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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 Beau’s 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.
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 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 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 . magnesium. chloride. 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.clean site Postprocedure – place specimen in a clean container & send to pathology laboratory use aseptic technique for biopsy site dressing. Inflammatory response and pain perception diminish. Skin cancer more common.MAN 2 ASSESSMENT Health History Presenting problem Changes in the color and texture of the skin. potassium. LABORATORY / DIAGNOSTIC STUDIES Blood chemistry / electrolytes: calcium.Secure consent . Abejo RN. affecting thermoregulation. distribution of temperature changes) Texture Mobility / Turgor Effects of Aging in the Skin Skin vascularity and the number of sweat and sebaceous glands decrease. 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.Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. hair and nails. sodium Hematologic studies Biopsy Removal of a small piece of skin for examination to determine diagnosis Nursing Interventions Preprocedure . Thinning epidermis and prolonged wound healing make elderly more prone to injury and skin infections.
Cyst is a sac containing fluid or semisolid material. Vesicle is a small fluid-filled bubble that is usually superficial & that is < 0.deeper. blood. Maceration is raw. Nodule is a small bump with a significant deep component & is < 1 cm. psoriasis.superficial. Provide emotional support and monitor behavioral adjustments. Administer analgesic as ordered (more painful than recipient site). multiple follicles coalescing Secondary lesions of the Skin Scale is the accumulation or excess shedding of the stratum corneum. Nursing care: Postoperative Donor site: Keep area covered for 24 to 48 hours.5 cm. Apply warm compresses as ordered. Tumor is a large bump with a significant deep component & is > 1 cm.deeper form of folliculitis carbuncle . Protect from pressure through the use of a bed cradle. pus) on the skin surface. serum. The patient will experience relief of pain. Monitor circulation distal to the graft. The patient will adapt to changes in appearance. Pustule is pus containing bubble often categorized according to whether or not they are related to hair follicles: follicular . tinea. ie. Possible alteration in pigmentation and hair growth. Excoriation is a loss of skin due to scratching or picking. Assess for hematoma. Recipient site: Elevate site when possible. EVALUATION Healing of burned areas. Outer dressing may be removed 24 to 72 hours postsurgery. Lichenification is an increase in skin lines & creases from chronic rubbing. Maintenance of effective airway clearance. ie. Protecting graft from physical injury. ability to sweat lost in most grafts. Scale is typically present where there is epidermal inflammation.5 cm. wet tissue. Need to report changes in graft. generally multiple furuncle . eczema Crust is dried exudate (ie. 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. 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. refer for counseling if needed. Abejo RN. Sensation may or may not return. edema and pain. fluid accumulation under graft. Relaxed facial expression/body posture. Trim loose edges of gauze as it loosens with healing. absence of drainage. Sources: Autograft – patient’s 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. Bulla is a large fluid-filled bubble that is superficial or deep & that is > 0.MAN 3 PLANNING AND IMPLEMENTATION Goals Restoration of skin integrity. The patient will be free from infection.generally indicative of local infection folliculitis . . cell or cell products. 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. Protecting grafted skin from direct sunlight for at least 6 months.Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. maintain fine mesh gauze until it falls of spontaneously. Maintenance of adequate peripheral tissue perfusion. Use bed cradle to prevent pressure and provide greater air circulation. Plaque is a large superficial bump that is elevated & > 1 cm. Scale is very important in the differential diagnosis since its presence indicates that the epidermis is involved. Recipient site: Apply warm compresses and topical antibiotics as ordered.
Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Secondary to superficial dilation of venous vessels and capillaries. central body with radiating branches. Oral antihistamines . the content of ducts are in open communication with the external environment. Lesions occur mostly on face. . consisting of flaky desquamation of the scalp ( Dandruff ) Nursing Management: Avoid secondary candidal infection by cleaning carefully the affected areas . Hypertrophic scar on the other hand does not overgrow the wound boundaries. Pruritus General itching Scratching the itchy area causes the inflamed cells and nerve endings to release histamine.Two or three different type of shampoo should be used in rotation to prevent the seborrhea from becoming resistance to a particular shampoo. There may be patches of sallow. Milium is a small superficial cyst containing keratin (usually <1-2 mm in size Vascular Skin Lesions Petechiae is a round or purple macule. may blanch with pressure and a normal age-related skin alteration.overly warm environment . certain medications. 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. Keloid overgrows the original wound boundaries and is chronic in nature. 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.Close Comedones (whiteheads). Cherry Angioma. Seborrheic Dermatoses Excessive production of sebum Two forms: . excessive heat and perspiration. The inflammatory response may result from the action of certain skin bacteria such as: Propionibacterium Acnes. pinpoint lesion. popular and round. Primary lesions of acne are comedones: . menstrual cycle. The color result not from dirt. rubbing and scratching prolong the disease Ance Vulgaris Associated with increased production of sebum from sebaceous glands at puberty.ingestion of alcohol or hot foods/liquids Activities causes much perspiration should be avoided. mild to severe. shaped varies: spider-like or linear. Majority of adolescents experience some degree of acne. Associated with liver disease. Avoid external irritants. bluish in color or sometimes red. . Dandruff Treatment: . Abejo RN.Frequent shampooing with medicated shampoo .Diphenhydramine (Benadryl) .Oily form appears moist or greasy. yellow and green hues.. Burrow is a small threadlike curvilinear papule that is virtually pathognomonic of scabies. red or purple.Hydroxyzine (Atarax) Nursing Management: Tepid bath as prescribed Avoid vigorous rubbing of towel to the affected parts Avoid situations that causes vasodilation: . papules and comedones.Dry form.neck. Associated with trauma and bleeding tendencies.” Atrophy is a thinning of the epidermal and/or dermal tissue. Lesions include pustules. which produces more generating itching. . 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). shoulders and back. Does not blanch when pressure applied. but from an accumulation of lipid. color varies and changes from black. pregnancy and vitB deficiency. associated with bleeding tendencies or emboli to skin Ecchymosis a round or irregular macular lesion larger than petechiae. Fibrosis or sclerosis describes dermal scarring/thickening reactions. typically referred to as “whiteheads” or “blackheads.The shampoo is left at least 5-10 min. greasy skin with slightly redness . emotional stress.Open Comedones (blackheads). Spider Angioma is a red. Telangiectasia . neck. formed from impacted lipids or oil and keratin that plug the dilated follicle. Commonly seen on face. arteriole lesion. edematous.MAN 4 Fissure is a linear crack in the skin.arms and trunk. Caused by variety of interrelated factors including increased activity of the sebaceous glands. well circumscribed papule or plaque seen in urticaria. often very painful. Comedone is a small. bacterial and epithelial debris. Usually more severe at night and less frequently reported during waking hours.
The symptoms of boils are red. 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. The lesions begin as small. thin-walled vesicles that soon ruptured and become coved with a loosely adherent honey-yellow crust. Contact with the infected person and his or her belongings should be avoided.cloxacillin . underarms. red macules which quickly become discrete. In a severe infection. In most cases of folliculitis. scrapes. pus-filled lumps that are tender. and extremely painful. paper towels can be used in place of cloth towels for hand drying. such as cuts. Folliculitis starts when hair follicles are damaged by friction from clothing. an insect bite. feelings of being “ugly.Penicillinase-Resistant. All members of the household should wash their hands thoroughly with soap on a regular basis. as well. In some people. anyone with impetigo should cover the impetigo sores with gauze and tape. resulting in the localize accumulation of pus and dead tissue. Minocycline Oral Retinoids: Isotretinion (Accutane) Note: commone side effect. multiple boils may develop and the patient may experience fever and swollen lymph nodes. bug bites. Mild cases may be treated with bactericidal ointment. It is primarily caused by Staphylococcus aureus. which in some countries may be available over-the-counter. and is often found on the arms. Psychologic problems such as social withdrawal. blockage of the follicle.erythromycin Treatment may involve washing with soap and water and letting the impetigo dry in the air. shoulders. itching may develop before the lumps begin to form. Squeezing merely worsens the problem. Discuss over-the-counter products and their effects. but may also be found elsewhere. A yellow or white point at the center of the lump can be seen when the boil is ready to drain or discharge pus. and rashes. areas of eczema. Doxycycline. axilla. It is also a good idea for everyone to keep their fingernails cut short to make hand washing more effective. Boils are most often found on the back. A recurring boil is called chronic furunculosis. 