Integumentary system

Ruby Ruth Roces, R.N.,

M.D.
Anatomy and Physiology
 Epidermis

B-asale
S-pinosum
G-ranulosum
L-ucidum-found in regions w/ thick
corneum
C-orneum
- Cells of the epidermis are composed
of keratinocytes, melanocytes,
langerhans cell, merkels cells
 Dermis

 Hypodermis-fastens skin to
underlying structures
 Cutaneous appendages
B. Eccrine sweat glands-not viscous,
controlled by cholinergic
C. Appocrine sweat glands-
vicous,odor-producing, controlled
by adrenergic, do not function till
puberty
D. Sebaceous glands- functions for
lubrication of hair and skin,
hormonal contol
 Hairs

 Nails
 History and Assessment
 C-haracter

 L-ocation

 I-ntensity

 T-ime

 A-asso.factors
 A-ggravating factors
 Macule-flat, circumscribed ,different color
 Patch- macule>2 cm

 Papule-elevated, circumscribed,<1 cm

 Nodule->1 cm

 plaque,-elevated, flat topped,>1 cm

 Vesicle-sharply marginated,elevated,w/
fluid, <1 cm
 Bullae- vesicular lesion > 1cm
 Scale- flaky accumulation of excess
keratin
 Crust- collection of inflammatory
cells and dried serum
 Excoriations- linear, angular
erosions,2 to scratching, loss of
epidermis
 Ulcer- deeper erosion, loss of
epidermis and papillary dermis
 Lichenification-thickening of skin 2 to
chronic rubbing
 Diagnostic Tests
1) Skin Biopsy
 Punch, excisional, incisional &
shave

Nursing Interventions
Preprocedure - Secure consent
- clean site
 Postprocedure – place specimen in a
clean container & send to pathology
laboratory
– use aseptic technique
for biopsy site dressing, assess site
for bleeding & infection
– instruct px to keep
dressing in place for 8hrs & clean site
daily
 Diagnostic Tests
2) Skin Culture
 Used for microbial study

 Viral culture is immediately placed

on ice
 Obtain prior to antibiotic
administration
3) Wood’s Light Examination
 Skin is viewed through a Wood’s
glass under UV

Nursing Interventions
Preprocedure – darken room
Postprocedure – assist px in adjusting
to light
 Diagnostic Test
1) Skin Testing
 Administration of an allergen by
patch, scratch, or ID techniques

Nursing Interventions
Preprocedure – d/c systemic
steroids or antihistamines 48º
prior, consent, ready
resuscitation equipments
Postprocedure
– keep skin-patch area dry
– instruct to avoid activities
which can increase sweating if
doing a patch test
– record site, date, time of test,
ff-up & reading
INTEGUMENTARY
DISORDERS
 Skin cancer
Etiology :
– chronic friction, irritation & exposure
to UV

Types:
1. basal cell – most common
2. squamous cell
3. malignant melanoma – most fatal
 Squamous cell Carcinoma
Risk factors:
 UV rays

 Radiation

 Actinic keratosis

 Immunosuppression

 Industrial carcinogens
 Squamous cell Carcinoma
History and Assessment:
 Slowly evolving

 Assymptomatic

 Occassionaly bleeding and pain

 Exophytic nodules w/ varying degree

of scaling or crusting
 Squamous cell Carcinoma
Diagnosis:
 Biopsy- irregular masses of
anaplastic epidermal celss
proliferating down to the dermis
 Squamous cell Carcinoma
Treatment
 Surgical excision

 Mohr’s micrographic surgery

 Radiation

 prevention-
 Basal Cell Carcinoma
Risk factors:
 UV rays

 May take several forms: nodular,

ulcerative, pigmented ad superficial
 Basal Cell Carcinoma
Hx and Assessment:
 Usually asymptomatic unless
secondarily infected in advanced
disease
 Pearly-colored PAPULE

 External surface - fine telangiectasia

and is translucent
 Basal Cell Carcinoma
Diagnosis:
 Biopsy- basophilic palisading cells
 Basal Cell Carcinoma
Treatment:
 Curettage

