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NURSING MANAGEMENT: INTEGUMENTARY SYSTEM

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Largest organ of the body. It includes skin, hair, nails, and glands Healthy skin reflects a healthy body

ASSESSMENT OF THE SKIN

Important health information


Past health history Medications Surgery or other treatments

HEALTH PROMOTION
Nutrition Exercise Rest Hygiene Avoid irritants and over exposure to the sun Quite smoking

GERONTOLOGICAL CONSIDERATIONS
Skin is thinner and dryer Be familiar with skin and assess regularly Shower less often Use warm rather than hot water Use mild soap Apply moisturizer immediately after shower while skin is still damp

SUN EXPOSURE AND YOUR SKIN


Sun exposure Ultraviolet rays of the sun Direct or indirect exposure Degenerative changes in the dermis Premature aging Loss of elasticity Thinning Wrinkles Drying Risk for precancerous and cancerous lesions Actinic Keratosis, Basal cell carcinoma, squamous cell carcinoma, and malignant melanoma Up to 90 percent of the visible changes commonly attributed to aging are caused by the sun.

Avoid sun between 10 AM and 3 PM Start with short sessions 15-20 minutes Sunscreen SPF >15 daily, all year Reapply after swimming, strenuous exercises, or prolonged sun bathing

Lip balm SPF >15 Protective clothing Hat Sunglasses Watch out for cloudy days and water reflection Avoid tanning lamps or tanning booths

PROTECTING YOUR SKIN FROM THE SUN

TANNING BEDS
Ten minutes in a sunbed matches the cancer-causing effects of 10 minutes in the Mediterranean summer sun.
Indoor ultraviolet (UV) tanners are 74 percent more likely to develop melanoma than those who have never tanned indoors. People who use tanning beds are 2.5 times more likely to develop squamous cell carcinoma and 1.5 times more likely to develop basal cell carcinoma.

STOPPING THE SPREAD OF INFECTION


Gloves Good hand washing Safe disposal of soiled dressings Avoid scratching of lesion Trim nails, no fake nails

NURSING MANAGEMENT: PRURITUS


Pruritus (itching)
Makes pruritus worse
Heat and rubbing Dryness Restricted clothing

Makes pruritus better

Numbs the itch receptors


Aveeno baths
Benadryl

Cool environment Corticosteroids Cool compress Menthol, camphor, or pheno Antihistamines

FURUNCLE (BOIL)
Deep infection of the hair follicle commonly caused by Staph Aureus Clinical manifestations: small, red, elevated, painful nodule. Management: warm wet compresses four times a day I & D Antibiotics-topical and/or oral Do not squeeze

IMPETIGO
Superficial skin infection: caused by Staph, Strep, or MRSA enters through a break in the skin Honey-colored crusts on erythematous base Areas beneath crust- glistening, weeping, and eroded Primarily face Treatment: Gently remove crust with soap and water Topical bactericidal ointment or oral antibiotics Usually heals without scarring

CELLULITIS
Bacterial infection of the skin
Skin is warm to touch, red, swollen and painful Pt has fever, malaise, chills

Treatment: Elevation of affect part Antibiotics Dressing changes if open wounds are present
Usually resolves in 2 weeks with TX Untreated risk of gangrene

FUNGAL INFECTIONS (DERMATOPHYTE)


Fungal infection are transmitted person to person or animal to person Avoiding fungal infections Keep your skin clean and dry Avoid sharing comb or brushes, hats or any type of headgear, clothes, and towels. Avoid eating foods high in sugar, dairy, caffeine, wheat, and yeast as all of these will enhance fungal growth. Wear loose fitting clothing Change damp or soiled clothing quickly Wear cotton underwear Keep toenails clean and short; and avoid walking barefoot on areas like locker rooms and public showers.

TINEA CAPITIS
Ringworm of the scalp is a fungal infection of the scalp and hair shafts

Usually appears as itchy, scaly, bald patches on the head. Possible permanent hair loss Oral antifungal medication such as Griseofulvin or Lamisil Selenium Sulfide shampoos Topical antifungal agents Avoid using the same comb Routinely wash scarf's and hats Examine family and pets for symptoms

Treatment

Teaching

TINEA CORPORIS
Ringworm Trunk, arms, legs Elevated ring shaped scaling, well defined red borders with center clearing Treatment Wash and dry the area first. Apply the cream Use the cream twice a day for 7 to 10 days. Do not use a bandage over ringworm . Medications Griseofulvin (Grifulvin V) Fluconazole (Diflucan) Terbinafine (Lamisil) Begin applying 1 inch beyond lesion and work inward for 1-2 weeks until resolved

