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INTEGUMENTARY SYSTEM Dermatology-study of skin diseases Dermatologist-physician who specializes in this field Dx Tests: Direct observation Diagnostic tests can be used to determine the origin of the skin disorder Wood’s light-use of UV rays to Dx pigment abnormalities, can also detect superficial fungal and bacterial infections Tzanck’s smear-examination of cells and fluids found in vesicles (ex. Herpes zoster and Varicella), they are applied to a glass slide and examined using a microscope Dx Tests: Biopsy-removal of skin-tissue specimen for microscopic exam to determine malignancy or to Dx a skin disorder Scabies scraping-shave off the top of a suspected lesion, place on a glass slide covered with immersion oil and examine the slide under a microscope Pruritis (Itching) Sx of skin disease Can also be caused by systemic disorders, dry skin Scratching is inevitable, and causes skin breaks which can result in scarring and infections Tx: divert attention, hypnosis Administer medications: antianxiety (hydroxyzine-Ataraz, Vistaril), antihistamines (diphenydramine-Benadryl, fexofenadineAllegra), topical corticosteroids Pruritis prevention Rinse clothes in clear ater Use soothing baths (colloidal oatmeal, starch) Apply lotion to dry skin Keep fingernails short, wear cotton gloves or cotton socks at night Lightly slap, rather than scratch the itching area Pruritis (Itching) Therapeutic baths Purposes: Cleanse body and soothe skin Promotes wound healing Relieves itching Aids in the removal of eschar Aids in prevention of infection Monitor for infection Give this type of bath in a WP or bathtub, disinfect after each pt. Use Don’t use soap (dries the skin), use medicated bath oil Tepid water-temp 100F (heat makes one itch) Pat the skin dry, rubbing increases pruritis Moist Dressings Moist packs reduce edema and weeping in acute dermatitis -soften and remove exudate and crusts -clean or sterile -closed dressing-covered with plastic or a firm material open dressing-not covered, tissues need O2 to prevent necrosis -requires frequent dressing changes or resoaking q2 hours MD will order the type of dressing or medication to use Skin infections Contact dermatitis Caused by allergic reaction Mediated by IgE Cellulitis Skin infection s/s include red, warm, painful area Wound Debridement Physician or Surgeon will remove loose skin, crusts, eschar or denuded (protective) tissue Sterile procedure that is often performed when changing moist packs Autolysis Uses bodys own enzymes to rehydrate wound and dissolve slough Enzymatic debridement Using commercially prepared chemical enzymes to the necrotic tissue Surgical debridement Uses a scalpel or scissors to remove slough and eschar Mechanical debridement Utilizes wet to moist or wet to dry dressings Surgical Treatments Plastic or Reconstructive Surgery- improves disfigurement, may be performed for cosmetic effects, to repair congenital defects or repair trauma tissue Skin and Tissue Grafts Skin grafts are used to cover areas of skin lost from burns, infections or wounds Graft-transplant of skin that is placed on viable tissue -very painful -may take months to heal, depending on success Free graft-skin completely removed from its original site and grafted on to the recipient site Pedicle graft-one end of the graft remains attached to the donor site so that new circulation is established Nursing Considerations: Explain procedure Can expect postop edema, ecchymosis Protect sites, grafts Provide emotional support Nursing Process Data Collection Assess the skin: report any changes in color or turgor Fluid and Electrolyte Balance Encourage the client to drink and eat Provide high Kcal, high protein meals Observe and document I & O Emotional Support Allergies Known food or drug allergies may aggravate skin conditions Acute and Chronic Skin Conditions Urticaria (hives) S/S: edematous, raised pink areas called wheals Wheals itch and burn May disappear quickly or stay for days Most commonly caused by an allergic reaction to meds, foods, spores or pollens Chronic urticaria lasts longer than 6 weeks, cause is unknown in 80-90% of adults Angioedema May be life threatening: extreme