Integumentary Flashcards
differentiate and randomly migrate upward, synthesize keratin
replace every 3-4 weeks
Keratinocytes
producing the pigment melanin which color the skin and hair
Melanocytes
role in cutaneous immune system reaction
langerhans cell
Largest portion of the skin, the connective tissue between the epidermis and subcutaneous tissue
-provides strength and structure in the form of collagen and elastic fiber
Dermis
Innermost layer of the skin primarily composed of adipose and connective tissue.
-provide cushion between the skin and muscle and bones.
-protect the nerve and vascular structure that transect the layers.
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subcutaneous Tissue or hypodermis
excessive hair growth
Hirsutism
hair loss
Alopecia
associated with hair follicles lubricating the hair and rendering the skin soft and pliable
Sebaceous gland
thin, watery secretion called sweat is produced in the basal coiled portion of the eccrine gland and is released into narrow duct.
Eccrine gland
Function of skin
-protection
-sensation
-fluid balance
- temperature regulation
-vitamin production
-immune response function
bluish discoloration that results from a lack of oxygen in the blood
Cyanosis
purple, black which fade to green, yellow or brown hues over time, most often seen following trauma
Ecchymosis
Redness of the skin caused by the dilation of capillaries
Erythema
yellowing of the skin
Jaundice
sequential reaction to cell injury
-neutralizes and dilutes the inflammatory agent, removes necrotic materials and establishes an environmental suitable for healing and repair.
Inflammatory response
inflammatory response can be divided into
-vascular response
-cellular response
- formation of exudate
-healing
stored in granules of basophils, mast cells platelet
-causes vasodilatation and increased capillary permeable
Histamin
stored in granules of basophils, mast cells platelet
-causes vasodilatation and increased capillary permeable
Histamine
stored in platelet mast cell, enterochromaffin cell of GI
-cause vasodilation and increased capillary permeability, stimulates smooth muscle contraction
Serotonin
produced from precursor factor kininogen as a result of activation of Hageman factor(XII) of clotting system
-cause contraction of smooth muscle and vasodilation result in stimulation of pain
Kinins (bradykinin)
Anaphylatoxic agent generated from complement pathway activation
- stimulate histamine release and chemotaxis
complement components
- produced from arachidonic acid
-causes vasodilation
Prostaglandins
- produced from arachidonic acid
- stimulate chemotaxis
Leukotrienes
proinflammatory mediator, promotes proliferation of B cell, activate T cell, NK cells and macrophages
Cytokines
Result from outpouring of fluid, seen in early stage of inflammation or when injury is mild
Serous exudate
found during the midpoint in healing after surgery or tissue injury, composed of RBC and serous fluid which is semi-clear pink and may have red streaks
serosanguineous
occurs with increasing vascular permeability and fibrinogen leakage into interstitial space, excessive amount of fibrin that coat tissue surface may cause them to adhere
Fibrinous
results from rupture of necrosis of blood vessel walls
hemorrhagic
consists of WBC, microorganism(dead and live) liquified dead cell and other debris
purulent(pus)
found in tissue where cells produced mucus, mucus production is accelerated by inflammatory response
Catarrhal
local manifestation of inflammations are
- redness(rubor)
-heat (carol) - pain(dolor)
-swelling (tumor)
-lost function
Type of Wound
Surgical or non-surgical
Acute or Chronic
Depth of Tissue Affected
Superficial – epidermis
Partial - dermis
Full-thickness – subcutaneous, fascia, muscle, tendon, bone
is a localized area of necrotic soft tissue that occurs when pressure applied to the skin usually a bony prominence
pressure ulcer
used for Predicting Pressure Injury Risk
Braden Scale
-Sensory Perception, Moisture, Activity,Mobility,Nutrition
Most common site for pressure ulcers is
sacrum
Heels being second
Risk Factors for Pressure Ulcers
Advanced age
Anemia
Contractures
Diabetes Mellitus
Elevated temperature
Friction
Immobility
Impaired Circulation
Incontinence
Low diastolic blood pressure (<60 mmHg)
Mental deterioration
Neurologic disorders
Obesity
Pain
Prolonged surgery
Vascular disease
Intact skin with non-blanchable redness of a localized area
Area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
Pressure Ulcer Stage I
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough
May also present as an intact or open/ruptured serum-filled or serosanguineous-filled blister
Presents as a shiny or dry shallow ulcer without slough or bruising
Pressure Ulcer Stage II
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed
May include undermining and tunneling
Pressure Ulcer Stage III
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present
-Ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
Pressure Ulcer Stage IV
Full-thickness tissue loss in which actual depth of ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in wound bed
Stable (dry, adherent, intact without erythema, or fluctuance) eschar on the heels serves as “the body’s natural (biologic) cover” and should not be removed.
