INTEGUMENTARY DISORDERSStructures & Functions of Skin & Appendages

Epidermis

Stratum Corneum (outer layer of dead keratinized cells) flat scale like cells called squamous cells

Stratum Germinativum (basal cell layer)– cells migrate from basal layer upward to corneum and sheds

Structures & Functions of Skin & Appendages

Dermis

Papillary layer- upper thin layer

Reticular layer- deep thick layer

Fibroblast cells- Primary cell type fround in the dermis

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Subcutaneous Tissue (fat) - below the dermis an is not part of the skin.

Skin (epidermal) Appendages – down growths of epidermis into dermis; develop from epidermis

- Hair & Hair Follicles- Nails- Glands:

Sebaceous glands – secret sebum which is emptied into the hair follicles

- prevents skin from drying

Apocrine Glands - sweat glands secrete milky substance that becomes odoriferous when altered by skin surface bacteria

Eccrine Glands- widely distributed over the body, except in a few areas, such as the lips.

- These glands function to cool the body by evaporation, to excrete waste products, and moisturize surface cells

Function of Skin:

A. Protection

B. Homeostasis

C. Thermoregulation D. Sensory Reception

E. Aesthetic functions- include the mirrowring of various emotions such as anger or embarrassment, as well as displaying te individual

identity of a person.

Effects of Aging on the Skin

Adolescence – surge of hormones (androgens) lead to maturation of hair follicles, sebaceous glands, apocrine and eccrine units. Sweat, odor, acne, Pigmented nevi (freckles)

Adult – male baldness, facial hair on women, sebaceous cysts, skin tags

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Older Adulthood – thinner skin; more sensitive to minor changes in humidity, temperature, wrinkles due to weakened collagen; Lentigines (liver spots – have nothing to do with liver) black or brown flat lesions can appear anywhere, but on face and dorsum of hand from prolonged sun exposure. (“Aging” pigment– left over from broken-down cells)

Assessment of the Integumentary System

A. History

B. Physical Exam Good lighting (natural lighting), privacy, moderate room temp, expose section at a time, pt comfortable Systematic – proceed head-to-toe; compare symmetrical parts; perform general inspection then lesion specific exam Inspect general color & pigmentation, vascularity or bruising, presence of lesions or discoloration Vascularity ( angioma, petechiae, purpura) Lesion – color, size, distribution, location, shape recorded; also configuration (pattern) and distribution (arrangement); note odor Refer to Table 22-7 & 22-8, pg. 483 Tattoos, needle-track marks

Lesion Configuration

Annular - ring-shaped Gyrate - Ring-Spiral-shaped Iris lesions - Concentric rings or “bull’s eyes” Linear - In a line Nummular, discoid - Coinlike Polymorphous - Occurring in several forms Punctuate - Marked by points or dots Serpiginous - Snakelike

Distribution Terminology

Asymmetric - Unilateral distribution Confluent- Merging together Diffuse- Wide distribution Discrete- Separate from other lesions Grouped - Closter of lesions Solitary- A single lesion Symmetric- Bilateral distribution

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Zosteriform- Band like distribution along a dermatome area

Hair & scalp

Examine body hair distribution, texture & quantity of hair Examine scalp for lice (Caucasian); nap of neck, behind ears bite marks, nets- eggs Nails – shape, thickness, curvature & surface Palpation – determine temp (use back of hand), turgor, mobility, moisture & texture

Skin Assessment 1. Pallor 2. Jaundice 3. Temperature 4. Texture 5. Turgor 6. Edema 7. Tenderness

Abnormalities Alopecia - loss of hair Comedo - black heads and white heads Cyanosis - bluish-grey or dark or dark purple discoloration of the skin Ecchymosis - bruise like lesions caused by collection of blood in dermis Keloid - hypertrophied scar beyond margin of incision or trauma Mole (nevus) - Benign overgrowth of melanocytes Petechiae - pinpoint, discrete deposits of blood Varicosity - Increased prominence of superficial veins Vitiligo - cyst depigmentation- congenital or acquired loss of melanin resulting in white, depigmented areas

Assessment of Dark Skin Color Refer to table 22-6, pg. 483

Cyanosis – Shen or gray color most easily seen in the conjunctiva of the eye, mucous membranes and nail beds

Jaundice - Yellowish-green color most obviously seen in sclera of eye (do not confuse w/ yellow pigmentation, which may be evident in dark-skinned patients) Palms of hands, and soles of feet

Pallor – Underlying red tone in brown or black skin is absent. Lighted

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skinned AA may have yellowish brown skin dark skinned AA may appear ashen or gray Assessment of color easily made where epidermis is thin & pigmentation lighter – lips, mucous membrane, palms & nail beds

