Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
CHAPTER 23 The Integumentary System © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-2 Learning Outcomes (cont.) 23.1 Describe the functions of skin. 23.2 Describe the layers of skin and the characteristics of each layer. 23.3 Explain the factors that affect skin color. 23.4 Summarize types of common skin lesions. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-3 Learning Outcomes (cont.) 23.5 Describe the accessory organs of skin along with their structures and functions. 23.6 Explain the process of skin healing, including scar production. 23.7 Describe the common diseases and disorders of the skin. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-4 Introduction • Integumentary system – Skin • • – Body’s outer covering Largest organ Accessory organs: • Hair follicles • Nails • Skin glands © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-5 Functions of the Integumentary System • Protection – First line of defense • Bacteria • Viruses – Protects underlying structures • UV radiation • Dehydration © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-6 Functions of the Integumentary System (cont.) • Body temperature regulation – If too hot • • Dermal blood vessels dilate More blood to surface so heat escapes – If too cold • • Dermal blood vessels constrict Prevents heat from escaping © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-7 Functions of the Integumentary System (cont.) • Vitamin D production – Skin must have sunlight – Needed for calcium absorption • Sensation – receptors • Excretion – perspiration © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-8 Apply Your Knowledge What are the functions of the integumentary system? ANSWER: The functions of the integumentary system are protection, regulation of body temperature, vitamin D production, sensation, and excretion. Super! © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-9 Skin Structure • Epidermis • Dermis • Hypodermis or subcutaneous layer © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-10 Epidermis • Superficial layer of the skin • Major layers – Stratum corneum • Outermost layer • Mostly dead cells form an impermeable layer – Stratum basale • Deepest layer • Cells constantly dividing and pushing older cells outward To Figure of Skin © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-11 Epidermis (cont.) • Cell types – Keratinocyte • Most common • Makes and accumulates the protein keratin – Melanocyte ~ makes the pigment melanin © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-12 Dermis • Deeper, more complex • Contains all major tissues, plus – Sudoriferous glands – Sebaceous glands – Hair follicles and arrector pili muscles – Collagen, elastin, and nerve fibers – Blood vessels To Figure of Skin © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-13 Subcutaneous Layer • Hypodermis • Composed of – Adipose (fat) and loose connective tissue – Blood vessels and nerves To Figure of Skin © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-15 Apply Your Knowledge What are the layers of skin and what is their function? ANSWER: Epidermis – superficial outer layer; cells produce keratin which makes it waterproof and resistant to bacteria and viruses; and melanin which absorbs UV radiation. Dermis – most complex layer; contains all major tissue types; binds epidermis to subcutaneous tissue Subcutaneous layer – inner most layer of adipose and loose connective tissue; the adipose cushions and insulates underlying structures and organs. Excellent! © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-16 Skin Color • Determined by amount of melanin and activity of melanocytes • Genetic trait © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-17 Skin Color (cont.) • Oxygenated blood – Oxygen dissolved in the hemoglobin of the red blood cells – Well-oxygenated blood ~ pink skin – Poorly oxygenated blood ~ pale or bluish skin © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-18 Apply Your Knowledge What affects skin color? ANSWER: The amount of melanin produced by the melanocytes and the oxygenation of the blood. Nice Job! © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-19 Skin Lesions • Any variation in the skin – As simple as a freckle – As serious as a tumor © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-20 Skin Lesions (cont.) • Primary – originate from disease or body changes • Secondary – reaction to external trauma • Vascular – anomalies of blood vessels © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-21 Skin Lesions (cont.) Lesion Name Bulla Description A large blister or cluster of blisters Cicatrix Crust A scar, usually inside a wound or tissue Dried blood or pus on the skin Ecchymosis A black-and-blue mark or bruise Erosion A shallow area of skin worn away by friction or pressure © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-22 Skin Lesions (cont.) Lesion Name Excoriation Fissure Keloid Macule Nodule Description A scratch; may be covered with dried blood A crack in the skin’s surface An overgrowth of scar tissue A flat skin discoloration, such as a freckle or a flat mole A large pimple or small node © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-23 Skin Lesions (cont.) Lesion Name Papule Petechiae Plaque Purpura Pustule Description