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. chloramphenicol or neosporin. is “cheilitis” inflammation of lips Hormone Therapy: Estrogen-progesterone preparation. Abejo RN. such as fusidic acid. thighs and buttocks. lip. stomach. The incubation period is 1–3 days. . Systemic symptoms absent. and sometimes by Streptococcus pyogenes Impetigo generally appears as honey-colored scabs formed from dried serum. Dried streptococci in the air are not infectious to intact skin. Provide positive reassurance. Furuncles (Boils) Is a skin disease caused by the infection of hair follicles. mupirocin. cola and fried foods Milk products should be promoted Advise the client to wash face at least twice a day with mild soap. shaving or too tight braids too close to the scalp traction folliculitis. Nursing Management: Elimination of food products associated with a flare-up of acne such as chocolate. towels. or face.Benzathine penicillin . nose. listening actively and being sensitive the feelings of the patient. In addition. and the infected person should use separate towels for bathing and hand washing. Patients are instructed to avoid manipulation of pimples or blackheads. legs. face. If necessary. The infected person's bed linens. Scratching may spread the lesions. low self-esteem. FOLLICULAR DISEASES Folliculitis Is the inflammation of one or more hair follicles.” Pharmacologic Therapy Benzoly Peroxide Oral Antibiotics: Tetracycline.Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. 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.MAN 5 Assessment findings: Appearance of lesions is variable and fluctuating. These areas should be kept clean and covered to prevent infection. warm.Penicillin-Allergic. Medical Management: Topical or oral antibiotics are usually prescribed: . Non-infected members of the household should pay special attention to areas of the skin that have been injured. 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. and clothing should be separated from those of other family members. eyes. The infection is spread by direct contact with lesions or with nasal carriers.
due to the presence of bacteria in the discharge. can suppress staph bacteria on the skin. Hands should always be washed thoroughly. Acyclovir: antiviral agent which reduces the severity when given early in illness. VIRAL SKIN INFECTION Herpes Zoster (Shingles) Commonly known as shingles. scarring and discolored skin remain. Washcloths and towels should not be shared or reused. Placing a warm moist cloth on the carbuncle helps it to drain. but they are most common on the back and the nape of the neck. Carbuncles may develop anywhere. Bandages should be changed frequently and thrown away in a tightly-closed bag. The affected area should be soaked with a warm.Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. The carbuncle should not be squeezed. Men get carbuncles more often than women. Proper hygiene is very important to prevent the spread of infection. After 1–2 days (but sometimes as long as 3 weeks) the initial phase is followed by the appearance of the characteristic skin rash. aching. Abejo RN. The infection is caused by varicella zoster virus. or occurs along with a fever or other symptoms. and malaise. and sheets or other items that contact infected areas should be washed in very hot (preferably boiling) water. Things that make carbuncle infections more likely include friction from clothing or shaving. A carbuncle is made up of several skin boils. washcloths. tingling. Deep or large lesions may need to be drained by a health professional. or paresthesia ("pins and needles": tingling. The cause are bacteria such as staphylococci. Nursing Management Carbuncles usually must drain before they will heal. hyperesthesia (oversensitivity). The infection is contagious and may spread to other areas of the body or other people. which include headache. Clothing. with sensations that are often described as stinging. particularly when drained or when discharge is present. Herpes Simplex Virus Assessment findings: Clusters of vesicles. may ulcerate or crust Burning. after touching a carbuncle. Treatment is needed if the carbuncle lasts longer than 2 weeks. often in a stripe. . The painful vesicles eventually become cloudy or darkened as they fill with blood. forming small blisters filled with a serous exudate. numbing or throbbing. Bacterial colonization begins in the hair follicles and can lead to local cellulitis and abscess formation. pus. the rash becomes vesicular. pricking. Apply topical antibiotics or anesthetic as ordered. towels. and dead tissue. crust over within seven to ten days. preferably with antibacterial soap. triclocarban or chlorhexidine. itching. Analgesics for pain Systemic corticosteroids: monitor for side effects of steroid therapy. or cut open without medical supervision. which speeds healing. itching. The infected mass is filled with fluid. Fluid may drain out of the carbuncle. Proper excision under strict aseptic conditions will treat the condition effectively. Symptoms The earliest symptoms of herpes zoster. Medical management: Analgesics Corticosteroids Acetic acid compresses Acyclovir (Zovirax) Nursing interventions: Apply acetic acid compresses or white petrolatum to lesions Administer medications as ordered. moist cloth several times each day. Later. as the fever and general malaise continue. returns frequently. is located on the spine or the middle of the face. and can be interspersed with quick stabs of agonizing pain. A doctor may prescribe antibacterial soaps and antibiotics applied to the skin or taken by mouth. tingling Usually appears on lip or cheek. is a viral disease characterized by a painful skin rash with blisters in a limited area on one side of the body. but sometimes the mass is so deep that it cannot drain on its own. or numbness). fever. most commonly Staphylococcus aureus. Nursing interventions: Keep lesions dry. generally poor hygiene and weakening of immunity. It is usually caused by bacterial infection. These symptoms are commonly followed by sensations of burning pain. daily use of an antibacterial soap or cleanser containing triclosan. If boils/carbuncles recur frequently. Carbuncles Is an abscess larger than a boil.MAN 6 Sometimes boils will exude an unpleasant smell. as this can spread and worsen the infection. The pain may be extreme in the affected dermatome. This most often occurs on its own in less than 2 weeks. and usually the crusts fall off and the skin heals: but sometimes after severe blistering.