swelling of the lips, around the eyes and dyspnea TX: removal of cause, tepid baths, antipruritic lotions, epinephrine for severe cases Vitiligo Occurs when areas of skin lack in pigmentation Results in patches of pale or white looking skin Cause unknown Can also use cosmetics to cover birthmarks Surgical tx: grafting and melanocyte transplantation Albinos are unable to produce melanin Vitiligo Eczema (atopic dermatitis) Sx: small vesicles appear along with red and pruritic skin, when the vesicles burst and ooze, crusts form Viral, bacterial or fungal skin infection may develop Cause unknown but heredity, allergy, and emotional stress can contribute Most commonly found in the folds of the elbow, back of the knees, on the face, neck, wrists, hands and feet Eczema Eczema Eczema (atopic dermatitis) Tx: prevent dry skin, cracking and itching Apply moisturizing creams-Eucerin, corticosteroid ointments, or wet dressings Use lanolin free lotions Meds: Topical corticosteriods-exert localized antiinflammatory activity, reduce swelling, redness, itching Psoriasis Chronic, noncontagious disorder that affects young adults and middle aged adults Epidermal cells proliferate and form small, scaly patches of skin Cause is unknown but hereditary, environmental, metabolic or immune factors contribute to breakouts Stress and anxiety precede exacerbations of the disorder Psoriasis S/S: red papules covered with silvery, yellow-white scales that the client sheds Patches appear on the elbows, knees, scalp and lower back, the nails may loosen at the fingertips (onycholysis) Tx: reduce scaling and itching, corticosteroids and methotrexate Psoriasis Psoriasis Infections Warts (verrucae) Small, flesh-colored, brown or yellow papules caused by HPV Common warts-found on the hands (esp. children), or on other sites subjected to trauma Filiform warts-slender, soft, thin, finger-like growths seen on the face and neck Plantar/palmar warts-firm, elevated or flat lesions occurring on the soles or palms Tx: electrodessication-short duration of high frequency electrical current or curettage-scraping or suctioning is the treatment for filiform warts Warts Infections Condylomata acuminate-venereal warts Grow in warm, moist body areas, skinfolds Usually develop in clusters Found on the foreskin and the penis or on vaginal and labial mocosa and the urethral meatus or perianal area Spread by sexual contact Infections TX-WARTS (cont.) Cryosurgery-application of liquid nitrogen Keratolytic agents-removes excess growth of the epidermis. Used to remove warts, callusues, and corns Ex. Salicylic acid may cause salicylate toxicity Wart Cryosurgery Bacterial skin infections Impetigo-contagious among infants and young children Caused by strept or staph Vesicles ooze a clear exudates that develops into golden-yellow crust that causes discomfort and pruritis Tx: systemic antibiotics Good handwashing Wear gloves when bathing the client or treating lesions Meds: mupirocin (Bactroban) Adv. Rxns: burning, stinging, pain, itching, rash, nausea, dry skin Impetigo Impetigo Bacterial skin infections Folliculitis-white pustules or follicular nodules A staph infection starting around the hair follicle Moisture, trauma and poor hygiene can contribute Deep folliculitis-on face Superficial folliculitis-responds to antibacterial soap cleansing or topical antibiotics Furuncle (boil) –firm, red, tender nodule May drain pus and finally extrude the core Core is dead tissue that can drain by itself or be reabsorbed into the skin Can also be I & D Bacterial skin infections Furuncle Found in areas of hair-bearing skin, esp. the face, scalp, buttocks and axillae Furunculosis-recurrent boils on people who have the staph organism Carbuncle-interconnecting boils in a cluster Drains at multiple sites Mostly located on the back of the neck, the back and the thighs Tx: warm, wt dressings or soaks to localize the boil and carbuncle infections to one spot I & D large boils Oral antibiotics after a sensitivity test Furuncle Parasitic Infections Scabies (mites that burrow under the outer layer of the host’s skin)-intense itching, red spots appear with rows of blackish dots with tiny vesicles and depressions Mostly found between