Unstageable
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
Suspected Deep Tissue Injury
Nursing Interventions for pressure Ulcer
Relieve Pressure
Positioning the patient
Use pressure-relieving devices
Improve mobility
Improve sensory perception
Improve tissue perception
Improve nutritional status
Reduce friction and shear
Minimize moisture
Promote pressure injury healing
Factors Delaying Wound Healing
-nutrition deficiency (vitamin C, proteins, zinc)
-inadequate blood supply
-corticosteroid drug
-Infection
- smoking
-mechanical infection
-advance age
- obesity
- diabetes mellitus
- poor genera health
-Anemia
Made of woven or nonwoven material. Provide absorption of exudates. Most often combined with another kind of dressing
- used for Cleansing, packing, and covering a variety of wounds
Gauze dressing
May be impregnated with saline, petrolatum, or antimicrobials. Minimally absorbent
used for minor wound or second dressing
Nonadherent dressing
Generally composed of polyurethane. Transparency allows visualization of the wound
used for Dry, uninfected wounds or wounds with minimal drainage
Transparent films
Film-coated gel or polyurethane. Able to hold large amounts of exudate
used for Wounds with moderate to heavy drainage. Often used on new wounds
Foams
Gelatin, pectin, or carboxymethylcellulose bonded to a film or sheet. Produce a flat occlusive dressing that forms a gel on wound surface.
used for Wounds with light to moderate drainage
Hydrocolloids
Available in gels, gel-covered gauze, or sheets. Donate moisture to a dry wound and maintain a moist environment. Can rehydrate wound tissue
used for Dry wounds. Wounds with minimal drainage. Necrotic wounds
Hydrogels
Derived from seaweed or kelp. Form a non-sticky gel on contact with draining wound. Easy to use over irregular-shaped wounds
used for Wounds with moderate to heavy exudates (e.g., pressure ulcers, infected wounds)
Alginates
Quick method of debridement to prevent, control, or remove infection
*Used when large amounts of nonviable tissue are present
*Prepares wound bed for healing, skin grafting, or flaps
Surgical debridement
Two methods:
*Wet-to-dry dressings,in which open-mesh gauze is moistened with normal saline, lightly packed into wound surface, and outer layer allowed to dry. Wound debris adheres to dressing and then dressing is removed
*Wound irrigation. Make certain bacteria are not accidentally driven into wound with high irrigation pressure
Mechanical debridement
Semi-occlusive or occlusive dressings used to soften dry eschar by autolysis
*Assess area around wound for maceration when using these dressings
Autolytic debridement
Drugs applied topically to dissolve necrotic tissue and then covered with moist dressing (e.g., saline-moistened gauze)
*Examples of these drugs include collagenase (e.g., Santyl)
*Process can be slow, and thick eschar may have to be scored with scalpel
Enzymatic debridement
Used to treat acute and chronic wounds.
A vacuum source creates continuous or intermittent negative pressure inside the wound to remove fluid, exudates, and infectious materials to prepare the wound for healing and closure.
Consist of a vacuum pump, drainage tubing, a foam or gauze wound dressing, and an adhesive film dressing that covers and seals the wound
this therapy pulls excess fluid from the wound, reduces bacterial load, and encourages blood flow into the wound base.