Pseudofolliculitis – bacterial disorder caused by staph aureus characterized by erythematous papules

Keloids – Overgrowth of collagenous tissue at site of skin injury

Mongolian spots – benign bluish-black macules

Pigmented nails (bands) pg. 478

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Types of Lesions Primary – lesions that develop on previously unaltered skin

Macule – flat, non-palpable; circumscribed; less than 1 cm in diameter; called a patch if greater than 1 cm; skin color change (brown, red, purple, white or tan); due to change in melanocytes or a change in vascularity;

Ex: freckles, petechiae, measles, flat mole (nevus)

Papule – elevated, palpable, firm circumscribed solid lesion; less than 1 cm in diameter; may involve epidermis or dermis or both

Ex: wart (veruca), elevated mole, drug related eruptions (allergic rash)

Nodule – raised, firm, palpable, solid lesion extending deeper into dermis and larger and deeper than papule – greater than .5 cm in diameter;

Ex: lipomas, erythema nodosum

Plaque – raised but flat topped, firm, rough, superficial papule greater than 1 cm in diameter; formed from merging papules or nodules; larger than papule but not deeper;

Ex: psoriasis, seborrheic and active keratoses

Tumor – larger than nodule, elevated firm lesion that may or may not be easily demarcated; greater than 2 cm in diameter; may or may not vary from skin color; can be benign or malignant;

Ex: neoplasm

Wheal – (also called hive, urticaria – due to allergic reaction) vascular reaction causes vasodilation which leads to erythema in which fluid leaks out of vessels into tissue causing edema in dermis; firm, edematous, irregularly shaped area; diameter variable; pale pink with lighter center;

Ex: insect bite, urticaria)

Vesicle (blister) – elevated sharply defined lesion containing serous fluid; Contains free fluid; up to .5 cm

Ex: blister, chicken pox, herpes simplex, SMALL

Bulla (e) – LARGE, elevated, fluid-filled lesion greater than 1 cm Ex: blister, pemphigus vulgaris, second degree burn

Cyst – elevated, thick walled, palpable, encapsulated lesion containing

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fluid or semi-solid material; similar to nodule but not solid; material from sebaceous glands and hair follicles;

Ex. Sebaceous cyst

Pustule – elevated superficial vesicles filled with purulent fluid (WBCs, debris, microorganisms, and their products); vary in size;

Ex: acne, impetigo (Im-pe-ti-go), ant bite

Boils, Furuncles – pustule larger than 1 cm

Carbuncle – collection of furuncles; deeper than furuncle; never incise

Abscesses – similar to furuncle but usually starts with some trauma

Types of Lesions Secondary – lesions that change with time or because of a factor such as scratching or infection

Fissure – Linear crack or break from epidermis to dermis; dry or moist; Ex: athlete's foot, cracks at corner of mouth

Scale – dried fragments of sloughed epidermal cells, irregular in shape and size and colors are white, tan, yellow or silver; Due to increased proliferation of epidermal cells; outer layer does not shed fast enough to keep up with proliferation, thus scales on top of scales; Ex: dandruff, dry skin, or psoriasis

Scar – Abnormal formation of connective tissue that replaces normal skin Ex: surgical incision, or healed wound

Crust (natures bandaide)– dried serum, sebum, blood, or pus on skin surface producing a temporary barrier to the environment; Brown or honey colored = bacterial; dark = blood; Ex: impetigo, eczema, scab on abrasion

Ulcer – loss of epidermis and dermis; crater-like, irregular shape Ex: pressure ulcer, chancre

Atrophy – depression in skin resulting from thinning of epidermis or dermis; Ex: aged skin, striae

Excoriation – area in which epidermis is missing exposing the dermis; Ex: scabies, abrasion or scratch

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Diagnostic Tests Refer to Table 22-10, pg. 485

KOH – (potassium hydroxide) – Hair, scales, or nails examined for superficial fungal infection

- Specimen is put on a glass slide and 10 %- 20% concentration of potassium hydroxide added

Culture – Identifies fungal, bacterial, and viaral organisms.Fungi- scraping performed if fungus is systemic involving the skinBacteria- material obtained from intact pustules, bvullae, or abscessViruses- bullae scarped and exudates taken from center of lesion

Tzanck Test- Fluid and cells from vesicles examined- Used to diagnose herpes infections- Specimen put on slide, stained and examined microscopically

- Use sterile technique for collection of fluid

Mineral Oil Slides – To check for infestations, scrapings are placed on slide with mineral oil