 Surgical

 Cryosurgery

 Radiation

 prevention

 Mohr’s micrographic surgery

 Melanoma
Risk factors:
 Sun exposure

 Fair skin

 Positive family history

 Presence of dysplastic nevi

 Melanoma
Hx and Assessment:
 Usually asymptomatic until late
 Pruritus or mild discomfort
 Recent changed in a previous skin
lesion
 A- asymetry
 B- border irregularity
 C- color variation
 D- diameter(large)
 Melanoma
Diagnosis:
 Biopsy- melanocytes w/ marked
cellular atypia and melanocytic
invasion of the dermis
 Melanoma
 Treatment:

 Surgical
excision
 Chemotherapy- metastasis
 Skin Cancer
Interventions:
a. preventive measures
b. monitoring of any lesion
c. have moles or lesions removed if they
are subject to chronic irritation
d. avoid contact with chemical irritants
e. use of sunscreen
f. avoid too much sun exposure
 Actinic Keratosis
Risk Factor:
 Sun exposure

Hx and assessment:
 Asymptomatic unless irritated

 Discrete, rough scaling patches and

papules
 Actinic Keratosis
Diagnosis:
 Biopsy- dysplastic squamous
epithelium w/o invasion
Treatment:
 Topical 5-Fu

 Cryosurgery

 Curettage

 Chemical peel

 prevention
 Contact dermatitis
Etiology:
– inflammatory response to contact
of an allergen
- any substance w/c the patient has
been previously sensitized
 Contact Dermatitis
Hx and Assessment:
a. Pruritus
b. Burning
c. Edema
d. Erythema
e. signs of infection
f. vesicles with drainage
 Contact Dermatitis
 Diagnosis:
2. Hx and PE
3. Biopsy- eosinophils
4. Patch test
 Contact Dermatitis
 Treatment:

2. Antihistamines

3. Prophylactic antibiotics
4. Topical steroids
Interventions:
a. elevate to reduce edema
b. Cold compress
c. prevent scratching
d. assist in skin testing
e. use hypoallergenic materials
f. administer antibiotics,
antipruritics, steroids
 psoriasis
Etiology:
– chronic, non-infectious
inflammation involving keratin
synthesis caused by stress, trauma
& infection
Koebner’s phenomenon –
development of a lesion at a site of
injury e.g. scratch
 Psoriasis
Assessment:
a. Pruritus
b. silvery white scales on a round
reddened plaque usually affecting
scalp, knees, elbows, extensor
surfaces of arms & legs & sacral
regions
c. Joint inflammation with Psoriatic
arthritis
 psoriasis
Management:
• Topical pharma therapy
(tar,anthralin, salicylic acid,
retinoid compound, corticosteroid)
• Intralesional therapy
(triamcinolone acetonide)
• Systemic therapy (methotrexate,
cephalosporins)
• Photochemotherapy (psoralens +
UV light)
Bacterial
Viral
Fungal
parasitic
 Lyme Disease
Etiology:
– spirochete Borrelia burgdorferi
(tick bite)

Assessment:
1st stage
- Small red pimple
- Ring shaped
- Flu-like symptoms
Interventions:
a. daily soaks & tepid H20 compress
b. remove scales
c. use of emolients
d. instruct px not to scratch area
e. check s/sxs of infection
f. use light cotton clothing
g. Assist in ways to reduce stress
2nd stage
- Neuro complications
- Cardiac complications
- Joint pain
3rd stage
- Large joints involved
- Arthritis progress
 Diagnosis:

- Hx and PE
- Antibody test

- Treatment:
- Penicillin
 Impetigo

 Etiology:
- Staphylococcus or B-hemolytic
streptococcus
 Impetigo
 Assessment:

- papule---pustule---vesicles---crust
- Characteristic honey colored crusts
- fever
 Impetigo
Treatment:
 topical antibiotics

 Oral antibiotics
Interventions
 Keep area clean

 Implement contact precaution

 Administer meds as prescribed

 Erysipelas & Cellulitis

Erysipelas
– inflammation, acute, superficial, rapidly
spreading caused by B-hemolytic
Streptococcus

Cellulitis
– inflammation/infecton of deeper dermis
usually caused by Streptococcus &
Staphylococcus
 Assessment:

- Swelling or edema
- Redness
- Pain or tenderness
- Fever
 Treatment:

- IV antibiotics ( penicillin, cloxacillin)

