2.7b Integument Flashcards
The basics of structure & function
EPIDERMIS
Five layers: mostly dead cells
Melanin: color of skin
Keratin: strength of skin
DERMIS
Capillaries & pain/touch receptors
Blood vessels, sweat/sebaceous glands, collagen fibers
SUBCUTANEOUS (HYPODERMIS): fat layer, insulation
Skin Assessment (history):
Onset/Duration of problem Characteristics: pain, pruritus, paresthesia Course Severity Precipitating/relieving factors: meds, travel, stress, diet etc Timing and circumstances History of associated Illness: e.g.DM Presence of risk factors: occupation
Physical assessment:
Physical examination
Private exam room (temp and lighting)
Patient comfort in gown that allows access to all areas of skin
Systematic head to toe
Compare symmetry
General inspection
Lesion-specific inspection
- Measure with metric system
- Appropriate terminology
- Remove cosmetics, oils
- Location, distribution, color, pattern, edges, size, elevation, exudate
primary lesions
Caused directly by disease
Present at onset of the disease
Example:
Vesicles RT chicken pox
Nodules RT RA
secondary lesions
Result from changes over time caused by disease progression, manipulation, or treatment.
Example: Crusted, excoriated or infected lesion caused by scratching the vesicle. Vascular ulcers RT PVD Pressure ulcers Scars, keloids
Pathological terms
Types of skin lesions
Macule?
Macule: flat, nonpalpable change in color
port-wine stains, freckles, petechiae, vitiligo
Pathological terms
Types of skin lesions
Papule?
Papule: small elevated, solid mass, <0.5 cm (patch
moles, warts, psoriasis <0.5cm mass
Pathological terms
Types of skin lesions
Plaque?
Plaque: raised, flat lesion – groups of papules
groups of papules that form lesions >0.5
Pathological terms
Types of skin lesions
Nodule?
Nodule: larger than a papule (more than 1 cm) raised solid lesion extending deeper into the dermis.
nodules are 1-2cm
Pathological terms
Types of skin lesions
Vesicle?
Vesicle: elevated, fluid-filled, thin wall (called bullae if >0.5cm
Pathological terms
Types of skin lesions
Pustule?
Pustule: elevated, pus-filled
Pimple
Pathological terms
Types of skin lesions
Cyst?
Cyst: elevated, encapsulated in the SQ, fluid or semi-solid
Pathological terms
Types of skin lesions
Ulcer?
Ulcer: deep, irregularly-shaped area of skin loss, dermis or SQ
What are the normal changes in skin RT aging?
Decreased thickness of epidermis
Hyperplasia of melanocytes (liver spots, aging spots)
Decreased Vitamin D production
Decreased vasomotor response
Elastin fibers degenerate
Proliferation of capillaries
SQ layer thins
Adipose redistribution
Decreased Sweat & sebaceous glands
What are some common lesions in the older adult?
Skin tags
Keratoses: scaly patches on top layer of skin, horney growth
Lentigines (liver spots)
Angiomas; look like small blood blister
Telangiectases: group of broken blood vessels
Photoaging
Venous lakes: larger blood blister looking, usually in/on the mouth or ears
Pruritus
Variable size of area
Itch-scratch-itch cycle
Trigger stimulates receptors in junction between epidermis and dermis and can also trigger release of inflammatory mediators
Pruritus
Causes:
Causes: May or may not be associated with rash Environmental factors & allergies Emotional distress Secondary to systemic disease
Pruritus
Management:
Management: Identify & eliminate cause Meds to manage itch? Secondary effects Box 16-1
Xerosis (dry skin)
Common in older adult due to decrease lubrication & reduced moisture retention
Sun exposure—
Cumulative and damaging
Loss of elasticity, thinning, wrinkling, drying
Major factor in precancerous and cancerous lesions
Actinic keratosis, basal cell carcinoma, squamous cell carcinoma, malignant melanoma associated directly or indirectly with sun exposure
Xerosis (dry skin)
Management
Management: Creams Lotions Ointments Antibiotics Corticosteroids Anesthetics
nevi
Nevi are some of the most common growths that occur on the skin.
moles, beauty spots or birthmarks.