the fingers Mites can live for months or years in people if left untreated Infection can be transmitted through clothing, linens, or towels Meds: lindane (Kwell) Leave medication on for 8-24 hours and then bathe thoroughly, repeat tx. In one week Scabies Scabies Lice-Pediculosis Pediculosis humanus capitis head lice Pediculosis humanus corporis-body lice Phthirus pubis, pediculosis pubis-pubic lice Survival depends on sucking blood Difficult to get rid of Nits (eggs) can live for a long time on clothes, bedding, furniture S/S: presence of nits, extreme pruritis Tx: permethrin (Elimite, Nix) and pyrethrings (RID), apply to hair for 5-10 minutes, rinse with water. Remove the nits by combing the hair with a fine-toothed comb, apply petroleum to the eyelashes and eyebrows to remove nits ALL LIVE LICE AND NITS MUST BE DESTROYED TO PREVENT RE-INFESTATION!! Bedbugs-Cimex lectularius 4-5 millimeters and can survive up to 1 year without food Live in clothing or bedding and are difficult to get rid of Bites appear as red macules that develop into nodules Bites often appear in groups of three, and bite the legs and feet resulting in itching and burning Tx: lotions containing menthol, phenol, or 0.5% hydrocortisione cream Spray all crevices in furniture with an insecticide Sebaceous Gland Disorders Sebaceous Cysts-secrete oil and when plugged with oil, small nodules form called cysts Usually not treated unless they become large and then they are I & D Seborrhea, Seborrheic Dermatitis and Dandruff Seborrhea-sebaceous discharge that forms large scales or cheeselike plugs on the body Seborrheic dermatitis causes scaling, primarily of the scalp that itches Sebaceous gland disorders Dandruff-dry form of seborrheic dermatitis Scales range from small and dry to thick and powdery Oily form of seborrheic dermatitis is characterized by greasy or ily scales and crusts on a red base Tx: Shampoo frequently with selenium sulfide suspension (Selsun Blue) and leave on for 5-10 minutes If lotions or solutions contain steroids, use sparingly Burn depth and size Partial-thickness-superficial, moderate and deep- dermal burns 1st degree and 2nd degree Full thickness (3rd degree)-includes all the characteristics of 1st and 2nd degree burns along with subq. Fat, connective tissue, muscle and even bone. See table 74-2 in book Classification: Thermal-most common, caused by steam, hot water, flames and direct contact with heat sources. Electrical – Caused by electric shocks due to exposure to lightning or electricity Chemical – caused by exposure to acids, alkalis or other organic substances. Radiation – exposure to the radiation, sun First aid for minor burns Box 75-2 Cool area Cover burn with sterile gauze Relieve pain Monitor “Rule of Nines” Used in determining% of body burned Adults: Head=9% Each arm = 9%, front 4.5%; back 4.5% Each leg = 18% Front or back = 18% Genitals = 1% Phases of Burn Injury Management Immediately – apply cold packs or cold water Resuscitative phase: Initial hours after burn, stabilize immediate health concerns!! Burn care unit Goal of this phase is to achieve physiologic stability!! Always wash hands, use sterile gloves V/S NEVER apply ointments to an extensive burn!!!! Monitor respiratory status-rate and depth of respirations Suspect inhalation injury if client was in a closed in area with fire and smoke Observe for singed nasal hairs Report cough immediately!! Note amount and character of sputum-black/gray indicates smoke inhalation May need O2, keep an ET tube or trach tube at bedside Prevent pneumonia Fluid and Electrolyte Balance: Lose body fluids from capillary leaks and open wounds, require large amounts of IV fluids particularly containing sodium (replace fluids) Record I&O!! Assess electrolytes: potassium, sodium Renal Function: Monitor urine output hourly, decrease could show shock If u/o is less than 30mls/hr. dialysis may be needed. Infection: Leading cause of death for burn clients May be placed in protective isolation to prevent exposure to pathogens Pain Management Assess pain level, location Superficial burns have more pain that full-thickness burns because the nerve endings have been destroyed PCA may be used Morphine – Monitor