Wood’s lamp (black light) Exam – Examination of skin with long-wave ultraviolet light causes specific substances to fluorescent (Pseudomonas organisms, fungal infections, Vitiligo)

Patch test – Used to determine whether patient is allergic to any testing material

- Small amount of potentially allergenic material pallied under occlusion, usually to skin on back

- Instruct pt. to return in 48 hr for removal of allergens and evaluation

Biopsy – Removal of tissue specimen for histologic examination (cellular assessment under microscope)

Punch Biopsy – circular instrument cuts down into epidermis, dermis, and SC tissues; the opening may need to be closed with sutures Excisional Biopsy – done when necessary to be sure to remove entire lesion; suture needed Incisional Biopsy – elliptical incision made in lesion too large to excise; does not cause extensive cosmetic defect Shave Biopsy – tissue obtained by cutting or shaving; goes through epidermis and upper portion of dermis; no need for sutures; little or no scarring* Verify that consent form is signed if needed

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Sun Exposure Wear broad spectrum sunscreen with a sun protection factor (SPF) of 15 or higher Protection – wear large-brimmed hat, UV-blocking sunglasses, long sleeved shirt of lightly woven fabric, carry umbrella Avoid unnecessary sun exposure especially during sun’s peak hour 1000 – 1600 Avoid tanning parlors and artificial tanning devices (sunlamps) Examine skin had to toe Q monthly Have professional skin exam annually Photosensitizing medication – tetracycline, NSAIDS, thiazide diuretics and tricyclic antidepressants) increases skin’s sensitivity to sun

Actinic Keratosis (AK) (Solar Keratosis)- is a pre-malignant form of squamous cell carcinoma that affects nearly all of the older white population Small crusty, scaly, or crumbly bump or horn arises from skin surface Color May itch or produce pricking or tender sensation Size –eighth – quarter of an inch ( 2-4 mm) or large as an inch; several at a time Location Dangerous – precursor of cancer or a pre-cancer

Actinic Keratosis (AK) Assessment – Cause – chronic sun exposure; artificial sources (tanning devices) Greatest Risk –

Treatment Cryosurgery – Liquid nitrogen applied to growth with spray device or

cotton-tipped applicator to freeze them; crusted & fall off; minimal side effect – redness, swelling, dark skinned individual may be loss of pigment

Curettage & Desicccation – lesions suspected to be early cancer – biopsy specimen taken by shaving of top of lesion with a scalpel or scraping of with curette, then curette used to remove base of lesion; bleeding stopped with electrocautery needle; wound care afterward

Topical 5-fluorouracil (5-FU) - creates a therapeutic inflammatory

response that causes erythema, vesicles, erosion, ulcerations, necrosis and finally epithelialization; Pin meds and topical corticosteroids may be used to enable to withstand process.

* Teach client it will get worse before it gets better & avoid sun during tx

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Imiquimod cream Gel with hyaluronic acid & anti-inflammatory drug diclofenac Chemical Peeling Laser Surgery Photodynamic Therapy (PDT)

Basal Cell Carcinoma

#1 most common skin cancer, least deadly Malignant epithelial tumor of skin arising from basal cells of epidermis; basal layer of skin SSx Small fleshy bump or nodule – dome shaped papule with well –defined borders; flesh –colored “pearly” or shiny appearance – dose not keratinize Painless Slow growing Rarely metastasizes, but can invade and destroy local tissue; invade bone and brainTreatment- Multiple treatment modalities are used depending on the tumor location and histologic type, history of recurrence, and partient characteristics- Electrodessication, curettage, excision, cryosurgery, radiation therapy, Mohs’ micrographic surgery, topical chemo, and intralesional alph-interferon.

Squamous Cell Carcinoma

- Second most common skin cancer among fair-skinned persons (rarely found in dark-skinned persons)- Malignant tumor of epidermal keratinocytes found in areas of sun exposure – long term exposure; outer layer of skin (the epithelium)SSX

- Early- firm nodules with indistinct border w/ scaling and ulceration; opaque

- Late- Covering of lesion with scale or horn form keratinization; most common on sun exposed areas such as face and hands

Treatment- Surgical removal, cryosurgery, radiation, chemo, Mohs’ procedure or

microscopically controlled excision, electrodessication, and curettage; untreated lesion possible metastasizes to regional lymph nodes; high cure rate with early detection and Tx

Malignant Melanoma

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Tumor in melanocytes (cells producing melanin) Deadliest form of skin cancer but least common Linked to excessive sun exposure; most often found in whites, Dark brown or black skin is not a guarantee against melanomaSSx Scaling, oozing, and /or bleeding nevus (mole) or other pigmented lesion

ABCDs of Melanoma

A symmetry – one side does not look like the other side

B order Irregularity – edges are ragged or uneven

C olor – more than one color present- streaks of tan, brown, black, red, blue, white

D iameter – larger than size of a pencil eraser (6 mm) or has changed shape

TreatmentIntial treatment is surgery.