Negative Pressure Wound Therapy
Delivery of O2at increased atmospheric pressures
Patient placed in an enclosed chamber, where 100% O2is administered at 1.5 to 3 times the normal atmospheric pressure
Elevated O2levels stimulateangiogenesis
Hyperbaric O2 Therapy
Complications of Wound Healing
Adhesion
Contractions
Dehiscence
Evisceration
Excess Granulation Tissue (Proud Flesh)
Fistula Formation
Infection
Hemorrhage
Hypertrophic Scars
Keloid Formation
A chronic suppurative folliculitis of the perianal, axillary, and genital areas or under the breasts
-Caused by the blockage and infection of the sweat glands
Present with a firm, pea-sized nodule that causes discomfort; noduleruptures and discharges purulent drainage; nodules can spread
Hidradenitis Suppurativa
Management of hidradenitis suppurativa
Warm compresses
Loose-fitting clothes over the nodules or lesions
NSAIDs to relieve the pain
Oral antibiotic
Incision and drainage of large suppurating areas
a common disorder affecting hair follicles and sebaceous glands.
Most commonly on the face, neck, torso, and upper arms
Can present either aswhiteheads, blackheads (comedones)
Acne Vulgaris
Acne Vulgaris: Management
Avoid sugary food products
Hygiene
Washing twice a day with soap and water
Phototherapy
Surgical Management
medication for Acne vulgaris
Benzoyl peroxide
Topical retinoids
Topical antibiotics
Oral isotretinoin + oral ATB
Contagious bacterial infection of superficial layers of skin
Nonbullous – honey-colored crusts (70%)
Bullous
Group A streptococcus, S. aureus, or MRSA
Spread through autoinoculation via hands, towels, clothing, nasal discharge, droplets
Impetigo
Clinical findings impetigo
Pruritus; spread of lesion to surrounding skin
Weakness, fever, diarrhea with bullous impetigo
Nonbullous – 1-2 mm erythematous papules or pustules, progress to vesicles or bullae which rupture – honey-colored crusts
Bullous – large, flaccid, thin-wall, superficial, annular or oval blisters/bullae – rupture
Lesions common on face, hands, neck, extremities, perineum
Regional lymphadenopathy
Management for impetigo
Topical antibiotics if superficial, nonbullous, localized
Oral antibiotics for multiple lesions, spread of infection to family members
Bullous impetigo in infant – parenteral beta-lactamase-resistant antistaphylococcal penicillin
Obtain culture if no response in 7 days
Educate about hygiene
Exclude from day care until treated for 24 hours
Complications of impetigo
Cellulitis
Lymphangitis
Staphylococcal scalded skin syndrome
Patient and family education for impetigo
Thorough cleansing of breaks in skin
Pigment changes may last weeks to months
No school/day care until 24 hours of treatment
Folliculitis and Furuncle clinical findings
Discrete, erythematous 1-2 mm papules or pustules on inflamed base near follicle
Face, scalp, extremities, buttocks, back
Nodules with furuncles
Pruritus papules, pustules, deep red/purple nodules in areas under swimsuit
Management Folliculitis and Furuncle
Warm compresses after bathing
Topical keratolytics
Topical antibiotics
Oral antibiotics
Review of hygiene/avoid shaving
complication of folliculitis and furuncle
deep abscess formation
Clinical findings Herpes Simplex
Primary herpes – fever, malaise, sort throat, decreased fluid intake
Primary genital HSV – painful vesicles
Recurrent – painful prodrome of burning, tingling, paresthesia, itching
Clinical findings HSV-1
Gingivostomatitis
Herpes labialis
Herpetic whitlow
Clinical findings HSV-2
Grouped vesicopustules/ulceration
Vaginal mucosa, labia, perineum, cervix in females; penile shaft and perineum in males
Regional lymphadenopathy
Diagnostic studies herpes simplex
Tzanck smear
Viral cultures
ELISA serology
PCR tests
Management herpes simplex
Burow solution compresses
Acyclovir to help shorten course
Topical acyclovir for initial genital HSV
Antibiotics for secondary infection
Oral anesthetics for comfort
Viscous lidocaine
Diphenhydramine/magnesium hydroxide 1:1 rinse
Newborn, immunosuppressed child, lesions in eye – consult
