiogenesis occurs concurrently with fibroblast proliferation when endothelial cells migrate to the area of the wound. The tissue in which angiogenesis has occurred typically looks red (is erythematous) due to the presence of capillaries Fibroblasts mainly proliferate and migrate, while later, they are the main cells that lay down the collagen matrix in the wound site. Fibroblasts begin secreting appreciable collagen. Collagen deposition is important because it increases the strength of the wound; before it is laid down. Formation of granulation tissue in an open wound allows the reepithelialization phase to take place, as epithelial cells migrate across the new tissue to form a barrier between the wound and the environment D. Remodeling Phase When the levels of collagen production and degradation equalize, the maturation phase of tissue repair is said to have begun. The maturation phase can last for a year or longer, depending on the size of the wound and whether it was initially closed or left open. During Maturation, type III collagen, which is prevalent during proliferation, is gradually degraded and the stronger type I collagen is laid down in its place

A. Homostasis Within minutes post-injury, platelets (thrombocytes) aggregate at the injury site to form a fibrin clot. This clot acts to control active bleeding (hemostasis) B. Inflammatory Phase When tissue is first wounded, blood comes in contact with collagen, triggering blood platelets to begin secreting inflammatory factors. Platelets, release a number of things into the blood, including ECM proteins and cytokines, including growth factors.Growth factors stimulate cells to speed their rate of division. Platelets also release other proinflammatory factors like serotonin, bradykinin, prostaglandins, prostacyclins, thromboxane, and histamine, which cause blood vessels to become dilated and porous. The main factor involved in causing vasodilation is histamine. Histamine also causes blood vessels to: Increased Capillary Permeability causes hyperemia that leads to redness (rubor) and presence of heat (calor) and Fluid and cellular exudation that causes edemaand presence of exudates Within an hour of wounding, polymorphonuclear neutrophils (PMNs) arrive at the wound site and become the predominant cells in the wound for the first two days after the injury occurs.They also cleanse the wound by secreting proteases that break down damaged tissue. Neutrophils usually undergo apoptosis once they have completed their tasks and are engulfed and degraded by macrophages The macrophage's main role is to phagocytise bacteria and damaged tissue and it also debrides damaged tissue by releasing proteases. Macrophages also secrete a number of factors such as growth factors and other cytokines, especially during the third and fourth post-wounding days. These factors attract cells involved in the proliferation stage of healing to the area

Primary Intention: When wound edges are directly next to one another Little tissue loss Minimal scarring occurs Most surgical wounds heal by first intention healing Wound closure is performed with sutures, staples, or adhesive at the time of initial evaluation Secondary Intention: The wound is allowed to granulate Surgeon may pack the wound with a gauze or use a drainage system Granulation results in a broader scar Healing process can be slow due to presence of drainage from infection Wound care must be performed daily to encourage wound debris removal to allow for granulation tissue formation Tertiary Intention (Delayed primary closure):

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

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The wound is initially cleaned, debrided and Pressure Ulcer Lesion from unrelieved pressure causing damage of underlying tissue or a localized area of cellular necrosis resulting from vascular insufficiency in tissues under pressure Occurs with limited mobility Once formed, pressure ulcers are slow to heal Result from mechanical forces Occurs most often over bony prominences

observed, typically 4 or 5 days before closure

Stage II

Skin breaks Abrasion, blister or shallow crater Edema persists Ulcer drains Infection may develop Ulcer extends into subcutaneous tissue Necrosis and drainage continue Infection develops Ulcer extends to underlying muscle and bone. Deep pockets of infection develop Necrosis and drainage continue

Stage III

Stage IV

Pressure Ulcers: Key Things to Remember Pressure Points Mechanical Forces Pressure Friction Shear Pressure relieving/reducing devices do not take the place of observation of skin color, integrity, and temperature at intervals to determine capillary blood flow. In some clients pressure can occur in less than 2 hours the actual turning/repositioning schedule should be individualized based upon assessment data

Risk Factors for Developing Pressure Ulcer Prolong pressure on tissue Immobility, compromised mobility Loss of protective reflexes Poor skin perfusion Edema Malnutrition Friction Shearing forces Trauma Incontinence of urine and feces Altered skin moisture Excessively dry skin Advance age Equipment: cast,traction and restraints

Pressure Ulcers: Nursing Diagnosis Impaired skin integrity Pain Disturbed body image Ineffective coping Imbalanced nutrition: less than body requirements Deficient knowledge

Nursing Intevention Prevention of Pressure: o Turned and repositioned at 1-2 hours interval o Encourage to shift weight actively every 15 minutes o Pressure relief and reduction devices: Dynamic vs. Static Frequent monitoring of ulcer progress Avoid massaging reddened areas, because this may increase the damage To avoid shearing forces when repositioning the patient, the nurse lifts and avoid dragging the patient across a surface Increase protein intake, iron, vitamin C Prevention of infection and wound extension o Be alert for classic signs of wound infection o Prevent further pressure damage Maintaining a safe environment o Meticulous local wound care o Minimize cross-contamination with pathogens o Standard precautions o Thorough handwashing before and after dressing changes

Pressure Ulcers: Wound Assessment Appearance changes with the depth of injury Assess for: Location, size, color Extend of tissue involvement Condition of surrounding tissue Presence of foreign bodies

Stages of Ulcer

Stage I

Area of erythema Erythema does not blanch with pressure Skin temperature elevated Tissue are swollen Patient complains of discomfort Erythema progresses to dusky blue-gray

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

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Anatomy of the Skin

Hair / Hair Growth

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

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Nail

Skin Testing

Woods Light Examination

Skin Grafting

Secondary Skin Lesion

Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN,MAN

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Burn Rule of Nine

Phases of Wound Healing