Pruritus Itching Caused by any physical or chemical stimulus to the skin – drugs, insects, dry skin Itch-scratch cycle must be broken (protective barrier) to prevent excoriation Keep fingernails short Mitten or gloves especially at bedtime Heat or rubbing (causes vasodilation) avoided Dryness of skin lowers the itch threshold & increases itch sensation Emollients – moisten and lubricate skin – apply to moist skin Pat dry & not totally dry

Eczematous Disorders/Dermatitis Acute or Chronic Erythema Papules Vesicles Pustules Scales Crust Scars Dry or Wet Varying degrees itching /burning

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Medication Vehicles Powders Lotions Creams Ointments Emollients

TOPICAL MEDICATIONS

Lotions – suspension; powder in water require shaking (calamine); applied directly to skin, may use dressing soaked in the lotion Powders – have a talc, zinc , bentonine or cornstarch base ; dusted on skin with shaker or cotton sponge Creams – suspensions or oil in water or emulsions of water in oil (may cause contact dermatitis); rubbed into skin by hand; moisturizing & emollient effects Gels – semisolid emulsions become liquid when applied to skin or scalp Pastes – mixtures of powders & ointments used to protect the skin; applied thickly with a tongue blade or a gloved hand Ointments – retard water loss and lubricate and protect skin; apply to clean skin and spread evenly in a downward motion small amount on affected area; ensure even distribution

Atopic Dermatitis (Eczema)

Patho – associated with allergic conditions, elevation of IgE levels common, genetically determined, often family hx; decrease itch threshold, stress, & increased water contact (hand washing) SSx – scaly, red to red-brown, circumscribed lesions; accetntuation of skin markings; pruritic; symmetric eruptions common in antecubital and popliteal space in adults Treatment – Hydration (water) & Lubrication; soak in tipid water 3-4 x day; Aveno in bath for itching; pat dry, don’t rub & scrub;

Contact Dermatitis

Irritant contact dermatitis – perfumes Allergic contact dermatitis – delayed hypersensitivity reaction (type IV); occurs when skin is exposed to substances that easily penetrate the skin and combine with epidermal proteins, the substance becomes antigenic ( nickel, mercury, rubber, catchols in poison ivy, poison oak, cosmetics) SSx - Red, hive like papules and plaques; sharply circumscribed with occasional vesicles; exposed areas more common; usually pruritic; relation

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of area of dermatitis to causative agent. Treatment- Topical corticosteroids, antihistamines; skin lubrication; elimination of contact allergen; avoidance of irritating affected area; systemic corticosteroids if sensitivity severe

Stasis Dermatitis Patho – Impaired venous circulation/insufficiency to lower extremities, inability to get circulation SSx –

Treatment 1. 2. 3. 4. Comparison of Compression Therapy Put the squeeze of venous ulcers – compression is the cornerstone 4. Unna’s Boot – a fixed protective dressing; stimulates granulation tissue and epithelial growth. Protects and enhances venous circulation like TED hose. Dressing soaked with zinc oxide, glycerin and gelatin – after application it hardens into a cast-like substance. Start at top of foot and work up to just below knee. Remove weekly to assess and reapply. Must teach pt and family to watch for pain, drainage, fever, warmth, swelling (all could mean infection); they should return ASAP with these findings and not wait until next appointment 5. Skin grafts may be necessary

Other Wound Care Principles Assess & treat underlying problems as part of wound management protocol (obesity, CV disease, DVT, family hx of varicose veins) - impair healing – expertise of other team members Clean wound regularly & prepare pt for aggressive debridement if indicated Wound characteristics – size, presence or absence of infection and characteristics of surrounding skin Wounds heal best in moist environment Moisture-retentive dressing (hydrocolloid, transparent film & certain foams) – wounds with light to moderate drainage Absorbent dressing (foams, alginates & specialty absorptive dressings – moderate to heavy exudate

Intertrigo Patho – surfaces rubbing against each other - skin breakdown, large areas, under breast, pendulous abdomen, rolls of skin tissue; moisture, obesity, Monilia infection (yeast) SSx – Dermatitis of overlying surfaces of skin Treatment –

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Psoriasis Patho – Inflammatory disorder- certain immune cells become overactive and release proteins called cytokines which cause proliferation of keratinocytes (skin cells) and the growth of small blood vessels that supply blood and nutrients to the affected area; skin cells grow much faster than they should SSx – Treatment

