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Review of the Integumentary system -The largest organ in the body Consists of three layers Comprises the: skin, hair, nails,sweat glands A. General functions o Protection o Temperature regulation o Sensory reception o Biochemical synthesis o Absorption B. Skin layers-epidermis(stratum corneum ,- stratum lucidum*** thin skin, stratum granulosum ,stratum spinosum ,stratum germinativum ) dermis (Upper papillary * fingerprints * receptors Lower reticular * hair follicles * nerves * glands), subcutaneous C. Skin derivatives-sebaceous, sudoreferous, cerominous, hair, nail D. Skin Changes associated with aging o Cherry angiomas( bright red moles) o Diminished hair on scalp and pubic area o Dyschromias (color variations) o Telangiectasis o Wrinkles o Xerosis (dryness) o Xanthelasma (yellowish waxy nodule on upper and lower eyelid o Dry, wrinkled, unevenly pigmented o Thinning of dermo-epidermal junction increase vulnerability to trauma o Thinning of the skin overlapping of skin folds o Decrease in the number and size of b.v. poor wound healing o Loss of SQ fat decrease insulation o Decrease activity of the sweat and sebaceous glands o Thinning of hair Examination of the skin A. Nsg Hx-Demographic Data, Current and past Health Problem( asks when, where, what made it better, worse.,association,recurrent?)personal and social factors B. Physical assessmentInspection Location and distribution of lesions Configuration/Pattern ~ Arrangement of lesions with respect with one another (Linear ,Annular,Nummular/Circinate/coinshaped/Discoid,Circumscribed,Clustered,Coalesced,Target/Bulls eye/Iris, Serpiginous,Reticulated, Diffused,Universal,Herpetiform*Zosteriform*

*Livedo reticularis may be a manifestation of systemic disease like SLE, RF, syphilis, PTB Color- ashen gray, cyanotic, differences in color or race. Palpation- Moisture, Temperature, Texture, Turgor PRIMARY LESIONS 1. Macule -flat, nonpalpable lesions usually 1 cm or less in diameter, although some apply the term to lesions of any size 2. Patch-Large macule ( >1cm in diameter) 3. Papule-Circumscribed, solid elevations with no visible liquid, usually 0.5 cm or less in diameter 4. Plaque-Broad papule (or confluence of papules)>0.5 cm in diameter 5. Nodule-0.5-2cm,form of papules, but larger and deeper extending into the dermis or subcutaneous tissue 6. Tumor->2cm,soft or firm and freely movable or fixed masses 7. Wheal (Hives)-Transient, edematous, elevated lesions with irregular shapes and various sizes usually associated with pruritus 8. Vesicle-Elevated, thin-walled lesions filled with clear fluid, less than 0.5 cm in diameter 9. Bullae-Clear fluid-filled blisters/vesicles more than 0.5 cm in diameter 10. Pustule-Elevated lesions that contain pus 11. Cyst Encapsulated,Found in the dermis or subcutaneous.Containing fluid or semi-solid material SECONDARY LESIONS 1. Scale- Dried or greasy laminated masses of keratin 2. Crust-A solid consolidation of dried serum, blood, and pus , usually mixed with epithelial and bacterial debris 3. Excoriation-Deep scratch, usually epidermis only 4. Fissure-Linear cleft or a small split or crack through the epidermis and rarely into dermis 5. Erosion-Discontinuity of the skin with loss of part or whole epidermis, Heals w/o a scar 6. Ulcer-Rounded or irregularly shaped excavations that result from loss of the epidermis and dermis.Heal with scarring 7. Scar- New formations of connective tissue 8. Lichenification -Palpably thickened and rough epidermis 9. Atrophy-Thinning of the skin surface with loss of skin markings.Skin appears dry and wrinkled .Aging skin, lupus erythematosus, chronic use of steroid Cutaneous symtoms 1. Pruritus 2. Sensation of heat (burning)

3. Sensation of cold (tingling) 4. Pricking 5. Pain 6. Numbness C. Diagnostic Examination Woods Light KOH Culture- bacteria, fungi, virus Skin biopsy- punch biopsy (Dermatologic punch), shave biopsy, excisional biopsy