TENIA CRURIS
Affects the skin of your genitals, inner thighs and buttocks Itching and redness in your groin, including your genitals, inner thighs and buttocks Possible itching in your anal area Burning sensation in affected areas Flaking, peeling or cracking skin in your groin

Treatment
Allylamines such as terbinafine (Lamisil AT) Azoles including clotrimazole (Lotrimin AF) Wet compresses or sitz baths may be soothing Keep area clean and dry Make sure your clothes fit correctly

Prevention

TENIA PEDIS
Athletes Foot Most commonly between toes and soles of the feet, can be on hands Red, scaly patches May contain bumps, blisters, or scabs Treatment: Butenafine (Lotrimin), Clotrimazole (Lotrimin), Miconazole (Desenex), Terbinafine (Lamisil), Tolnaftate (Tinactin) Keep using the medicine for 1 - 2 weeks Prevention: Dry your feet thoroughly after bathing or swimming Wear sandals or flip-flops at a public shower or pool Change your socks often to keep your feet dry Wear shoes that are well ventilated

TENIA UNGUIUM
Fungal infection of the nails Brittleness Change in nail shape Crumbling of the outside edges of the nail Loosening or lifting up of the nail Loss of luster and shine Thickening of the nail White or yellow streaks on the side of the nail Treatment Topical or oral antifungals for about 2 to 3 months Fluconazole and griseofulvin, are used In some cases, the health care provider may remove the nail

NON-DERMATOPHYTE INFECTIONS
Candidiasis Yeast Likes warm moist areas Glistening, fiery red or moist pink, beefy red with satellite pustules Severe itching/burning Skin folds/groin area Diaper rash (dermatitis)

Oral-thrush

TEACH PREVENTION AND MANAGEMENT


Healthy diet Manage stress Keep skin clean and dry Diabetic control blood sugar Antibiotics eat live cultured yogurt
Anti Fungal Medicine clotrimazole (Lotrimin) or nystatin. Diaper rash Zinc oxide oint, avoid using wipes Fluconazole (Diflucan) or Nystatin swish and swallow for Oral Thrush Home Remedies Tea Tree Oil, Garlic, Live cultured yogurt (acidophilus)

CONTACT DERMATITIS
Contact dermatitis is an inflammation of the skin caused by direct contact with an irritating substance. Hypersensitivity to allergen 2-7 days after exposure
Poison Oak or Ivy, nickel, wool, detergents, soap, hair dyes, paint, insecticides, rubber/latex Red, hive like papules, edema, and pruritus

TREATMENT
Avoidance of irritant Teach Wash exposed skin with Topical corticosteriods, cool water asap post antihistamines, skin exposure hydration antipruritic Within 15 minutes Trim nails Avoid breaking of blisters, fluid spreads the disease.

URTICARIA
Pruritic transient wheals of varying shapes and sizes (Hives) Response to irritant: drugs, food, insect bites, inhalants, stress, exposure to heat and cold, and exercise Treatment: antihistamines cold compresses Remove of irritant source

DRUG REACTION

Hypersensitivity to certain drugs Red macular and papular rash Generally abrupt onset Can appear as late as 14 days post drug TX: withdrawal of drug and corticosteroids

ATOPIC DERMATITIS (ECZEMA)


Often begins in infancy 2-6 months Scaly, red to redish-brown circumscribed lesions Itches more at night In children positive correlation with allergies to milk, eggs, wheat, and peanuts

TREATMENT
Teaching Dietary restrictions in children Keep nails trimed Avoid overheating (nylon clothing) Avoid people infected with chicken pox or herpes simplex Avoid live vaccines Wear non-irritating clothing

Corticosteriods Phototherapy Coal tar therapy Intralesional injections of steriods Hydration of skin Reduction of stress Stress causes flare up

VERRUCAE (WARTS)
Verruca Vulgaris Hands Flesh-colored or brownish gray scaling, vegetative papule Treatment: Cryosurgery Chemical destruction (salicylic acid) Curettage Desiccation Laser

HERPES SIMPLEX (HSV)


Most common virus in humans Two types HSV-1 Fever blister and cold sores HSV 2 Genital herpes Treatment: Antiviral Zovirax, Famvire, Valtrex

HSV-1
Grouped, burning, and itching vesicles on erythematous base Mouth, oral cavity, eyes and brain Teach: direct contact, spread by kissing, oral genital sexual contact, contact with fingers Exacerbated: Stress, trauma, Menes, sunlight, fatigue, systemic infection Hand washing Last 7-10 days

HSV-2
Genital herpes is a common sexually transmitted infection that affects both men and women. Symptoms include: pain, itching and sores in genital area Infected people have no signs or symptoms of genital herpes An infected person can be contagious, even if he or she has no visible sores