- antipyretics
- Elevate affected area
 Staphylococcal infections
 Folliculitis- infection of hair follicle
 Furuncle

 Carbuncle
 Staphylococcal infections
 Assessment:

- Papule, pustule, nodule, node, cyst

- Fever
- Pain and tenderness
 Staphylococcal infections
Treatment:
- Incision and drainage

- Antibiotics

- antipyretics
 Acne vulgaris

Etiology:
- Propiniobacterium acne

Assessment:
- Papule

- Pustule

- nodule
 Acne vulgaris
Management:
 Topical

- Benzoyl peroxide
- Retinol
 Intralesional therapy
 systemic

- Tetracycline
- clindamycin
 Chickenpox
Etiology
 VZV

 Mode of transmission- droplet or skin

lesion contact
 Incubation- 10-20 days
 Chickenpox
 Hx and Assessment
 Hx of exposure

 Prodrome of malaise, fever, HA and

myalgia- 24 hrs before onset of rsh
 Pruritic lesions in crops

 Pink-red macules---central
vesicles---crusting
 Chickenpox
 Treatment:

 Self-limitedin healthy children

 Adults- uncomplicated- oral acyclovir

 Immunocompromised- IV acyclovir

 Vaccine- prevention
 HZ (Shingles)
Etiology:
– VZV, reactivation of VZV from the
dorsal root ganglia
 HZ (shingles)
Assessment:
a. dermatomal distribution of vesicles
b. Neuralgia
c. Fever
 HZ (shingles)
Diagnosis: Culture
Interventions:
a. Isolate
b. assess neurovascular status
c. Keep area clean and dry
d. Give analgesics as ordered
 Herpes Simplex
Etiology
 Oral form- HSV 1

 Cenital form- HSV 2

 Herpes simplex
Hx and Assessment:
 1 Eruption- more severe, longer-
lasting
- Acccompanied by LAD, fever,
malaise and edema
 Recurrent- limited to mucocutaneous
are innervated by involved nerve
- Tingling, burning sensation
precedes the lesion
 Herpes simplex
 Grouped vesicle on an erythematous bases
 Herpes simplex
Diagnosis:
 Culture- definitive
 tzanck smear- multinucleated giant
cells

Treatment:
 Topical
 Oral/IV acyclovir
 Molluscum Contangiosum
Etiology:
 Poxvirus

 Common in young children and in

AIDS patients
 Molluscum Contangiosum
HX and Assessment:
 Asymptomatic unless inflamed

 Discrete dome-shaped, shiny pauples

w/ central umbilication
 2-5 mm in diameter

 In children- trunk

 In adults- perianal and perigenital

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

 Liquid nitrogen cryotherapy

 Tricloroacetic acid
 Tinea
Etiology:
- dermatophytes, yeasts

Tinea capitis- fungal infection of scalp

Tinea corporis- fungal infection of the
body
Tinea cruris- fungal infection of the
inguinal area
Tinea pedis- foot
Tinea inguinum- nails
 Assessment:

- Circular, annular, plaques,

- hypo/hyperpigmented
- Scaling and erythematous plaques
- pruritic
 Tinea
 Diagnosis:

- KOH smear
- Woods light exam

- Treatment:
- Topical/oral antifungals
Interventions
 Keep area clean and dry

 Do not scratch

 Proper hygiene

 Cut off nails or trim nails

(onychomycosis)
 Candidal Intertrigo
Predisposing factors:
 Obesity

 DM

 Recent antibiotic therapy

 Warm, moist environment

 Candidal Intertrigo
Hx and Assessment:
 Pruritus

 Pain

 Well-demarcated, beefy-red,
erythematous patches surrounded by
satellite pustules
 Restricted to intertriginous areas

 In infants- diaper rash

 Candidal Intertrigo
Diagnosis:
 KOH smear of scrapings-
pseudohyphae and yeasts forms
 Candidal Intertrigo
Treatment:
 Topical antifungal +/- low- potency
steroid
 Reduce moisture

 Reduce friction through weight loss

 Pityriasis versicolor
 Etiology:

 Malassezia furfur
 Pityriasis versicolor
Hx and assessment
 Usually asymptomatic

 Mild itching

 Small, scaling Macules that enlarges

and coalesce
 Pinkish, lightly pigmented,
hypopigmented
 Pityriasis Versicolor
Diagnosis
 KOH- short, blunt hyphae and small
spores
 Wood’s light exam
 Pityriasis versicolor
 Treatment:

 Topical antifungal- resolution in 2-3

wks
 Seleniium sulfide shampoo- 1-3x/wk;
leave for 10 mins and scrub off
 Systemic antifungals- sever cases
 Scabies
Etiology:
– caused by parasite Sarcoptes
scabiei
– there is 1 mos delay from
exposure to onset of pruritus
 Scabies
Assessment:
• Erythematous papules & pustules
• Threadlike brownish linear
burrows
• 2ndary lesions (crust, vesicles,
nodules & excoriations)
• Intense pruritus that worsens at
night
Interventions:
• Antihistamines
• Topical antiscabies (Lindane) – not
to be used on <2y/o (neurotoxic)
• Treat close contact
• All beddings & clothes should be
washed in very hot water
 Frostbite

Assessment:
a. Numbness
b. Paresthesia
c. Pallor
d. severe pain
e. necrosis & gangrene may develop
Interventions:
a. rewarm rapidly & continuously for 15
to 20 mins or until skin flushing occurs
b. Avoid slow thawing, interrupted
periods of warmth or massage
c. Do not debride blisters
 Burns
types:
thermal
chemical
electrical
radiation
Classification:
• Superficial – mild to moderate
erythema, no blisters, pain eased
by cooling
• Partial thickness – (+) blisters,
edema, painful, injured are
sensitive to cold air
• Full thickness – injured space
appears dry, fat exposed, little or
no pain
 Disorders
Methods of estimating extent of injury
Rule of 9’s
 Head & Neck 9%
 Anterior trunk 18%
 Posterior trunk 18%
 Arms 18%
 Legs 36%
 Perineum 1%
Management:
• Emergent phase – time of injury 
restoration of capillary permeability
(48% – 72%)
1º goal is prevent hypovolemic shock
Prehospital care
1. remove victim from source
2. ABC
3. Assess for trauma
4. Cover wounds with clean cloth
5. Remove jewelries
6. Need for IV ?
7. Transport
ER care - continuation of care
• Resuscitative phase – initiation of
fluids  capillary integrity near
normal
- Fluid resuscitation
- pain management
- escharotomy
- fasciotomy
- nutrition
a. Acute phase – hemodynamically
stable  restored capillary
permeability
- wound care
- debridement
- wound closure
- PT
Autografting
care of graft site
a.Elevate & immobilize
b.Keep free from pressure
c. Check for infection
d.Instruct client to protect
affected area from sunlight
e.Use splints & support garment
a. Rehabilitative phase
goals – promote wound healing
– minimize deformities
– increase strength &
function
– provide psychological
& emotional support
 Lichen planus
Etiology:
- unknown, idiopathic, drugs(gold),
HLA asso predisposition

- acute, chronic involving skin &

mucous memb.
Assessment:
4 Ps-
 Purple
 Polygonal
 Pruritic
 Papule

Treatment:
 cyclosporine
 steroids
 Erythema multiforme
 EM minor- no mucus involvement,
extensor surfaces
 EM major-

 SJS and TEN-necrotizing

tracheobronchitis, renal tubular
necrosis, meningitis
 Erythema Multiforme
Etiology:
Immune mediated reaction due to
 Drugs

 Infection

 Vaccination

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

 Clinical
Hx of exposure
 Elevated eosinophils
 Erythema Multiforme
 Treatment:

 mild cases- resolve spontaneously

 Identify the cause

 Severe forms- corticosteroids and

analgesia
 SJS- rehydration
3. Steven johnsons syndrome is
managed thru
b. Antibiotics

c. Steroids

d. Identifying the cause

e. All of the above

4.A 15 y.o. patient was diagnosed w/
lichen planus. This disorder is
characterized by except
b. A purple papule

c. Pruritus

d. Polygonal lesion

e. patch
5. A patient was involved in a fire
accident and sustained burns. Half of
her anterior face and neck, whole left
arm and anterior chest was involved.
Compute for the estimated burn area
using rule of nines.
6. Scabies is caused by a
b. Parasite

c. Protozoan

d. Bacteria

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

e. Avoid massage