Integumentary System

Medical and Surgical Nursing

Integumentary System Lecture Notes

Prepared by: Mark Fredderick R. Abejo RN,MAN 1

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

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

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

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

Nails

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

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.



Prepared by: Mark Fredderick R. Abejo RN,MAN 2 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



Prepared by: Mark Fredderick R. Abejo RN,MAN 3 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.

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 post-

surgery; 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.

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.

EVALUATION

Healing of burned areas; absence of drainage, edema and pain.

Relaxed facial expression/body posture. Changes into self-concept without negating self-

esteem

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.




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




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.

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.

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

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.




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.

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.

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.

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.




Condition Description Illustration

Herpes labialis

Infection

occurs when

the virus

comes into

contact with

oral mucosa

or abraded

skin.

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.

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

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

Tinea Pedis

athletes foot

- soles of feet have

scaling and mild

redness with

maceration in toe webs

- Soak feet in

vinegar and water

solution.

- Resistant

infection:

griseofulvin or

terbinafine

- Lamisil daily for

3 months

Tinea

Ungum

(toenails)

- 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.

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




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.


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.

Psoriasis

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)

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.


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

Skin Cancer

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




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

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.

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.

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

Second-degree

Superficial

(papillary)

dermis

Blisters,

clear fluid,

and pain

Partial

thickness deep

Second-degree

Deep

(reticular)

dermis

Whiter

appearance

Full thickness

Third- or

Fourth-

degree*

Dermis and

underlying

tissue and

possibly

fascia, bone,

or muscle

Hard,

leather-like

eschar,

purple fluid,

no sensation

(insensate)




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

3. 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

4. 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

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%.

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

catheterization

2. Wound care:

Hydrotherapy

Debridement (enzymatic or surgical) 3. Drug therapy:

Topical antibiotics

Systemic antibiotics

Tetanus toxoid or hyperimmune human tetanus globulin

Analgesics 4. Surgery: excision and grafting

F. 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

2. 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.

3. 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).

4. Monitor alterations in fluid and electrolyte balance:

Weigh daily. Monitor circulation status regularly. Administer/monitor

crystalloids/colloids/water solutions.

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.




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 solution as ordered.

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 high-

calorie, 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.

8. 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.

9. If (+) to burn of the head and neck and face Assist in intubation

10. Assist in hydrotherapy 11. Assist in surgical wound debridement

Analgesics before debridement 12. Prevent complications

Infections Septicemia Paralytic ileus Curlings ulcers (H2 receptor

antagonists)

13. Assist in surgical procedure

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.




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 steady-

stated 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

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

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

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):




The wound is initially cleaned, debrided and observed, typically 4 or 5 days before closure

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

Pressure Points

Mechanical Forces Pressure Friction Shear

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: 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

Stage II

Skin breaks

Abrasion, blister or shallow crater

Edema persists

Ulcer drains

Infection may develop

Stage III

Ulcer extends into subcutaneous tissue

Necrosis and drainage continue

Infection develops

Stage IV

Ulcer extends to underlying muscle and

bone.

Deep pockets of infection develop

Necrosis and drainage continue

Pressure Ulcers: Key Things to Remember

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

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




Anatomy of the Skin

Hair / Hair Growth




Nail Skin Testing Woods Light Examination

Secondary Skin Lesion

Skin Grafting




Burn Rule of Nine

Phases of Wound Healing

Documents

Integumentary System