Common Skin Problems of the neonate. 1.. Vascular nevi Hemangioma -dilated blood vessels in one place of the skin Capillary hemangioma -lesion that is characterized by bright red patches that resemble a strawberry it tends to grow rapidly in the neonatal stage but later disappears completely usually by age 7 Treatment options: special circumstancesCorticosteroid medication 30-90 days.Laser surgery Cavernous hemangioma -raised bluish lesions composed of dilated blood vessels occurs deeper in the dermis to subcutaneous tissue treatment:Corticosteroid,Argon Laser Nevus flammeus Port-wine stain,Present at birth (birthmark)Congenital hemangioma involving the capillaries. More bluish or purple with age Tx:Difficult to treatTattooing, concealing cream.Laser therapy satisfactory 2. Pigmented nevus-Synonym:Giant hairy nevus.Bathing trunk nevus Treatment:Excision with graft resurfacingDermabrasion 3. Mongolian spots-bluish gray discoloration. Sacral area.


Childhood 1. Diaper rash-Rashes is attributed to the alkaline irritative effects of ammonia formed in wet diaper by the splitting of urea by the ammoniaforming bacillus in feces. Tx freq diaper changing, ointments,cornstarch?Intertrigo-involves skin fold, skin skin friction( 2. Milia-Are white pearly keratinous papules/cysts, 1-4 mm in diameter, appearing chiefly on the face, esp. under the eyes Primary and secondary

-found on the roof of the mouth in infants are called Epstein pearls and are normal in newborns. Persistent and stubborn milia may occasionally be treated with the following: Topical retinoid cream such as tretinoin, tazarotene, or adapalene Removal with a sterile lancet or scalpel followed by use of a special tool (a comedone extractor)

3. Cradle cap-Yellow or brown scaling lesions on the scalp with accumulated adherent epithelial debris;not itchy Cradle Cap Synonyms: infantile or neonatal seborrhoeic dermatitis crusta lactea, milk crust,honeycomb disease ,pityriasis capitis Related to Malassezia furfur. Tx shampoo off with oil. 4. Impetigo contagiosa-Skin infection caused by either Streptococcus pyogenes or Staphylococcus aureus bacteria or both Tx; Oral antibiotic Cloxacillin, Erthromycin, or Penicillin x 7-10 days plus Topical antibiotic Mupirocin (Bactroban) 5. Ecthyma-an ulcerative streptococcal pyoderma nearly always of the chins or dorsal feet. Deeper form of impetigo. Tx;Cleansing with soap and water,Topical application of mupirocin ointment BID, Oral or parenteral penicillin, cloxacillin, or erythromycin 6. Warts-Verrucae vulgaris Small tumors caused by HPV.Transmitted mainly via direct contact Verruca vulgaris- common wart found in the exposed areas of the skin Verucca plantaris- plantar warts on the sole, thick callus that when removed, reveals tiny black dots (thrombosed capillaries) Verucca plana juvenilis or flat juvenile wart- less elevated, flesh to brown black papules. This wart usually affects the face and hands Genital warts (Condyloma acuminatum) Tx; aimed destroying the skin cells containing the virus,surgical excision, electrodessication and curettage, cryosurgery,salicylic acid 7. Tinea infection- Superficial fungal (Dermatophyte) infections Lesions can differ in appearance, anatomic location and species of infecting organism Tinea capitis Tinea pedis Tinea corporis Tinea unguium Tinea cruris tines vesicolor(flava)

Avoid sharing personal items Topical antifungal agents for at least 2 weeks Clotrimazole, Tioconazole, Ketoconazole Terbinafine

8. Atopic dermatitis-Atopic/Infantile/Flexural Dermatitis/Eczema,Disseminated neurodermatitis ,Prurigo diathesique itch scratch cycle.; RIST & PRIST- IgE Infant Phase- between ages 2 and 3 months; remission 3-5 y/o - Usually coincides with the introduction of the foods in the infants diet Childhood phase atopic dermatitis (2-10 years) Adolescent and adult atopic dermatitis IV. Tx; Limit caffeine and chocolate Avoid extreme cold or heat, emotional stress For infants & children, avoid excessive bathing, vigorous rubbing, heavy, tight or soiled clothing, medicated oils & protect areas prone to be scratched Use of less irritative soaps in bathing (Dove, Neutrogena) Antipruritcs

