INTEGUMENTARY SYSTEM

Integumentary System Largest body organ Skin Hair Nails Glands

Integumentary System Epidermis Outermost layer of the skin Dermis Contains collagen Supports nerve and vascular network Succutaneous Fat and loose connective tissue

Structure Epidermis: Thin avascular, superficial layer Nourished blood vessels (dermis) Replaced every 28 days Types of cells: Melanocytes keratinocytes

Structure Melanocytes: Deep, basal layer Melanin Keratinocytes: Produce keratin: Stratum corneum

Structure Dermis Highly vascular Nerves, lymphatic vessels, hair follicles, sebaceous glands

Structure Subcutaneous tissue Beneath dermis, adipose tissue Provides insulation

Skin Appendages Hair: Except: lips, palms, soles Nails: Grows from matrix

Appendages Hair Primarily dead cells Hair root begins in bulb of hair follicle and grows from dermis upward Typical loss: hairs/day Melanocytes on bulb determine color Attached to Arrector pili muscles

Glands: Sebaceous (oil glands) Sebum: lubricates skin, decrease water loss aid in killing bacteria on skin surface Apocrine sweat glands Located in the axilla, anus, genital area Function: unknown Eccrine Sweat glands Sweat glands located on forehead, hands, soles of feet Maintain a stable temp for body (perspiration) when body is overheated

Integumentary System Functions: Protect underlying tissue of body Barrier against bacteria, virus, excessive water loss Sensory perception Synthesis of Vit D Esthetic function Absorption

Physical Assessment Inspection Color and pigmentation, vascularity, bruising Lesions or discolorations Palpation Temp, turgor, moisture, texture Percussion Auscultation

Abnormalities Alopecia Loss of hair Carotenemia Yellow discoloration (palms,soles)

Abnormalities Jaundice Yellowish discoloration of skin Sclera Cyanosis Bluish-gray, dark purple discoloratrion

Petechiae Pinpoint deposit of blood (1-2 mm) Telangiectasia/sp ider angioma Dilated, superficial, small blood vessels

Erythema Redness in patches of variable size/shape Ecchymosis Large, bluishlike lesion Hematoma Extravasation of blood with swelling

Assessment Hirsutism Male distribution of hair (women) Mole Benign overgrowth of melanocytes

Assessment Abnormalities Tenting Failure of skin to return immediately after gentle pinch Varicosity Increased prominence of superficial veins

Physical Assessment Comedo Enlarged hair follicle plugged with sebum, bacteria, skin cells (keratin) Closed: whitehead Open: blackhead

Primary Lesions (Non-palpable) Macule Flat, nonpalpable, circumscribed less than 1 cm Ex: freckle Patch Flat, non-palpable Irregular shape Greater than 1 cm in diameter vitiligo

Primary Lesion Papule Elevated, palpable, firm, circumscribed Less than 1 cm Wart, nevi Plaque Elevated, firm Greater than 1 cm in diameter psoriasis

Primary Lesions Nodule Solid elevated, circumscribed with palpable deeper portion to dermis 1-2 cm in diameter Lipomas Tumor Solid, elevated with palpable deeper portion greater than 2 cm Cyst Raised lesion with sac containing solid material Sebaceous cysts

Primary Lesions Wheal Edematous round or flat topped Disappears within hours Insect bite

PRIMARY LESIONS (fluid-filled) Vesicle Elevated, circumscribed Filled with serous fluid Less than 1 cm Blister (chickenpox) Bulla: Vesicle greater than 1 cm 2 nd degree burn

Primary lesion (Fluid-filled) Pustule Similar to vesicle but with purulent fluid Acne, impetigo

Erosion Loss of epidermis Surface is moist but does not bleed Moist area after the rupture of vesicle Ulcer Loss of epidermis and dermis Irregular shape Fissure Linear crack in the epidermis that extend to dermis Chapped hands, lips Athletes foot

Secondary Lesions Scales Heaped-up keratinized cells Flaky exfoliation, irregular Thick or thin Psoriasis Crust Dried serum,bld,purulent exudate Slightly elevated Scab on abrasion

Secondary Lesions Lichenification Thickening and roughening of the skin Caused by rubbing, irritation Chronic dermatitis Atrophy Thinning of the skin with loss of normal skin furrows Skin looks shinier and more translucent than normal Arterial insufficiency