An elevated mass similar to but smaller than a nodule Pinpoint skin hemorrhages that result from bleeding disorders A small, flat, scaly area of skin Purple-red bruises usually due to clotting abnormalities An elevated (infected) lesion containing pus © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-24 Skin Lesions (cont.) Lesion Name Scale Description Vesicle Thin plaques of epithelial tissue on skin’s surface A swelling of abnormal tissue growth A wound that results from tissue loss A blister Wheal Another term for hive Tumor Ulcer © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-25 Apply Your Knowledge Match the following: C Keloid ___ ANSWER: A. A blister A Vesicle B. A crack in the skin’s surface ___ E Crust ___ C. An overgrowth of scar tissue B Fissure D. A small, flat scaly area of skin ___ F Ulcer ___ E. Dried blood or pus on the skin D Plaque ___ F. A wound that results from tissue loss © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-26 Accessory Organs • Hair follicles – Tube-like depressions in the dermis of skin – Generate hairs – Alopecia – follicles die – Arrector pili ~ muscles that pull on follicles Diagram © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-27 Accessory Organs (cont.) • Sudoriferous glands • – Eccrine glands • Watery sweat • Activated by heat – Apocrine glands • Thicker sweat • Armpit and groin areas • Activated by nervousness or stress Sebaceous glands – Produce sebum to keep hair soft – Prevent bacteria from growing on skin Diagram © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-28 Accessory Organs • Nails – Protect the ends of fingers and toes – Epithelial cells with hard keratin – Nail body – Nail root – Lunula – Nail bed © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-29 Apply Your Knowledge ANSWER: Matching: A.Sudoriferous glands B.Sebum C.Apocrine glands D.Hair follicles E.Nails F.Eccrine glands G.Alopecia H.Sebaceous glands I.Arrector pili Perfect! D tube-like depressions in the skin’s dermis; generate hairs G baldness F produce watery type of sweat I muscles attached to hair follicles; cause “goose bumps” A produce sweat H produce sebum B keeps hair soft and pliable E protect the ends of fingers and toes C become active during puberty © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-30 Skin Healing • Injury inflammation – Redness due to dilation of nearby blood vessels – Swelling because vessels leak fluid into spaces between cells – Pain because excess fluid activates pain receptors © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-31 Skin Healing (cont.) • Inflammation promotes healing – Extra blood to area – Extra nutrients – Defensive cells Scab replaces blood clot Collagen fibers replace scab Injury occurs Blood clot forms Clotted blood and other dried tissue Binds the edges of wound; scar may form © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-32 Apply Your Knowledge How does inflammation promote healing of the skin? ANSWER: Inflammation promotes healing by bringing extra blood, nutrients for skin repair, and defensive cells to the area of injury. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-33 Common Diseases and Disorders of the Skin • Burns – Extent of body surface area and degree of a burn – Rule of nines is used to determine extent of burn • Estimate body surface area • 11 body areas © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-34 Burns Head and neck 9% Anterior trunk 18% 4½% Anterior legs and feet 18% Posterior trunk and buttocks 18% Arms, hands, and shoulders 18% 4½% Perineum 1% 4½% 4½% Posterior legs and feet 18% Back © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-35 Burns (cont.) • Full-thickness • Superficial – Epidermis only – Pain, redness, swelling • Partial-thickness – Epidermis and dermis – All layers of skin and often underlying structures – Skin appears charred – Always requires medical attention – Pain, redness, swelling, blisters Burns © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-37 Burns (cont.) • General guidelines for treatment – Do not remove anything sticking to the burn – Do not apply butter, lotions, or ointments – Cool with large amounts of water © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-38 Burns (cont.) • General guidelines for treatment – Cover with sterile sheet or plastic bag – Contact emergency services – Check airways for swelling © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-39 Skin Cancer and Common Skin Disorders • Skin – vulnerable due to exposure • Skin cancer – Epidermis – Excessive exposure to sunlight – Types • Basal cell and squamous cell carcinoma • Malignant melanoma © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-40 Skin Cancer and Common Skin Disorders (cont.) • Basal Cell – Signs / symptoms • Growth or sore that will not heal • Waxy, smooth, red, pale, flat, or lumpy – Treatment • Curettage and electrodessication • Mohs surgery • Cryosurgery • Laser therapy © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-41 Skin Cancer and Common Skin Disorders (cont.) • Squamous Cell – Less common than basal cell – Flat cells of the epidermis – Found on face, lips, ears, and backs of hands – Signs and symptoms and treatments are the same as for basal cell carcinoma © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-42 Skin Cancer and Common Skin Disorders (cont.) • Malignant Melanoma – Signs / symptoms • Mole that itches or bleeds • ABCDE rule – Treatment • Surgery • Determination if cancer has spread • Chemotherapy and radiation therapy • Immunotherapy © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-43 Skin Cancer and Common Skin Disorders (cont.) Asymmetry – a mole should not become asymmetrical. Border – a mole should not have irregular borders and edges should not blur into normal tissue. Color – a mole should not change or become mixture of colors. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-44 Skin Cancer and Common Skin Disorders (cont.) Diameter – a mole should not grow larger than the diameter of a pencil eraser (6 mm.) Evolving – a mole that has been changing in size, color and appearance, or growing in an area of previously normal skin © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-45 Skin Cancer and Common Skin Disorders (cont.) Stages of Melanoma Stage 0 Only found in epidermis Stage I Stage II Spread to epidermis and dermis (1 to 2 mm thick) 2 to 4 mm thick and may be ulcerated Stage III Spread to one or more nearby lymph nodes Stage IV Spread to other body organs or lymph nodes far from original melanoma © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-46 Common Skin and Hair Disorders • Alopecia • Dermatitis – Inflammation of skin or a rash – Eczema ~ chronic dermatitis – Hair loss – Heredity • Cellulitis – Inflammation of connective tissue in skin – Red, tight, painful skin • Folliculitis – Swimmer’s rash – Inflammation of hair follicles © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-47 Common Skin Disorders (cont.) • Herpes simplex – Type 1 – Shingles • Cold sores • Spread through saliva – Type 2 – genital • Genital • Sexually transmitted – No cure • Herpes zoster – Chicken pox virus lies dormant – Symptomatic treatment – Vaccine © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-48 Common Skin Disorders (cont.) • Impetigo • Pediculosis – Oozing skin lesions that eventually crust over – Capitus ~ head lice – Corporis ~ body lice – Pubis ~ pubic lice – Highly contagious • Psoriasis – chronic, inflammatory skin condition © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-49 Common Skin Disorders (cont.) • Ringworm • Rosacea – Three types • Tinea corporis • Tinea capitis • Tinea pedis – Dilation of small facial blood vessels – Not curable – Dermatophytes – Antifungal agents © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-50 Common Skin Disorders (cont.) • Scabies • Warts – Contagious skin condition caused by mites – Redness and itching – Harmless growths caused by a virus – Vary in appearance – OTC medications – Treat entire family © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-51 Apply Your Knowledge 1. True or False: ANSWER: F Basal cell carcinoma is the most aggressive form of skin ___ cancer and can form anywhere. Melanomas are more aggressive. T Squamous cell carcinoma is more likely to spread to ___ surrounding tissues. T Lesions of melanoma appear on trunk, head, neck of ___ men and on arms and legs of women. F The borders of skin cancers are usually regular. ___ Borders are irregular. T Basal cell carcinoma progresses slowly and rarely ___ spreads to other body parts. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-52 Apply Your Knowledge 2. Using Figure for Rule of Nines, determine burn extent for a patient who has burns to his anterior face and both arms. Click for Rule of Nines ANSWER: Face = 4.5% Both arms, hands, and shoulders = 18% 4.5% + 18% = 22.5% It all adds up to a right answer! © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-53 In Summary 23.1 The functions of skin include: protection, body temperature regulation, vitamin D production, sensation, and excretion. 23.2 The topmost layer of the skin is the epidermis. The dermis is the complex middle layer. The innermost layer attaching the skin to muscle is the subcutaneous layer. 23.3 The amount of melanin affects and determines skin color. The amount of oxygen-carrying hemoglobin in the blood also affects skin color. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-54 In Summary (cont.) 23.4 Skin lesions are split among three main types: primary lesions such as macules and vesicles; secondary lesions, which include ulcers and keloids; and vascular lesions, which involve blood vessels and include telangiectasias and ecchymoses. 23.5 The accessory organs of skin include: hair follicles, arrector pili muscles, sebaceous glands, sudoriferous glands, and keratin-filled nails. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-55 In Summary (cont.) 23.6 Injured skin becomes inflamed from dilating blood vessels that leak and cause swelling. A blood clot is formed, which is replaced by a scab, which is then replaced by collagen fibers that produce scar tissue. 23.7 Common diseases and disorders of the skin include alopecia, cellulitis, dermatitis, eczema, folliculitis, herpes simplex, herpes zoster, impetigo, pedicuosis, psoriasis, ringworm, rosacea, scabies, and warts. © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part. 23-56 End of Chapter 23 We may have different religions, different languages, different colored skin, but we all belong to one human race. ~ Kofi Annan © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.