Communicable diseases A. Pediculosis- infestation of lice -- blood-feeding ectoparasitic insects a. Pediculosis capitis b. Pediculosis corporis (Pediculosis vestimenti, Vagabond's disease) Pediculosis pubis (Crabs) Tx. Use of lindane shampoo Removal of nits by combing the hair with fine tooth comb Disinfect or boil the clothing, bedding and pillows Check all treated people for two to three weeks. B. Scabies- the itch, is a contagious ectoparasite skin infection characterized by superficial burrows and intense pruritus (itching). It is caused by the mite Sarcoptes scabiei Tx; Wash linens and bedclothes in hot water. Treat sexual contacts or relevant family members Topical Medications Permethrin 5% Lindane (Kwell). Malathion Eurax (USP Crotamiton) This is not a cure but helps to relieve itch(pruritis) Tea tree oil at 5% is currently under investigation. Oral Medications

Ivermectin Antihistamines


Common problems of the adolescent and the young 1. Acne Vulgaris-pimples, blackheads, blemishes, whiteheads, spots, or zits; hormonal activity produces hyperkeratosis of follicular orifices leading to blockage; comedone= blackheads or whiteheads TreatmentAntibiotics ,Hormonal treatments ,Anti-inflammatory, Retinoids ,Acne Surgery,Laser treatment 2. Contact dermatitis-inflammatory reaction of the skin to physical, chemical or biologic agents. Pruritus, eerthyma, edema. Types; Poison Ivy Dermatitis,Cosmetic Dermatitis,Clothing Dermatitis, Dermatitis MedicamentosaTx;Avoid allergen,Antihistamine,Corticosteroid,Antibiotic 3. Furuncle/ foliculitis/ carbuncle-Warm compress and oral antibiotic may arrest early furuncles Incision and drainage cornerstone of definitive tx Gram stain and culture on high-risk patients 4. Psoriasis-chronic, recurring, non-contagious autoimmune disease which affects the skin and joints.genetic b. Aggravating factors;Stress ,withdrawal of systemic corticosteroid, excessive alcohol consumption smoking c. Variants:Plaque psoriasis (psoriasis vulgaris) is the most common form of psoriasis,Flexural psoriasis (inverse psoriasis) Guttate psoriasis,Pustular psoriasis Nail psoriasis thickening of the skin under the nail loosening onycholysis)crumbling of the nail, Psoriatic arthritis involves joint and connective tissue inflammation can affect any joint but is most common in the joints of the fingers and toes.It can also affect the hips, knees and spine (spondylitis). Erythrodermic psoriasis involves the widespread inflammation and exfoliation of the skin Tx; topicals:(Salicylic acid,Coal tar),Moisturizers,Occlusion dressing,Antihistamine, Retinoids,Encourage ventilation of feelings ,dense foods such as fruits, vegetable, whole grains and legumes, Vit. A rich,Caution client to use dark glasses during exposure to UV light, steroids, UVB, PUVA (psoralen + UV A)

5. Urticaria-Hives/ Nettle rash,Common vascular and allergic reaction of the skin. When etiology is not yet established, and food allergy is suspected,maintain on hypo allergenic diet. 6. Tx: epinephrine (IM), antihistamine, corticosteroids,nonsedating antihistamines(as prophylaxis): Physical factors a. Cholinergic: Reaction to body heat (exercise, hot shower) b. Cold (Chronic cold urticaria): Reaction to cold, such as ice, cold air or water c. Delayed Pressure: Reaction to standing for long periods, brastraps, belts d. Dermatographic: Reaction when stroking or scratching the skin e. Aquagenic:Inhalants- pollens, feathers, formaldehyde, cosmetics, aerosols, etc Infection,Neoplasm,Emotional stress,Alcohol Angioedema 7. Lyme disease-Borreliosis; Erythema chronicum migrans (ECM) As the rash fades, flu-like symptoms occur.Accompanied by a burning sensation. Skin biopsy of rash will reveal presence of the spirochete.Remove the tick with tweezers or fingers and disposeTetracycline - DOC for early Lyme disease,Amoxicillin + Probenecid or Doxycycline Ceftriaxone + Penicillin DOC if with arthritis

8. Frosbite-Synonym: Congelatio Pathophysiology:Frozen body part poor blood flow tissue necrosis Treatment:Covering the affected part with clothing, with hand, or other body surface,Rapid rewarming in a water bath between 100110F,Supportive:Analgesic,Anticoagulants,Papaverine and nicotinic acid for vasospasm,Antibiotic prophylaxis,Tetanus toxoid,Bed rest with elevated feet and slightly flexed knees,Daily wound care,hemorrhagic bullae are kept intact,Non-hemorrhagic bullae are debrided ,Escharotomy ,Fasciotomy, Avoidance of trauma,High protein and high caloric diet,Avoid tobacco, alcohol, and caffeine,Massage is contraindicated. VI. A. Common skin problems of middle aged and older adult A. Cellulitis-Skin infection into the deeper dermis and subcutaneous fat Apply warm compress to promote circulation and to decrease discomfort and edema ,Administer analgesics and antibiotics .Clean daily with antibacterial soap.Monitor vs and WBC count.