Excoriation An abrasion or scratch mark. May be linear, or rounded as in a scratched insect bite Scar Thin fibrous tissue replacing injured dermis, irregular Keloid Irregular, elevated Progressively enlarging scar Grows beyond bounderies of wound

Diagnostic tests Biopsy Sterile field, local anesthesia Cover biopsy site, control bleed Shave: superficial lesion; scalpel Punch: stretch tight, punch pressed into dermal skin Incisional: Excisional:

Diagnostic tests Cultures and Sensitivity: Bacterial: exudate from lesion Viral: lesion unroofed, floor of lesion is scraped Fungal: area brushed with cytology brush Culturette sterile swab and tube Place swab in tube. Crush bottom of tube Label, send to lab

Diagnostic Studies Scrapings: Fungal: scraping from edge of lesions (scales, hair, nails) placed on slide 10 – 20% KOH added, examined microscope Infestations: Mineral oil scraping Mineral oil applied to lesion Scrape off top of lesion/burrow with scalpel blade Glass slide,microscope for mites, eggs, fecal material

Diagnostic Tests Tzank test (Wrights and Geimsa stain) Fluid and cells from vesicles Slide and stained Examined microscope

Microscopic Tests Woods lamp (Black light) Examination of skin with long- wave ultraviolet light Causes substances to fluoresce Detect fungal infection, pseudomonas org

Diagnostic tests Scratch test: tine or prick test Allergen applied to superficial skin scratch Patch Test Antigen applied to skin and covered with gauze Removal of allergens after 48 hrs Intradermal test Injection small amt of allergen into intradermal layer

Diagnostic test Interpreting results: Positive reaction: Erythema and wheal (15-20 min) Previous exposure Negative: antibodies have not formed yet

Bacterial Infections Impetigo Folliculitis Furuncle Carbuncle Cellulitis

Impetigo Group A B-hemolytic streptococci, staphylococcal infection Poor hygiene,low socioeconomic status Contagious, Common on face Untreated: glomerulonephritis

Impetigo Assessment: Vesiculopustular lesions honey-colored crust Erythema, Pruritic

Impetigo Mx: Local: topical oint Gentle washing 2-3 X/day: crust removal Soap and water Topical antibiotic (Bactroban) cream Systemic antibiotic: extensive and facial lesions Oral penicillin, erythromycin Take full course Bath daily, bactericidal soap, ind towel/washcloth Good hand washing

Folliculitis (Pimple) Inflammation of one/more hair follicles Staphyloccocus aureus In areas subjected to friction, moisture, or oil Common on scalp, beard, extremities Increased incidence in patients with DM Assessment: Small pustule at hair follice, erythema, crusting Tender to touch

Folliculitis Mx: Antistaphylococcal soap (Hibiclens, dial) and water Warm compress of water or aluminum acetate solution Topical (Bactroban), systemic antibiotic

Furuncle (boil) Deep infection with staphyloccoci around hair follicle Common: face, back of neck, axillae, breast, buttocks, perineum, thigh Furunculosis Malaise, elevated body temperature Regional lymph nodes enlargement

Furuncle (Boil) Assessment: Tender erythematous area around hair follicle Draining pus and necrotic debris on rupture Painful Mx: I and D with packing Antibiotics

Carbuncle (Multiple boils) Multiple, inteconnecting furuncles Common: nape

Carbuncle Assessment: Many pustules appearing in erythematous area Mx: I and D Antibiotics

Cellulitis Inflammation subcutaneous tissues Cause: S. Aureus and streptococci

Cellulitis Assessment: Hot, tender, erythematous, edematous area Chills, malaise, fever Mx: Systemic Antibiotics (Penicillin) Moist heat, immobilization and elevation

Erysipelas Superficial cellulitis involving the dermis Group A B-hemolytic strepcococci Common: face, extremitis

Erysipelas Assessment: Red, swollen, warm, hard, painful rash Fever, elevated WBC, headache, malaise Mx: Systemic antibioitc

Fungal Infections Candidiasis Tinea Tinea corporis Tinea cruris Tinea Pedis Tinea unguium (Onychomycosis)

Candidiasis (Moniliasis) Caused by Candida Albicans Warm, moist area: groin, oral mucosa Mouth: White cheesy plaque (milk curds) Does not come off with rubbing