etc. FUNGAL INFECTION Types and Location Clinical Manifestation Treatment Tinea Capitis ( Head) . Use special shampoo and comb the hair. discouraging sharing of brushes..small papules or pustules in scalp . scaling. Provide client teaching and discharge planning concerning: How to check self and other family members and how to treat them..MAN 7 Condition Description Illustration Tinea Pedis “athletes foot” .Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Medical management: Special medicated shampoos (Lindane). Household pets should be examined. Washing of clothes. including area between the toes. bed linens.very pruritic . .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. Assessment findings: White eggs (nits) firmly attached to base of hair shafts.Begins with red macule. red scaling patches which spread to form circular elevated plaques.whole nail maybe destroyed . Only the superficial regions of the skin are affected in contact dermatitis. . which spreads to a ring of papules .Nails thicken.lesions found in cluster . Wear clothing and socks should be made of cotton Anti-fungal powder may applied twice a day to keep feet dry. Inflammation of the affected tissue is present in the epidermis (the outermost Tinea Cruris (Groin) . hats.Mild condition: Topical antifungal creams -Severe condition: Griseofulvin or Terbinafine . caps.brittle hair .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.Soak feet in vinegar and water solution. 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.Resistant infection: griseofulvin or terbinafine .very pruritic . etc. erythematous patches . . crumble easily and luck cluster . Usually caused by irritants and allergens Contact dermatitis is a localized rash or irritation of the skin caused by contact with a foreign substance.Shampoo hair 2 or 3 times with Nizoral or Selenium sulfide shampoo Tinea Corporis (Body) . combs and hats. clips.Oval. PEDICULOSIS Parasitic infestation Adult lice are spread by close physical contact such as sharing combs. 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.Griseofulvin for 6 weeks . Occurs in school-age children particularly those with long hair.Begins with small. . Use of fine-tooth comb to remove nits. Nursing interventions: Institute skin isolation precautions.Itraconazole (sporanox) Nursing Management Keep feet dry as much as possible. Pruritus of scalp. Abejo RN.Lamisil daily for 3 months Tinea Ungum (toenails) Herpes genitalis When symptomatic.