Macules and papules with defined borders
Arise from melanocytes early in life & migrate up
Dysplastic nevi – can become malignant
Management: monitor for changes in size, thickness, color, bleeding or itching
Moles
Moles
Flat or raised macules, papules, with rounded well-defined borders
Small tan to deep brown and grow in groups
Melanocytic nevi
Melanocytic nevi can be present at birth or around the time of birth.
These tend to be larger moles and are referred to as congenital nevi.
During childhood “regular moles” may begin to appear.
Typically they are skin color to dark brown, flat to dome shaped growths that can appear anywhere on the skin.
The average person has 15-20 melanocytic nevi.
Genetic predisposition
Continue to develop throughout life
Non-contagious
keratoses
Generally benign overgrowth and thickening of epithelium
Adults >50 yrs old
Tan, waxy, can appear greasy, commonly on face or trunk
Seborrheic ketatoses: waxy or warty, uneven pigment; can be malignant (25%)
keratoses
Benign, genetically determined superficial growths
- Found in increasing number with age
- Irregularly round of oval, flat-topped papules or plaques
- Surface often verrucous
- Well-defined shape
- Appearance of being “stuck on”
- Increase in pigmentation with age of lesion
- Usually multiple and possibly itchy
- Removal by curettage or cryosurgery for cosmetic reasons or to eliminate source of irritation
- Minimal scarring
-May be removed for biopsy
psoriasis
Chronic, immune characterized by raised, red, round, circumscribed plaques covered by silvery white scales.
Most common lesions on elbows, knees, scalp
Associated problems: pruritus, fissures, infections
psoriasis
triggers?
Triggers: sunlight, stress, seasonal changes, hormones, trauma to skin
Meds that trigger: steroid withdrawal, beta blockers, lithium
psoriasis
medication treatment?
MEDS:
steroids (topical, oral, injectable) decrease inflammation & mitotic activity of lesions, delay keratin migration, rarely cause lasting remission
topical: tar preps
calcipotriene (Dovonex) safe effective ST and LT treatment inhibits proliferation in epidermis
psoriasis
phototherapy
PHOTOTHERAPY:
UVB: decreases the growth rate of epidermal cells
PUVA: administer psoralen to make skin more sensitive to UVA (penetrates deeper)
Gradually increasing exposure times 3X/wk with eye shielding
Risk of burns, delayed response
psoriasis
photochemotherapy
PHOTOCHEMOTHERAPY
UVA rays activates methoxsalen
Bacterial infections: hair follicles
Furuncle?
Furuncle: inflammation of hair follicles
Deep, firm, read, painful nodule 1-5 cm → cystic nodule
Contributing factors: trauma, poor hygiene, systemic disease
**These are usually Staph aureus
Bacterial infections: hair follicles
Carbuncle?
Carbuncle: group of infected hair follicles
Multiple openings to skin surface, firm mass in SQ/dermis
Common on neck, upper back, and thighs
S/S: swelling & pain, systemic: chills, fever, malaise
**These are usually Staph aureus
Bacterial infections: cellulitis
- Localized infection of dermis & SQ tissue
- Spreading factor: excreted by causative organism and breaks down fibrin network and barriers in tissue
- Area is red, swollen, & painful, diffuse borders
- Systemic S/S; fever, chills, HA, swollen lymph nodes
-MRSA: HA-MRSA, CA-MRSA,
1/3 population+ is colonized
Box 16-3 MRSA prevention
cellulitis treatment:
Culture to identify correct antibiotic Assess local and systemic S/S Cover draining lesions with sterile dressing Handwashing & isolation (if indicated) Moist heat Immobilize & elevate Hospitalize if severe Can progress to gangrene or sepsis
cellulitis treatment:
meds
Cloxacillin; cephalosporins, MRSA-Bactrim, minocin, doxycycline, cleocin.