Candidiasis Vagina: Vaginitis with red, edematous, painful vaginal wall white patches, Vaginal discharge, pruritus Pain on urination and intercourse Skin: papular erythematous rash with pinpont satellite lesions around edges

Candidiasis Mx: Nystatin (suppository, lonzenge, powder) Use of condom Keep clean and dry

Tinea (Ringworm) Tinea Corporis Ring-like scaly appearance Erythematous Tine Cruris (Jock itch) Scaly plaque in groin area

Tinea Pedis (Athletes foot) Interdigital scaling Pruritic, painful Tinea Unguium (Onychomycosis) Toenails Thickened, broken nail with yellowish discoloration, scale under nail

Tinea Mx: Topical antifungals: clotrimazole (Lotrimin) Nail removal (avulsion): option

Common Infestations: Pediculosis Scabies

PEDICULOSIS Pediculus humanus capitis (head) Sharing contaminated head coverings/ hairbrushes) Pediculus humanus corporis (body) Close contact: Phthirus pubis (pubic/crab louse) Sexual contact

PEDICULOSIS Female: lays eggs (nits-white, oval) hair shaft Live lice: grayish white, wingless insect Assessment: Itching, skin irritation

Pediculosis Management: Permethrin 1% (Nix): shampoo Clean, slightly damp hair Leave 10 mins, rinse thoroughly Fine-toothed comb Bedding/clothing: hot water laundry,hot dried (20 min) Non-washable: dry-cleaned or plastic bags for 2 wks

Scabies Sarcoptes Scabies Female burrows under skin: lay eggs Transmission: direct contact

SCABIES Assessment: Intense itching (worse at night): folds Burrows bet fingers, wrists, axillary folds Redness, swelling

SCABIES Mx: Permethrin 5% topical lotion (Eliminate): Applied to skin head to soles of feet: 8-14 hrs, then washed 2 nd application after 1 wk later Sulphur/special soaps Launder all clothes/linen: bleach Antibiotic: secondary infection

Common Benign Conditions Skin tags Vitiligo Lentigo Acne Psoriasis

Acrochordons Skin Tags Small, skin-colored, soft, pedunculated papules Mx: Cryotherapy, cautery

Vitiligo Cause unknown Genetic, precipitated by crisis Complete absence of melanocytes, noncontagious Assessment: Symmetric, may be permanent Mx: Topical steroids Psoralen with UVA

Lentigo Increased melanocytes Assessment: Hyperpigmented brown to black macule/patch Mx: liquid nitrogen, laser (may recur)

Acne Chronic skin disorder caused by inflammation of sebaceous glands Interplay of hormonal, bacterial and genetic factors Assessment: Comedones (blackheads/whiteheads) Papules and pustules

Acne Mx: Comedo extractor Topical : benzoyl peroxide, retinoids Systemic antibiotics Wash face 2X a day (antibacterial soap) Use sparingly: cosmetics, creams,etc

Psoriasis Chronic dermatitis Rapid turnover epidermal cells Localized/general, intermittent/continuous Unknown, Family predisposition, triggered stress

Psoriasis Sharply demarcated silvery scaling plaques Scalp, elbows, knees, palms, soles, fingernails

Psoriasis Mx: Topical: corticosteroids, tar shampoo, anthralin Intralesion inj: corticosteroids Photochemotherapy: Psoralen plus UVA lights (PUVA) 1/2 – 2 hrs; 2-3 times/week Goggles (cataract); genitals (cover) Systemic: methotrexate

PSORIASIS Teaching: Avoid factors that worsen itching Light cotton bedding/clothes Hypoallergenic/glycerin soap and tepid bath; pat dry Emotional support and acceptance

Verruca (Warts) Cause: human papillomavirus Transmission: direct contact, birth canal Flesh-colored papules Types: Vulgaris: knees, elbows, hands Subungual/periungual: around and beneath nail beds Plantaris: feet Condyloma: genital warts

Verruca (Warts) Mx: Chemical: Salicylic acid Tretinoin cream (Retin-A): keratolytic Podohyllin and trichlororcetic acid: condyloma Cryotherapy: liquid nitrogen Immunotherapy: Squaric acid: topical solution Imiquimod (Aldara): chondyloma Laser therapy

Herpes Simplex Viral infection that infects mucosa of vagina, cervix HSV 1: Fever blister, cold sore Contagious: direct contact Excacerbated by stress, sunlight, fatigue, systemic infection corners of mouth, edge nostrils Vesicles, erythematous base