RR!! Imagery, distraction may also be used Some cultures may not use drugs to relieve pain Acute Phase: Client remains ill and requires continuous assessment, focus on the burn wound Dressings such as OpSite, DuoDerm (synthetic) promote healing and cover the wound Tight occlusive dressings help to prevent keloid (scar) tissue Acute Phase: Topical agents: Mafenide Acetate (Sulfamylon) Associated with c/o burning after application Silver sulfadiazine (Sivadene) Bacitracin ointment Used for superficial and facial burns applied as a thin layer 2-3 times/day Silver Nitrate Acute Phase: Topical proteolytics (enzymes) may be used to remove dead tissue Debridement-removing eschar, exposing living tissue WP is used, more comfortable MD’s can use laser scalpels or scalpels to excise eschar Burns Skin grafting-replaces tissue that does not heal or can be used for cosmetic reasons Autograft-uses the client’s own skin, MD cuts slices of skin from an unaffected part of the client’s body and places these graft on the affected areas Homograft/Allograft – cadaver skin Take immunosuppressive meds to prevent rejection Burns Heterograft/Xenograft – using pigskin **The client’s body will reject in 1 week but the pigskin will aid the body in fluid retention, promote healing and prevent infection CEA – cultured epithelial autografts Biopsy is performed on unburned skin and grows new skin, used to cover extensive burns Pedicle graft-skin remains attached on one end Grafts DO NOT DISTURB SKIN GRAFTS! They need to attach to the live tissue underneath and grow Other Considerations Diet high in calories, nitrogen, and protein Monitor wound drainage Administer LR (per MD order) STRICT I&O Rehabilitative Phase Lasts months to years May need PT Service for WP tx’s Financial assistance Complications: anemia Infections, GI disturbances, pneumonia, kidney failure, anemia, skin ulcers, contractures (ROM) Escharotomy may need to be performed to relieve tension on skin. Rehabilitative Phase Curling’s ulcers-may develop 1 week after the injury causing a GI bleed Occurs when gastric mucosa becomes ischemic, excess hydrogen ions, inadequate mucosal cell proliferation Monitor GI pH, internal feedings, medications that reduce stomach acid Provide emotional support Teach: wound care, meds, s/s infection Neoplasms: New growths, tumors Malignant Benign NEOPLASMS Nonmalignant tumors are warts, angiomas, keloids, cysts and nevi (moles) Moles may become malignant Angiomas can be difficult to remove, or they may often go unnoticed. Birthmarks or vascular skin tumors involving underlying tissues and blood vessels Port-wine angioma-difficult to remove Most angiomas are not noticeable or dangerous Keloids – benign overgrowths that develop at scar sites Skin Cancer Most common Most curable Caused by sun exposure Light skinned, light-eyed people or those that burn vs. tan are at the highest risk A deeply pigmented mole should be checked American Cancer Society rules for mole evaluation: Asymmetry Border Color Diameter Skin Cancer Tx: curettage, electrodessication, cryosurgery, or wide excision Pathologist examines the tissue Basal cell carcinoma-small, fleshy bump or nodule Found in UV exposed tissues, head and neck Most common type Skin Cancer Basal cell carcinoma Found in areas exposed to sunlight or UV light Most common form of skin cancer Skin Cancer Squamous cell carcinoma – appears as a nodule or red, scaly patch Found on rim of ear, face, lips, or mouth May metastasize, increases in size and develops into large mass 95% cure rate with surgery! Malignant melanoma – darkly pigmented mole or skin tumor Most virulent of all skin cancers May metastasize to the skin, bone, brain, and lung Skin cancer prevention Box 75-3 Avoid midday sun SPF of 15 or higher Avoid sunlamps and tanning beds Premature aging of skin and subsequent skin cancer is associated with UVA rays of the sun and tanning bed bulbs (d/t loss of collagen) Miscellaneous skin problems Closed comedones-whiteheads Fungal infection Tinea corporis Ringworm-passed from human to human Shingles Herpes Zoster Incubation period is 14-21 days Rash appears on the face and trunk and then develops into blisters surrounded by a red ring Herpes Zoster/Shingles