Fungal/yeast Skin Infections
Skin fold appear moist and beefy red or brown,
itch, may have pustules on edge
Fungal/yeast Skin Infections
Types?
Vaginal and oral candidiasis
Tinea corporis (body-”ringworm”)
Tinea pedis- (athlete’s foot)
Tinea cruris (jock itch)
Fungal/yeast Skin Infections
Teaching?
Teaching:
Contagious
Keep skin cool and dry
Breathable coverings, cotton underwear
Candidiasis:
Candidiasis:
- Mouth—white, cheesy plaque, resembles milk curds
- Vagina—vagtinitis with red, edematous, painful vaginal wall, white patches; vaginal discharge, pruritis; pain on urination and intercourse
- Skin—diffuse papular erythematous rash with pinpoint satellite lesions around edges of affected area
Candidiasis:
Treatment?
Treatment
Nystatin or other specific medication as vaginal suppository or oral lozenge
Abstinence or use of condom
Eradiation of infection with appropriate medication
Keep skin clean and dry
Mycostatin powder effective on skin lesions
Tinea Corporis
treatments
Tinea Corporis—cool compresses; topical antifungals for isolated patches; creams or solutions of miconazole, clotrimazole, and butenafine
Tinea Pedis
treatments
Tinea Pedis—topical antifungal cream, gel, solution, spray or powder
Viral skin infections
Warts
Warts: (verucca)
Caused by HPV
Genital or nongenital
Transmitted through skin contact
Tx: meds, cryotherapy, electrodesiccation, curettage
Viral skin infections
Plantar warts
Plantar warts
On bottom of foot
Usually treatment is liquid nitrogen
Frequent paring
Followed by application of patches of impregnated chemicals to decrease regrowth
Overaggressive destruction may result in painful, hypertrophic scar
Most common viral infection of the skin are caused by?
Most common viral infection of the skin
Caused by HPV Multiple treatments including surgery Blunt dissection with scissors or curette Liquid nitrogen therapy Blistering agent Salicylic acid CO2 Laser destruction
Viral skin infections
Herpes simplex:
Caused by herpes virus (HSV1 (oral) & HSV2 (genital)
Burning, tingling then erythema, vesicle forms & pain
Can have systemic manifestations (fever, sore throat etc)
Virus lives in nerve ganglia & can recur
Most often found on lips, face, mouth
Treatment: antivirals
Viral skin infections
Herpes simplex:
transmitted?
Transmitted:
physical contact,
kissing, oral sex
Viral skin infections Herpes zoster (Shingles)
Caused by reactivation of varicella zoster (also causes chickenpox)
Increased risk for immune compromised
Outbreak lasts 2-3 wks, usually won’t recur but can have long-lasting effect
Vesicular lesions with erythematous base, usually follows the path of nerve along face, trunk, thorax, unilateral
Pain & pruritus
Viral skin infections
Herpes zoster (Shingles)
complications?
care?
Complications: : Post-herpetic neuralgia
Care: vaccine prevention, antiviral meds, pain management
Isolation
Viral skin infections
Herpes zoster (Shingles)
and healthcare workers
Healthcare workers without immunity or vaccination can be contagious from day 8-21 after exposure and should be reassigned from direct patient care during that period.
Pregnant women should not be exposed. There is a small risk of catching chickenpox from someone with Shingles which, depending on the time of gestation that infection occurs, can cause problems for baby and mom.