B.Seborrheic Keratosis-Seborrheic verruca," "Senile keratosis," and "Senile wart benign skin growth that originates in keratinocytes giving it a pasted on appearance Management No treatment necessary Small lesions can be treated with light electrocautery. Larger lesions can be treated with electrodessication and curettage, shave excision, or cryotherapy C. Skin Cancer-

three types of skin cancer: Basal Cell Carcinomas (BCC) are the most common, 80% of the skin cancers that develop each year develops from abnormal growth of the cells in the lowest layer of the epidermis Genetic predisposition and chronic irritation are risk factors but UV exposure is the most common cause Squamous Cell Carcinoma (SCC) involves changes in the squamous cells, found in the middle layer of the epidermis (stratum spinosum) Chronic skin damage from repeated injury or irritation is a predisposing factor Malignant Melanoma the least common form of skin cancer is by far the most lethal occurs in the melanocytes (cells that produce pigment) Basal Cell CA Basal cell epithelioma Basaloma Rodent ulcer, Rodent carcinoma Jacobis ulcer Squamous Cell CA Prickle call CA Epidermoid CA Feature associated with skin cancer A- asymmetry of shape B- border irregularity C- color variation within one lesion D- diameter greater than 5mm Risk factors:Complexion: light-colored skin, hair, and eyes.Genetics, Age: more common after age 40. Sun exposure and sunburn: This is considered the primary cause of all skin cancers.

D.Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson Syndrome Potentially fatal skin disorders,Most severe forms of erythema multiforme Characterized by erythema, urticarial plaques bullae epidermis comes off in large sheet Caused by drug reaction ( sulfonamides, anticonvulsants, NSAIDs) + Nikolskys sign; scalded skin syndrome These conditions occur in all ages and both genders Incidence is increased in older people because of multiple drug use Treatment: Same as 2degree burn;Surgical debridement/Hydrotherapy,Fluid replacement,IV immunoglobulin,Corticosteroid. DECUBITUS ULCER*braden scale/ stages 1-4? Management; Emphasize preventive care Dressings

BURN a. Common causes of fire at home and community 1. Open flames-Candles, cigarettes, matches 2. Electrical-Overloaded electrical circuits, loose electrical connections, faulty electrical equipment ( >1000V) 3. Cooking b. Clients vulnerable to burns 1. Males>female 2. Greatest risk are the very young, younger than 4 years old 3. The elderly, older than 65 years 4. The very poor c. First aid intervention For minor burns:Cool the burn.Cover the burn with a sterile gauze bandage. Take an over-the-counter pain reliever. Don't apply butter or ointments to the burn. Don't break blisters For major burns: Don't remove burned clothing. Don't immerse large severe burns in cold water. Check for signs of circulation (breathing, coughing or movement). No breathing or other sign of circulation, begin CPR. Elevate the burned body part or parts. Cover the area of the burn.

d. Major causes of Burns-scalds, flames, electricity, chemicals,sunburn(miliaria rubra-prickly heat) Classification of burn a. Accdg to depth and severity First degree Superficial; Epidermis is destroyed or injured and a portion of the upper dermis Recovery within a week; no scarring Second degree - Partial Thickness Superficial Epidermis and upper 1/3 third dermis Deep Dermal - Epidermis and deeper part of the dermis Third Degree - Full Thickness; Epidermis and entire dermis Skin is Pearly white, Grayish, Black-brown, Black with severe edema.Inelastic and leathery (eschar) Sensation: anesthetic, + deep pressure sensation Ex. Flame, immersion scalds, high-voltage electricity, exposure to concentrated chemicals, contact with hot objects Graft required Fourth Degree - Deep full thickness; Entire epidermis and dermis extending into underlying fascia and tissue a. Accdg to extent(TSBA)- Burn Size;Quantified as the percentage of Total Body Surface Area (TBSA) Alteration of skin function: Skin can regenerate as long as parts of the dermis are present.