HERPES ZOSTER
Shingles is a viral infection that causes a painful rash
Related to chicken pox virus Potentially contagious to anyone who has not had varicella or who is immunosuppressed Aging, stress, immunosuppressed

Painful vesicles in a linear pattern along dermatome (spinal and cranial nerve tracts)

HERPES ZOSTER
Grouped vesicles on erythema base Most commonly to the trunk Fluid-filled blisters that break open and crust over Pain, burning, numbness or tingling Heals without complication may scar Treatment: Antiviral agent Acyclovir, famiciclovir Cool compresses, analgesia, bedtime sedation Shingles Vaccine Zostavax

VITILIGO

Unknown cause Genetically influenced Precipitated by an event Illness or crisis Complete absence of melanocytes Non-contagious

VITILIGO
Complete loss of pigment, macular, variation in size and location May be permanent Topical steroids for small areas PUVA Light treatment and psoralens Cosmetics and stains

PSORIASIS
Chronic hereditary disorder Light-skinned race Environmental factors that trigger

Skin injury Infections Hormone changes Stress Drugs Alcohol Smoking obesity

PSORIASIS CON T.
Erythematous plaque with sharp well defined borders and silvery white scales. Elbows, knees, scalp, lumbosacral skin, can occur anywhere Teach reducing pruritus Avoid scratching Room humidifier Warm not hot bathing Avoid strong soaps Lubricate skin antihistamines

Management

Topical treatment
Coal tar treatment Anthralin

corticosteriods
Photo-therapy PUVA Psoralin Ultra violet A light

INSECT AND ANIMAL CONTACTS


Scabies (Mites) Mite infestation in the dermis to lay eggs Inflammation and itching (worse at night) Burrows between fingers, wrist, axillary folds, popliteal, and inguinal Treatment: Elimite Lotion Apply head to toe then repeat in 1 week

PEDICULOSIS
Lice infestation 3 types Pediculosis Capitus Head lice Pediculosis Corpus Body lice Pediculosis Pubis Pubic lice crabs

PEDICULOSIS CAPITIS
Head lice School-age children Lives 48 hours Female lays eggs (nits) on the hair shaft Hatch in 7-10 days Does not live on animals Head lice can only survive on humans Easily transmitted person to person Does not jump or fly Sharing: combs, hats, caps, scarves, coats, shared lockers, slumber parties, or other items used on or near hair Can invade all ages

LICE
Manifestations Visual Itching/scratch marks Behind ears, head, nape of the neck Treatment Pediculocides and manual removal of nit cases NIX, RID Apply treatment Leave on 10 minutes, rinse and towel dry Remove nits with nits comb Lice treatment kill, but do not remove the nits

TEACH
Machine wash all washable clothing, towels, and bed linens in hot water, and dry in hot dryer for at least 20 minutes Thoroughly vacuum carpets, car sets, pillows, stuffed animals, rugs, mattresses, and upholstered furniture Seal non-washable items in a plastic bag for 14 days if unable to dry clean or vacuum Soak combs, brushes, and hair accessories in lice killing products for 1 hours or in boiling water for 10 minutes

CIMICIDE
Bedbugs Feed at noc, during the day, they hide in the cracks and crevices of beds, box springs, headboards and bed frames Red, often with a darker red spot in the middle Itchy Arranged in a rough line or in a cluster of 3 Located on the face, neck, arms and hands Treatment: Cortisone cream Antihistamine Treat pruritus

STINGS
Allergic reactions account for 30 deaths each year Honeybees, bumblebees, wasps, hornets, yellow jackets, mud daubers, and fire ants Reaction may be immediate or delayed (after 2 hours) Non-allergic reaction Local edema, erythema pain, itching Resolves in a few hours

Severe with possible anaphylaxis reaction Generalized urticaria and pruritus, bronchospasms, laryngeal edema, shock and death 10-30 minutes post sting Epinephrine 0.1-0.5 mL of 1:1000 sol, may repeat 15-15 minutes until symptoms resolve Stinger removal Honeybees only leave stingers Clean area Remove by scraping a flat item over stinger against the entry. Avoid breaking or squeezing Treatment Ice, elevation, antihistamines

CANCER OF THE SKIN


Risk factors Fair skin type Over exposure to sunlight Family history of skin cancers Environmental factors include Outdoor occupation frequent participation in outdoor activities Behavioral factors include

PREMALIGNANT LESISONS
Actinic keratosis Face, neck, back of hands, forearms Rough scaly patch, irregular shaped, flat, slightly Sun exposure May progress to squamous cell CA

MALIGNANT NEOPLASMS
Basal Cell- most common least
deadly

Reoccurring Does not metastasize

superficial and doesn't extend very far into the skin occurs most often on areas of the skin exposed to the sun Face and neck Pearly, translucent rounded border with dilated blood vessels