Malignant & pre-malignant skin disorders
Non-melanoma cancers:
Risk factors:
Fair skin, freckles, blond or red hair, blue or green eyes
Family hx skin CA Unprotected/excessive exposure to UV radiation Occupational exposures Sunlight chemicals Severe sunburn as a child
Malignant & pre-malignant skin disorders
Actinic keratosis
Directly RT sun exposure & photodamage
20% convert to squamous cell carcinoma
Erythematous, rough macules, shiny or scaly
Malignant & pre-malignant skin disorders
Actinic keratosi
characteristics
Actinic keratoses—sun damage—precursor to squamous cell carcinoma
- Flat or elevated, dry, hyperderatotic scaly papule
- Possible recurrence even with adequate treatment
Malignant & pre-malignant skin disorders
Basal cell:
Epithelial tumor that originates in basal layer
bulky tumors that grow by direct extension & destroy all types of surrounding tissues; frequent recurrence
Most common, least aggressive – rare metastasis; several classes
Superficial: erythema, ulceration, well-defined borders
Malignant & pre-malignant skin disorders
Squamous cell
Skin, mucous membranes, eyes
Aggressive cancer; invasive, metastasis via lymph
Small firm red nodule progressing to ulceration, bleeding, painful, and indurated
Malignant & pre-malignant skin disorders
Squamous cell
treatment
Treatment:
Surgical excision: remove surrounding margins, may require grafting
Moh’s surgery: excision of thin layers to determine margins, preserves normal tissues
Curettage & electrodesiccation: (laser) scrape and cauterize, works best over fixed surface
Radiation therapy: for inoperable lesions, or poor surgical risks
Local therapy: cryosurgery, topical chemo, phototherapy, IRMS (biologics-targeted), laser
Malignant & pre-malignant skin disorders
Squamous cell carcinoma
Squamous cell carcinoma
Frequent occurrence on previously damaged skin (from sun, radiation, scar)
Malignant tumor or squamous cell of epidermis
Invasion of dermis, surrounding skin
Metastasis possible
Superficial
-Thin, scaly erythematous plaque without invasion into the dermis
Malignant & pre-malignant skin disorders
Squamous cell carcinoma
Early and Late?
Early
Firm nodules with indistinct borders, scaling and ulceration; opaque
Late
Covering of lesion with scale or horn from keratinization
Most common on sun-exposed areas such as face and hands
Treatment of skin cancers
Focus on removal of tissue Depends on stage, type, size, location Surgery Curettage & electrodessication Radiation Cryotherapy
Malignant & pre-malignant skin disorders
Malignant melanoma
10X more common in fair-skinned people
Least common but most deadly skin cancer, increasing
Wide age range (adolescents to older adults)
Malignant & pre-malignant skin disorders
Malignant melanoma
Risk factors
Cause unknown but risk factors are: Moles (lg number or size) Immune suppressant meds Over age 50 Fair skin, blond hair, blue eyes Excessive UV exposure Genetics –dx of melanoma or other specific types of cancers
Malignant & pre-malignant skin disorders
Malignant melanoma
Interdisciplinary care?
Interdisciplinary care:
Total skin assessment
Biopsy
Diagnostic workup for metastasis
Treatment options:
- Surgery: wide excision, can remove lymph nodes, & metastasis
- Immunotherapy
- Radiation therapy
- Biologics: monoclonal Ab, GF, vaccines (direct tumor effect)
ABCDs
ABCDs—
- Asymmetry—one half unlike the other half
- Border irregularity—edges ragged, notched or blurred
- Color—varied pigmentation—shades of tan, brown, and black
- Diameter: greater than 6 mm
Skin cancer patient teaching:
Lemone box: 16.5 prevention of skin cancer 16.6 sunscreen information 16.7 skin self-examination “slip, slop, slap, wrap” rule
Skin cancer patient teaching:
“slip, slop, slap, wrap” rule
Slip on a shirt
Slop on sunscreen
Slap on a hat
Wrap on sunglasses
Nursing diagnoses integument problems
- Impaired skin integrity
- Acute pain
- Disturbed body image
- Risk for infection
- Anxiety
- Ineffective health maintenance
- Deficient knowledge
- Anticipatory Grieving
- Hopelessness