Herpes Simplex HSV 2: genital herpes herpesvirus 11 (requires darkness to survive) Incubation: 6 days vagina, cervix; penis Newborn maybe infected during vaginal delivery

Herpes Simplex Assessment: Headache, fever, swolen inguinal lymph nodes Multiple vesicles, papules Small painful ulcers Erythema and edema Painful urination, vaginal discharge Mx:No cure Acyclovir (Zovirax) Sedation (severe pain) Analgesics, topical anesthetic, sitz bath No sex when lesion exist

Herpes Zoster (Shingles) Along pathway of peripheral nerves Cause: reactivation of varicella zoster virus Immune suppressed, Had chickenpox Risk: not had chickenpox Pruritic, painful vesicles along involved nerves Thoracic region Trigeminal nerve: face, scalp, eyes Crusts, fever, malaise

Hepes Zoster (Shingles) Dx: Symptom history, visual exam of lesions Tzanck test, viral culture Mx: Antiviral agents Acyclovir (Zovirax), Vidarabine (Ara-A, Vir-A) Analgesics, antipruritics

ECZEMA Inflammation of the epidermis Types : Atopic dermatitis: Infantile eczema hereditary (asthma, allergic rhinitis) Red, oozing, crusty rash Elbow, knees, neck, eyelids, hands

Eczema Contact dermatitis Allergic: Delayed hypersensitivity response to allergen (poison ivy, nickel (jewelry) Hrs to wks after contact Irritant: Inflammatory response to chemical (solvent) irritant (cleaning products, fragrance, skin care products)

Eczema Xerotic dermatitis: severe dry, itchy, cracked skin Worsens in winter Seborrheic dermatitis: cradle cap Dry, greasy peeling of scalp

Eczema Dx: Patch test Mx: Daily baths/shower Short. Avoid hot or very cold superfatted soap (Dove, neutrogena, Aveeno, cetaphil) Aveeno (oatmeal) baths and topical soaks Apply emollients (Aquaphor, eucerin, cetaphil cream)

Eczema Topical steroids (apply before emollient) Relieves inflammation and itching Thin layer, 2 X/day Systemic Antibiotics, Corticosteroids Antihistamines Keep room temp constant Cotton, loose clothing Keep nails short

Skin Cancer Basal Cell Basal cell of the epidermis Pearly white waxy border, papule, red, central crater Metastasis rare Squamous cell Tumor of keratinocytes Oozing, bleeding, crusting lesion Potentially metastatic Melanoma ABCD Rapid metastasis

Skin Cancer Risk Factors: Fair skin Dark skin: more natural protection Family history Repeated exposure to ultraviolet rays 11:00 Am and 3:00 PM Radiation exposure Long-term ulceration

Skin Cancers Treatment: Surgery Radiation Topical chemotherapy: 5-fluorouracil

Pressure Ulcer Decubitus ulcer, bedsore Occurs when capillary blood flow to the skin is occluded as a result of prolonged pressure (immobility) Poor blood supply cause cells to die

Pressure Ulcer Stages: Stage1: Skin intact, non-blanchable redness, painful Involves only epidermis; reversible if pressure is relieved Stage 2: Abrasion, blister, shallow crater, painful Loss of dermis

Pressure Ulcer Stage 3: Full-thickness skin loss, deep crater Destruction into subcutaneous layer Not painful, foul smelling with yellow or green drainage Tunneling may or may not be present

Pressure Ulcer Stage 4: Damage extends to the muscle, tendon, bone Foul smelling discharge Leathery black crust: edges of ulcer tunnelling

Pressure Ulcer Common areas: bony prominences Skull, elbows, sacrum,coccyx, heels Prevention actions: Relieve pressure: Frequent changing of position: Q 2 hrs Support surface to decrease capillary pressure Eggcrate mattress, Air-filled surfaces, Floatation surface Sheepskin pads

Pressure Ulcer Avoid shearing forces and friction: Trapeze bar: moving Turning sheet to pull patient up Keep skin dry and clean mild soap Provide optimal nutrition High protein, carbohydrates, Vit C

Pressure ulcer Mx: Antibiotics Wound cleansing Chemical/Enzymatic Debridement: dissolves necrotic tissue Collagenase (Santyl, Granulex), Elase, travase wet to dry dressing (NS) Pain management before removal