Alteration in the vascular system-Blood vessel occlusion blood flow Release of mediators e.g.catecholamines vasoconstriction blood flow Third spacing/Capillary leak loss of plasma fluid and proteins from intravascular to extravascular space blood volume blood pressure Hypovolemic shock

Alteration in other system Pulmonary-Inhalation injury may occur results from inhalation of superheated air or noxious chemical e.g. CO, CN, ammonia, sulfur Closed structure


Requires direct heat >150C/302F This plus hypermetabolism leads to increased O2 consumption hypoxia

Carbon Monoxide Poisoning Leading cause of death associated with fire

Carbon Monoxide Poisoning Leading cause of death associated with fire

Flui balance-Weight loss should not exceed 1 kg/day RBC are destroyed and causing hemoglobinuria. Hemoconcentration will result because the liquid blood component is lost in extravascular space Potassium excess- massive cellular trauma causes release of K into ECF Sodium deficit- Na is lost in trapped edema fluid and exudate and by shift into cells G.I. System-Curlings Ulcer
Oliguria is expected, as well as intestinal ileus

Nursing process as Applied to the care of burned patient a. Assessment-What was the burning agent?.... ABC? Of burns,

Anatomic Structure Surface Area Anatomic Structure

Surface Area

Head Anterior Torso Posterior Torso Each Leg Each Arm Perineum

9% 18% 18% 18% 9% 1%

Head Anterior Torso Posterior Torso Each Leg Each Arm Perineum

18% 18% 18% 14% 9% 1%

rule of ninelund and browder / berkows

b. Interventions-Assess for airway patency,Administer O2 as needed,Cover the patient with a blanket,Keep the patient on NPO status,Elevate the extremities if no fractures are obvious,Obtain vital signs,Initiate an IV line and begin fluid replacement,Administer tetanus toxoid for prophylaxis Perform a head-to-toe assessment 1. Adequate airway 2. Fluid resuscitationFirst 24-48 hrs.I.V. fluids balance solution (LR), insertion of indwelling catheter to monitor output Check for signs of fluid overload versus dehydration, monitor BP, temp., weight, electrolytes. PRBC- 2-5 days after burn Parkland/ Baxter Formula4ml LR x weight in kg x TBSA DO NOT GIVE DEXTROSE SOLUTIONS!!!!!! 3. Adequate nutrition wound care and healingPromote Healing- reverse isolation, wound care at least once a day,Debridement- (removal of non viable tissue)hydrotherapy is used to loosen dead tissue (maximum of 30 mins.) Escharotomy- (incising of leathery covering of dead tissue conducive for bacterial growth) to alleviate constriction and infection

high caloric CHO,CHON diet; may have TPN or tube feeding, Vitamins B, C and Iron, H2 blockers,antacids to prevent Curlings ulcer, NGT for gastric decompression to prevent distention, paralytic ileus 4. Skin graft-XENOGRAFTS,HOMOGRAFTS ,AUTOGRAFTS ,MESH GRAFTPOSTAGE STAMP GRAFT,- SHEET GRAFTING 5. Prevention and control of complicationControl Pain- MEPERIDINE/MORPHINE Silver Sulfadiazine closed method, monitor hypersensitivity, rash, burning, itching sensation Mafenide- Sulfamylon- open method, remove previously applied cream. Silver nitrate- keep dressing wet with solution to avoid over concentration. Can leave gray or black stain Check:Pervasive odor,Purulent dischargeFever,Color changes,Changes in texture Possible dermatologic complications Wound contracture Hypertrophic scar Cosmetic problems Wound infections Miliaria rubra-Prickly heat Common disorder of the eccrine sweat glands that often occurs in conditions of increased heat and humidity

Phases of burn1. Emergent Phase- onset of injury and continues up to 48 hrs Hx taking, age, weight (preburn weight is calculated for fluid replacement) P.E. assess the mouth, nose, and pharynx (burn of lips, mouth, face, ears and eyelashes) indicates exposure to flame 2. Acute Phase- begins 48 hrs. after injury until wound closure is complete Collaborative approach to care 3. Rehabilitative Phase- begins with wound closure and ends with the highest possible level of functioning Light from the sun consists of 3 types of radiation:

(1) Infrared Radiation (>760 nm)

(2) Visible Radiation (400-760 nm) (3) Ultraviolet Spectrum (<400 nm) 3 Bands of Ultraviolet Spectrum (1) UVA ( 340-390 nm) (2) UVB (290-340 nm) (3) UVC (200-290nm)