Common Bacterial Infections (Pyodermas)

Cellulitis Patho – infection in skin; inflammation of subcutaneous tissue; not clearly demarcated; staph aureus, strep; Local SSx – Treatment – Moist heat, immobilization (bedrest) and elevation, ABX,

Erysipelas Patho – Superficial cellulitis involving the dermis; group A β-hemolytic strip SSx – Red, hot sharply demarcated plaque, indurated & painful, fever, Leukoctyosis WBC Treatment – Same as cellulites – PCN

Impetigo - Peds

Viral Infections of Skin

Herpes Zoster (Shingles) Patho – Same virus as chicken pox (varicella-zoster) dormant; ends up along nerve root in body from chicken pox years ago. Occurs in immunocompromised pt – chronically ill, transplant, older adults SSx – Treatment – Symptomatic, antiviral agents – acyclovir, Zovorax; wet compresses, analgesia, mild sedation at HS, systemic steroids; TX: for post therapeutic neuralgia (PHN) – gabapentin (Neurontin) & tricyclic antidepressants (TCAs) amitriptyline (elavil or nortryptyline (Pamelor); extended-dose opioid pain meds – oxycodone (OxyContin) or fentanyl (Duragesic Patch)

Herpes Zoster (Shingles) – Interventions

Rx TCAs and opioids – stay well hydrated, select high-fiber foods;

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use fiber laxative or stool softener to avoid constipation; carefully assess for suicidal ideation & promptly refer for tx if needed Shingles itself not contagious – close exposure can pass varicella virus to others, causing initial episode of chickenpox; pts with open lesions educate to reduce exposing others (unvaccinated, immunocompromised or pregnant individuals who never had chickenpox Profound itching – discouraged scratching; measures to protect skin and reduce risk from bacterial infection important Soothing oatmeal baths, painted-on topical lotions (calamine or Benadryl; application of washcloths with cool water; Domeboro astringent and gel from aloe vera plant relieve itching & pain

Fungal Skin Infections

Candidiasis Patho – caused by Candida Albican (moniliasis); present in warm, moist areas such as crural (leg or thigh, femoral area), oral mucosa, and sub mammary folds; depression of cell mediated immunity allows yeast to become pathogenic SSx –

Treatment – Antifungals, nystatin or other specific meds for vaginal suppository, oral lozenge; keep skin clean and dry, Mycostatin powder

Tinea – Fungal Infection

Patho – Also called ringworm because of characteristic appearance of ring or rounded tunnel under skin

Types of tinea infection Tinea Corporis – dermtophytes; ringworm on body; red macular/papular; annular appearance, well-defined margins; active border with clearing center Tinea Capitis – ringworm scalp; patchy loss of hair Tinea Cruris – jock itch, well defined border in groin area; itchy, painful, red, raw Tinea Pedis – athlete's foot; interdigital scaling, and maceration, erythema and pruritus, painful

Treatment of Tinea InfectionsParasitic Skin Infestations

Pediculosis (Head lice, Body lice, Pubic lice

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Patho – parasites suck blood, leave excrement and eggs on skin, live in seams of clothing (body lice) and in hair as nits; transmission of pubic lice often by sexual contact SSx – minute red non inflammatory; points flush with skin; progression of wheal-like lesions, pruritus, secondary excoriation (parallel linear

Scabies Patho – infestation of skin with itch mite Sarcoptes scabie, penetrates stratum corneum; deposits eggs, allergic reaction resulting from presence of eggs, feces, mite parts; transmission by direct physical contact SSx Treatment

Nursing Management

Wet Dressing – used when skin is weeping from infection or inflammation (water, NS); also used to relieve itching, suppress inflammation and debride a wound; left in place 10-30 mins, 2-3 x’s/day; avoid maceration (softened) skin; protect for discomfort and chilling by using linen & bedclothes with pads or plastic

Baths (balneotherapy) – used when large body area need to be Tx; sedative antipruritic effects; tub full enough to cover effected area; soak 15-20 mins 4 x’s/day; stress importance that skin should not be rubbed dry with a towel but gently patted to prevent irritation and inflammation; oils make tub slippery, safety

Nursing Care Plan (Chronic Skin lesions)

Refer to NCP 23-1, pg. 504 Risk for infection Impaired skin integrity Situational low self-esteem Psychological impact – psychic pain it can cause “They glance at me and glance away, pained. My hands and my face mark me. The name of the disease, spiritually speaking is Humiliation”( Lead to social isolation, situational low self esteem) novelist John Updike developed condition as child (psoriasis) Ineffective health maintenance Social isolation

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