wheals (welts). but can affect any area including the scalp and genitals. Unknown caused. 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. Skin rapidly accumulates at these sites and takes on a silvery-white appearance. they are most prominent on the face. Administer topical steroids and antibiotics as ordered. It occurs when the melanocytes. 4 times a day to help clear oozing lesions. Importance of adhering to prescribed treatment and avoidance of commercially advertised products.Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. It commonly causes red scaly patches to appear on the skin. or fur fibers on sensitive skin. Although patches are initially small. and environmental factors. 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). Depigmentation is particularly noticeable around body orifices. Preventing skin dryness: Use mild soaps. Allowing crusts and scales to drop off skin naturally as healing occurs. such as the mouth. genitalia and umbilicus Psoriasis Skin Cancer Is a chronic. This is the usual reaction.MAN 8 layer of skin) and the outer dermis (the layer beneath the epidermis) Symptoms of both forms include the following: Red rash. Administer methotrexate as ordered. The scaly patches caused by psoriasis. When skin lesions occur. locally invasive and rarely metastasizes. Avoidance of wool. the rash sometimes does not appear until 24–72 hours after exposure to the allergen. most frequently located between the hairline and upper lip. Provide relief from pruritus. nylon. Risk factors: UV rays May take several forms: nodular. Blisters or wheals. Protect areas treated with coal tar preparation from direct sunlight for 24 hours. eyes. Apply prescribed steroid cream immediately after bath.fine telangiectasia and is translucent Treatment: Curettage Surgical Cryosurgery Radiation prevention Mohr’s micrographic surgery . Nursing Interventions: Apply wet dressings of Burrow’s solution for 20 minutes. Irritant contact dermatitis tends to be more painful than itchy. burning skin. Plaques frequently occur on the skin of the elbows and knees. Need to use gloves if handling irritant or allergenic substances. ulcerative. Provide client teaching and discharge planning concerning: Avoidance of causative agent. the cells responsible for skin pigmentation which are derived from the neural crest. assess for side effects. nostrils. Abejo RN. while allergic contact dermatitis often itches. and urticaria (hives) often form in a pattern where skin was directly exposed to the allergen or irritant. pigmented ad superficial Hx and Assessment: Usually asymptomatic unless secondarily infected in advanced disease Pearly-colored PAPULE External surface . genetic. hands and wrists. Nursing Interventions: Apply occlusive wraps over prescribed topical steroids. are areas of inflammation and excessive skin production. called psoriatic plaques. Soak in plain water for 20 to 30 minutes. non-contagious autoimmune disease which affects the skin and joints. Itchy. die or are unable to function. but there is some evidence suggesting it is caused by a combination of autoimmune. Vitiligo Is a chronic disorder that causes depigmentation in patches of skin. in allergic contact dermatitis. Symptom of vitiligo is depigmentation of patches of skin that occurs on the extremities. Blisters. Avoid extremes of heat and cold. The rash appears immediately in irritant contact dermatitis. they often enlarge and change shape.
lack of blisters Partial thickness – superficial Superficial Second-degree (papillary) dermis Blisters. and pain Precancerous lesions: Leukoplakia – white shiny patches in the mouth or on the lip. Use sunblock or lotion containing PABA. Nomenclature Traditional nomenclature Depth Clinical findings Superficial thickness First-degree Epidermis involvement Erythema. Protection against UV rays from the sun Wear thin layer of clothing. Abejo RN. First degree burns (superficial) Epidermis Common cause is thermal burn (+) blanching upon pressure and erythema (+) pain 2. Senile keratoses – brown. thick. Need to report lesions that change characteristics and/or those that do not heal.metastasis BURNS Direct tissue injury due to: o Thermal: scald.Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. sunburn. Full thickness 1. Partial thickness 1. Partial thickness – deep Deep Second-degree (reticular) dermis Whiter appearance Nursing interventions: Limitation of contact with chemical irritants. contact with flames o Electrical o Chemical o Smoke inhalation: fumes. bone. TYPES A. Second degree burns (deep burn) Chemical (+) very painful (+) erythema or fluid filled blisters B. compound and dermal nevi unlikely to become cancerous. 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. Nevi (moles) – junctional nevus may become malignant.MAN 9 Squamous cell carcinoma (epidermoid) – grows more rapidly than basal cell carcinoma and can metastasize. gasses. leather-like eschar. smoke I. lower lip. scale-like spots on older individuals. Full thickness Third. leathery texture Eschar – devitalized tissue A description of the traditional and current classifications of burns. no sensation (insensate) . frequently seen on mucous membranes. 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. capable of invasion and metastasis to other organs.irregular masses of anaplastic epidermal celss proliferating down to the dermis Treatment Surgical excision Mohr’s micrographic surgery Radiation Malignant melanoma – least frequent of skin cancers. neck and dorsum of the hands. or muscle Hard. Third to fourth degree burns Affect all layers of skin. clear fluid. purple fluid.melanocytes w/ marked cellular atypia and melanocytic invasion of the dermis Treatment: Surgical excision Chemotherapy. minor pain. hot grease. but most serious.or Fourthdegree* Dermis and underlying tissue and possibly fascia. muscle and bones Electrical burns Less painful than 1st and 2nd degree burns Dry.
Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R.MAN 10 C. maintain airway. hyponatremia. STAGES 1. Day 2: half of previous day’s colloids and electrolytes. increased urine output. metabolic acidosis 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. 4. Administer/monitor crystalloids/colloids/water solutions. Abejo RN. Day 1: half to be given in 1st 8 hours. increased urine output. 2. full thickness less than 2%. 5. F. E. Smoke inhalation – ensure patent airway. Emergent – removal of client from source of burn Thermal – smother burn beginning with the head. Monitor alterations in fluid and electrolyte balance: Assess for fluid shifts and electrolyte alterations. Minor: partial thickness less than 15%. identify entry and exit routes. Monitor Foley catheter output hourly (30 ml/hr desired). full thickness less than 10%. Administer IV fluids as ordered. Severity of burns: Major: partial thickness greater than 25%. lavage are with copious amounts of water. D. Provide IV route if possible. 3. full thickness greater than or equal to 10%. all of insensible fluid replacement. Chemical – remove clothing that contains chemical. hyponatremia. Electrical – note victim position. metabolic acidosis Convalescent/Recovery phase – characterized by continuous wound healing Healing starts immediately after injury Assessment findings: Elevated blood pressure. Rule of 9’s Head and neck = 9 Anterior chest = 18 Posterior chest = 18 Upper extremity = 9 x 2 Lower extremity = 18 x 2 Genital = 1 2. Monitor balance: alterations in fluid and electrolyte Weigh daily. 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. Wrap in dry. remaining half over next 16 hours. Monitor circulation status regularly. Administer analgesics/narcotics 30 minutes before wound care. ASSESSMENT FINDINGS 1. Assess how and when burn occurred. 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. Supportive therapy: IV fluid management. Position burned areas in proper alignment. Moderate: partial thickness 15%-25%. Transport immediately. catheterization . Hypokalemia. 4. 3. clean sheet or blanket to prevent further contamination of wound and to provide warmth. Maximum of 10 L over 24 hours. 3. 2. 4. Hypokalemia. 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. MEDICAL MANAGEMENT: 1.
high carbohydrate diet with vitamin and mineral supplements. Promote maximal nutritional status: Diet high in CHO. Avoid trauma to area. Test stools for occult blood. When oral intake permitted.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. 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 Curling’s ulcers (H2 receptor antagonists) Assist in surgical procedure 8. monitor patency/drainage. Monitor bowel sounds. 14. remaining fluid to be given over next 16 hours. Schedule wound care and other treatments at least 1 hour before meals. . Apply sterile dressing. Administer analgesics 30 minutes before application. Observe and report hypersensitivity reactions. Handle carefully: solution leaves gray or black stain on skin. Apply silver sulfadiazine as ordered. Importance of reporting formation of local trophic changes. Monitor acid-base status and renal function studies. Abejo RN. Apply silver nitrate as ordered. 12. Second and third-degree burns exceeding 50% BSA calculated on basis of 50% BSA Parkland/Baxter Formula: Lactated Ringer’s: 4 ml x wt (kg) x % BSA burned Day 1: Half to be given in first 8 hours. all of insensible fluid replacement. Keep dressings wet with solution. Methods of coping and resocialization. 10. remaining half over next 16 hours. Assist with insertion of NGT to prevent/control Curling’s/stress ulcer. Place the patient in a controlled sterile environment. Wash area with prescribed solution or mild soap and rinse well with water. Apply mafenide (sulfamylon) as ordered: Administer analgesics 30 minutes before application. 11. Serve small portions. dryness increases the concentration and causes precipitation of silver salts in the wound. Adherence to prescribed diet. Apply povidone-iodone ordered. clothing and utensils. Consensus Formula: Lactated Ringer’s: 2-4 ml x wt (kg) x % BSA burned Half to be given in first 8 hours after burn. Avoid use of fabric softeners or harsh detergents (might cause irritation). Administer prophylactic antacids through NGT and/or IV cimetidine or ranitidine.Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Avoid constrictive clothing over burn wound. Prevent wound infection. 9. 6. 7. dry with clean towel. Assess for metabolic acidosis/renal function studies. high-protein. half of electrolytes. Maintain strict aseptic technique Use hydrotherapy for no more than 30 minutes to prevent electrolyte loss. Administer analgesics 30 minutes before application. Day 2: Half of colloids. Store drug away from heat. half to be given over next 16 hours. solution as Administer analgesics before application. Day 2: Varies. CHON.5 ml x wt (kg) x % BSA burned Electrolytes (lactated Ringer’s): 1. provide highcalorie. Provide client teaching and discharge planning concerning: Care of healed burn wound Assess daily for changes. Prevent GI complications: Assess for signs and symptoms of paralytic ileus.MAN 11 Second and third-degree burns exceeding 50% BSA calculated on basis of 50% BSA Brooke Army Formula: Colloids: 0. Prevention of injury to burn wound. VIT C Monitor tube feedings/TPN if ordered. Provide daily tubbing for removal of previously applied cream. colloid is added. Administer gentamicin as ordered: assess vestibular/auditory and renal functions at regularly intervals. 13. Wash hands frequently during dressing change. Observe wound for separation of eschar and cellulitis.