Applying Wet to Dry dressing Prepare client and remove dressing Forcep (soiled dressing If dressing adheres: do not moisten, gently remove Observe dressing for amount, characteristic of drainage Place fine-mesh gauze into sterile basin and pour solution Sterile gloves Cleanse with antiseptic solution/NS moving from least to most contaminated areas Squeeze excess fluid Apply several dry, sterile gauze Secure dressings with tape

Burn Tissue injury or necrosis Causes: Thermal: flame,explosion, scald injuries Chemical: ingestion/contact with caustic/corrosive chemicals Electrical: lightning, electric current Radiation: sunburn, radiation Inhalation : noxious gases/heat

BURN DEPTH: Superficial (first-degree) Erythema, mild swelling, no vesicles/blisters Painful, sensitive to touch Heals: 3-5 days Sunburn, low-intensity flash, brief scald

Burn Partial-thickness (second degree): Epidermis and dermis Red, shiny vesicles, edema Very painful, sensitive to touch Heals: days Scalds, flash flame

BURN DEPTH: Full thickness (Third degree) Includes subcutaneous layer and muscle Nerve endings, sweat glands, hair follicles destroyed Dry appearance, maybe white of charred Variable pain, often severe Fire, contact with hot object Healing: poor, requires grafting

Burn Full thickness (Fourth degree) Includes muscles, fascia, bone Dull and dry, bone may be exposed

Burn Clinical Findings: Restlessness Pain (depends on degree) Cellular destruction:Hyponatremia, hyperkalemia Hypovolemia: fluid shift

BURN Extent: Area affected Rule of Nines (Adults) Lund and Browder (children and adult)

BURN Severity Minor <10% TBSA No involvement of hands, face, genitalia OPD Moderate >10% - 20% TBSA hospital Major/Severe: > 20% TBSA Specialized burn center

Burn Management Emergent Phase: injury to 72 hrs Onset of injury through fluid resuscitation First Aid: Stop burn Flame: drop, log, roll; cool water; remove burned clothing/jewelry Chemical: dust dry powder, flush with water Electrical: shut off, remove client

Burn Managment Assess victims condition: ABC Assess smoke inhalation Client trapped in a closed space Hair in nostrils: singed Face, nose, lips: burned Blood: carboxyhemoglobin Mx: Elevate head of bed

Burn Managment Cover burn: sterile or clean cloth Hypothermia, pain, contamination Transport: Fluid replacement: Brook (Modified): ¾ crystalloid plus ¼ colloid LR: 2 ml/kg/% TBSA Parkland (Baxter): LR only LR: 4 ml/kg/%TBSA ½: 8 hrs; ½ next 16 hrs Foley cath: 30 ml/hr

Computation 70kg patient with 50% TBSA burn; 50 kg with burn anterior chest, anterior lower extremities Brooke; Parkland Compute: ½: 8 hrs: Total ml infused: No of gtts/min ½: 16 hrs: Total ml: Ml/hr No of gtts/min

Burn management Wound care Cleansing (shower, spray, tubbing with mild soap and warm water), gentle debridement Strict aseptic technique Wound dressing Open: topical antimicrobial Silver sulfadiazine 1%(Silvadene, Flamazine) closed: antibiotic on dressing Silver-impregnated dressings (Acticoat, silverlon) Air/fluid bed, bed cradle

Burn Management Tetanus immunization Tetanus toxoid: Tetanus globulin: not immunized Meds: Pain: morphine sulfate IV (No IM, Oral) Antibiotics, antacids, H2 block, sucralfate

Burn Management Nutrition: NPO then clear liquids High protein, carbohydrates, v/m

Burn Management Acute Phase: 3-5 days Start of diuresis (48-72 hrs) and ends with wound closure Wound care Cleansing Debridement (remove dead tissue) Mechanical: scissors/forceps Enzymatic: fibrinolytic enzyme Surgical: remove eschar (OR) to expose healthy tissue

Burn Managment Topical Antimicrobials Positioning: Anticontracture positions: splints Physical therapy Skin graft: promote healing Heterograft (Xenograft) From animal Homograft (Allograft) Another person Autograft Clients body

Burn Management Rehabilitation Phase: Wound closure to optimal level of physical/psychological adjustment: 5 yrs Client gains independence and maximal function

Thank You