Exclude from day care if child cannot control secretions
complication of herpes simplex
eczema herpeticum, erythema multiforme, Stevens-Johnson syndrome
Herpes Zoster
Recurrent varicella infection – shingles
Reactivation of latent varicella zoster from sensory root ganglia
Rare in childhood
Clinical findings Herpes Zoster
burning, stinging pain, hyperesthesia, tingling
2-3 clustered groups of macules/papules progressing to vesicles
Develop over 3-5 days; last 7-10 days
Commonly follow dermatomes; do not cross midline
Management Herpes Zoster
Burow solution/warm, soothing baths
Antihistamines/analgesics for comfort
Moisturizing ointment
Antiviral medications not recommended unless immunosuppressed
Refer if eyes, forehead, nose involved for ophthalmologic exam
Complications Herpes Zoster
Rare except in immunocompromised children
Occasionally is initial finding in AIDS
Patient and family education Herpes Zoster
New vesicles appear up to 1 week
Contagious for varicella until all lesions crusted
fungal infection of beard or moustache of men
-Red, inflamed abscess-like lesions, pustules, or crusting
*May develop secondary infection
Tinea barbae
treatment for Tinea barbae
-Griseofulvin for 4–6 wks or terbinafine for 2–4 wks
*Shampoo beard or moustache twice weekly with selenium sulfide shampoo for 2 wks
scalp or eyebrows; contagious fungal infection of the hair shaft
-Oval, scaling, erythematous patches
*Small papules or pustules on the scalp or eyebrows
*Brittle hair that breaks easily; patchy alopecia
Tinea capitis
treatment for Tinea capitis
Griseofulvin for 4–6 wks or terbinafine for 2–4 wks
*Shampoo hair or eyebrows twice weekly with selenium sulfide shampoo for 2 wks
Begins with red macule, which spreads to a ring of papules or vesicles with central clearing
*Lesions found in clusters; many spread to the hair, scalp, or nails
*Pruritis is a common complaint
Tinea corporis (body)
treatment for Tinea corporis (body)
Local infections—topical antifungal creams once or twice daily (e.g., clotrimazole, econazole, ketoconazole)
*Extensive infections or concomitant tinea capitis or immunosuppressive conditions (e.g., active neoplasms)—oral antifungal medications (e.g., fluconazole for 2–4 wks, itraconazole for 1 wk, terbinafine for 2 wks)
Begins with small, red scaling patches, which spread to form circular elevated plaques
*Very pruritic
*Clusters of pustules may be seen around borders
Tinea cruris (groin area; “jock itch”)
education for client with Tinea cruris (groin area; “jock itch”)
Educate patients to avoid wearing clothing that is tight over the groin; patients should pat dry skin folds thoroughly (avoid rubbing) after bathing and use separate towels for groin and other body parts
Soles of one or both feet have scaling and mild redness with maceration in the toe webs
*More acute infections may have clusters of clear vesicles on dusky base
Tinea pedis (foot; “athlete’s foot”)
treatment for Tinea pedis (foot; “athlete’s foot”)
Local infections—topical antifungal creams once or twice daily (e.g., clotrimazole, econazole, ketoconazole)
*Extensive infections or concomitant tinea capitis or immunosuppressive conditions (e.g., active neoplasms)—oral antifungal medications (e.g., fluconazole for 2–4 wks, itraconazole for 1 wk, terbinafine for 2 wks)
education for client with Tinea pedis (foot; “athlete’s foot”)
educate to put on socks before underwear to avoid cross-contamination to groin
*to either dispose of old shoes or treat them with antifungal powder to prevent reinfection
*to wear protective footwear at communal pools and tubs
Nails thicken, crumble easily, and lack luster
*Whole nail may be destroyed
*If untreated, can result in pain, loss of balance, and candida infection
Tinea unguium (toenails; onychomycosis)
treatment for client with Tinea unguium (toenails; onychomycosis)
Oral antifungal medications for 12 wks (e.g., itraconazole, terbinafine) with or without concomitant topical ciclopirox olamine nail lacquer
*Nail avulsion may be indicated, either surgically or chemically using a 40–50% urea compound