which is prevalent during proliferation. 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. blood comes in contact with collagen.They also cleanse the wound by secreting proteases that break down damaged tissue. 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. release a number of things into the blood. (3) proliferative and (4) remodeling C.Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Macrophages also secrete a number of factors such as growth factors and other cytokines. before it is laid down. forming a protective barrier against the external environment. they are the main cells that lay down the collagen matrix in the wound site. especially during the third and fourth post-wounding days. depending on the size of the wound and whether it was initially closed or left open. bradykinin. marking the onset of the proliferative phase even before the inflammatory phase has ended. Homostasis Within minutes post-injury. type III collagen. is gradually degraded and the stronger type I collagen is laid down in its place A. including ECM proteins and cytokines.Growth factors stimulate cells to speed their rate of division. 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. prostaglandins. 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. Proliferative Phase Fibroblasts begin to enter the wound site. including growth factors. Fibroblasts begin secreting appreciable collagen. phases: (1) hemostasis (2) inflammatory. or wound repair. the maturation phase of tissue repair is said to have begun. platelets (thrombocytes) aggregate at the injury site to form a fibrin clot. Inflammatory Phase When tissue is first wounded. Formation of granulation tissue in an open wound allows the reepithelialization phase to take place. Platelets also release other proinflammatory factors like serotonin. prostacyclins.MAN 12 Wound Healing Process Wound healing. is an intricate process in which the skin (or some other organ) repairs itself after injury. Once the protective barrier is broken. staples. the epidermis (outermost layer) and dermis (inner or deeper layer) exists in a steadystated equilibrium. During Maturation. which cause blood vessels to become dilated and porous. and histamine. while later. The tissue in which angiogenesis has occurred typically looks red (is erythematous) due to the presence of capillaries Fibroblasts mainly proliferate and migrate. 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. 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): . triggering blood platelets to begin secreting inflammatory factors. Collagen deposition is important because it increases the strength of the wound. The maturation phase can last for a year or longer. as epithelial cells migrate across the new tissue to form a barrier between the wound and the environment D. thromboxane. This clot acts to control active bleeding (hemostasis) B. The main factor involved in causing vasodilation is histamine. Remodeling Phase When the levels of collagen production and degradation equalize. In normal skin. yet overlapping. Platelets. Abejo RN. Angiogenesis occurs concurrently with fibroblast proliferation when endothelial cells migrate to the area of the wound.
MAN 13 The wound is initially cleaned. 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. 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.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. 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. Abejo RN. 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. 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. 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. the nurse lifts and avoid dragging the patient across a surface Increase protein intake. because this may increase the damage To avoid shearing forces when repositioning the patient. 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. 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. and temperature at intervals to determine capillary blood flow. integrity. iron. Static Frequent monitoring of ulcer progress Avoid massaging reddened areas.
Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R. Abejo RN.MAN 14 Anatomy of the Skin Hair / Hair Growth .
Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R.MAN 15 Nail Skin Testing Wood’s Light Examination Skin Grafting Secondary Skin Lesion . Abejo RN.
Abejo RN.Medical and Surgical Nursing Integumentary System Lecture Notes Prepared by: Mark Fredderick R.MAN 16 Burn Rule of Nine Phases of Wound Healing .