TREATMENT
Treatment Mohs Micrographic Surgery Electrodessication and curettage Excision Cryosurgery Radiation therapy Photodynamic Therapy (PDT) For small lesions Topical chemotherapy 5-Fluorouracil (5-FU) For superficial lesions Post procedure Keep wound moist and covered Clean with NS Antibiotic ointment Yearly exam for life

SQUAMOUS CELL CARCINOMA


Risk factors prolonged exposure to sunlight or from tanning beds, fair skin, age-most common >45, genetic, smoking flat lesion with a scaly crust Slowly enlarges Treatment: Surgical excision Mohs surgery Laser Chemo Radiation May metastasize Smoking increases the risk of SCC to mouth or lips

MALIGNANT MELANOMA

E -evolving over time

RISK FACTORS
Fair skin hair and eyes Hx of sunburns Excessive exposure to sun and tanning beds Many or unusual moles Family hx of melanoma

Typically affects areas with greatest exposure to the sun

DIAGNOSIS

Excisional biopsy

Punch biopsy

TREATMENT
4 Treatment options Surgery Chemotherapy Radiation Immunotherapy

PREVENTION
Avoid unnecessary exposure to sunlight Includes tanning beds Use sunscreen Apply often Wear protective clothing Hat, sunglasses Know your skin Inspect moles Report any changes Report development of any new lesions Self examination of the skin Check skin monthly
Professional check- up at 3 mo, 6 mo, and yearly for life if skin cancer is removed

PROGRESSION OF SUSPICIOUS MOLES

ACNE VULGARIS
Involves the hair follicle and sebaceous glands of the face, neck, chest, and upper back Few comedones (blackheads) to severe inflammatory reaction Cystic acne Cause Hormone Products that contain oily components Increased comedones Fast food chains No dietary link

NURSING MANAGEMENT
Do not pick, squeeze, or finger Secondary infection Avoid creams/oils Make-up bases can aggravate acne Adequate rest, moderate exercise, well-balanced diet, reduction of stress Gentle cleansing with mild cleanser once or twice a day (dove)

Forehead acne may improve by keeping hair off the forehead Do not leave make-up on over night Expect improvement in 46 weeks Acne may appear worse in the beginning

TREATMENT OF ACNE
Antibiotics tetracycline OCP Oral contraceptive pill - Yasmin Accutane Cystic acne Significant side effect Causes birth defects Contraindicated with pregnancy Pregnancy test Effective contraceptive method during treatment and for 6 months after treatment Elevates triglyceride and cholesterol Monitor levels

PEELING AGENTS
Treatment Retin A Cream, gel, or liquid apply 20-30 minutes after washing Burning sensation/ redness of skin Avoid sun exposure Sunscreen Apply at bedtime

Benzoyl Peroxide
Cream, lotion, gel, wash Bleaching effect on sheets, bedclothes, and towels

PLASTIC SURGERY
Elective cosmetic surgery Main reason To improve self-image Most common procedures Breast enlargement, breast reduction, rhinoplasty, tummy tuck, liposuction, mechanical and surgical face-lift, eyelid lift, hair transplant, removal of double chin

CHEMICAL FACE-LIFT/PEEL
Chemical burn Moderate swelling and crusting for 1 week Within 7-8 days new skin will appear Healing is complete in 10 days Redness for 6-8 weeks Pink tone for several months Complete sun block(reduction in melanin)

DERMABRASION

Removal of epidermis Prevent drying Emollients and wet soaks Sunscreen

BOTOX INJECTIONS
Temporarily eliminates brow furrows, frown lines and crow's feet. Paralyzing small muscles involved in facial expressions Does not cause botulism (small doses) Redness, pain, swelling, HA, and double vision for 1-2 weeks Injections are expensive Must be repeated every 3-6 months

NURSING DIAGNOSIS
Social isolation Coping Nutrition Anxiety

REVIEW
An elderly patient who is diagnosed with herpes zoster (shingles) has draining vesicles. Which action, if observed by the nurse, would require an intervention?
A. The student nurse who takes prednisone requests a different patient assignment. B. The nursing assistant washes hands frequently and wears gloves when in the room. C. The licensed practical nurse wears a mask when entering the patients room. D. The patient keeps the draining vesicles covered with a dressing.

REVIEW
The nurse teaches a patient several interventions to reduce pruritus associated with dry skin. Which statement, if made by the patient to the nurse, indicates further teaching is required?
A.I will avoid taking hot showers. B.I should rub my skin instead of scratching. C.A wet dressing followed by a lubricating lotion will help. D.Menthol can be used to numb the itch sensation.