Integumentary Flashcards
Functions of the Skin
- Barrier to injury/infection
- Temperature regulation
- Nerves - sensation of touch/pain
- Insulation with adipose tissue
- Fat storage
* * Largest organ in the body
Burow’s Solution
Been around since the 19th century - may see a prescription for use with skin conditions
It is: Acetic Acid
1. Antibacterial
2. Antifungal
How does aluminum acetate help with skin conditions?
- Astringent
- Treats inflammation
- Relief of itching
- Decreases stinging
Anatomical differences of the skin of children versus adults
- Epidermis is thinner
- Blood vessels are closer to the surface
- Decreased subQ fat
- Loses heat quicker
- Higher water content
- Less pigmented
The effects of the anatomical skin variations of children versus adults
- Lose heat faster
- Substances/bacteria absorb quicker
- More easily affected by friction
- More affected by UV radiation
Differences in dark-skinned versus light-skinned children
- More pronounced cutaneous reactions compared to children with lighter skin
- Hypo or Hyperpigmentation in the affected area following healing of a dermatologic condition is common
- Tend to have more prominent papules, follicular responses, lichenification, and vesicular or bullous reactions than lighter-skinned children with the same disorder
- Hypertrophic scarring and keloid formation occur more often
Macule
- Flat/non-palpable area of change in skin color
- Less than 1 cm across
- Examples: freckles, scarlet fever rash, flat moles
Patch
- Flat/non-palpable change in skin color
- Similar to macule but larger than 1 cm
- Examples: port wine stain, Mongolian spot
Papule
- Solid elevation of epidermis less than 0.5 cm across
- Palpable
- Examples: warts, early varicella lesions, raised nevi
Nodule
- Solid lesion
- 0.5 - 1 cm across (if larger, tumor)
- Can be raised, level with, or below skin
- Examples: lipoma, warts
Plaque
- Elevated
- Flat top
- Larger than 1 cm
- Firm and rough
- Psoriasis, seborrheic and actinic keratoses
Vesicle
- Superficial fluid filled elevation
- Less than 1 cm across
- Palpable
- Examples: late varicella lesions, poison ivy, herpes simplex and zoster
Bulla
- Similar to vesicle
- Larger than 1 cm
- Examples: blisters, burn lesions
Pustule
- Similar to vesicle but contains purulent material
2. Examples: acne, impetigo, boils (furnucles)
Wheal
- Circumscribed elevation of skin
- Caused by fluid or serum in dermis
- Examples: urticaria, insect bites, intradermal TB test
Signs of Infection on the Skin
- Redness
- Streaking
- Purulent drainage
Impetigo
- Two types
- Contagious until the child has been on antibiotics for 24 hours
- Incubation 1-2 days
- Common sites are nose and mouth
- Causative organism carried in mares and attacks breaks in skin integrity
- Spread with scratching and may show linear pattern with scratching
What are the 2 types of impetigo?
- Nonbullous
2. Bullous
Nonbullous Impetigo
Papules progress to vesicles then painless pustules, pruritis
- Honey colored crust forms when pustules/vesicles rupture
- Staph aureus or Group A hemolytic strep
- develops where skin trauma or another skin disorder is present
Bullous Impetigo
- Red macules and bullous eruptions on a red base
- Could be mm to several cm in size
- Staph aureus may develop on intact skin
How is impetigo diagnosed?
Cultures
General impetigo treatment
Usually self-limiting, although can be severe which will require PO antibiotics, and extensive will require IV antibiotics
Nonbullous impetigo treatment
- Topical antibiotics - mupirocin (bactroban) ointment
- PO antibiotics - first generation cephalosporin
- IV - clindamycin (MRSA)
Bullous impetigo treatment
PO - first generation cephalosporin
What is potential complication of impetigo?
Poststrep glomerular nephritis
Poststrep Glomerular Nephritis
- Potential complication of impetigo
1. The bacteria cause the filter units of the kidneys to become inflamed -which decreases the filtration rate
Poststrep Glomerular Nephritis Symptoms
- Decreased UOP
- Rust colored or blood in urine
- Swelling
- Joint stiffness
Impetigo Nursing Management
- Contact isolation
2. Education!!!
Impetigo Patient/Parent Education
- Good hygiene
- Do not share towels bed linens
- Wash frequently
- Mitts for scratching
- Remove crusts with warm/cool water soaks
- May use Burow’s solution
Occurence/Prevention of Cellulitis
- Common on legs and around diaper area
2. May occur at site of insect bite or minor scratch/cut
Cellulitis Patho
- Infection of dermis and subcuatneous layers of skin
2. Cellulitis can follow an injury or infection in other body location
Usual causes of cellulitis
- Staph aureus MRSA
- Hemophilus influenza
- Group A strep
S/Sx of cellulitis
- Localized - erythema, pain, edema, warmth to site (warm hard swollen mass)
- Enlarged lymph nodes, red streaking to area, hard swollen mass
- Systemic - fever, chills, malaise
Cellulitis Diagnostics
- Culture and sensitivity (from fluid/pus)
- Blood culture if systemic signs
- WBC elevated
Cellulitis Treatment
- IV or IM antibiotics - cephalosporins = clindamycin, cefotaxime, ceftriaxone (specific to what is growing on culture)
- PO antibiotics if minor - cephalexin or amoxicillin/clavulanic acid
- IV (cephalosporins) for severe cases, affects face, neck, or joint
- Incision and drainage may be done
Cellulitis Complications
- Sepsis
- Meningitis
- Septic arthritis
- Brain abscess
- Osteomyelitis
Cellulitis Nursing Management
- Can apply warm wet compresses for comfort
- Pain control
- Contact isolation
- Good hand hygiene with dressing changes
Diaper Candidiasis Occurence/Prevention
- Common fungus
- 80% of diaper rash that last longer than 4 days have C. albicans
- Thrush if in mouth
- Vaginal infection in older children/teens
- Higher risk in children with high antibiotic use or low immune system
Diaper Candidiasis Patho
- Overgrowth of candida albicans
2. Thrives in warm, moist areas
S/Sx of diaper candidiasis
- Bright red
- Confluent rash
- Satellite lesions
- Raised borders
- Very painful
- Scaling in the skin folds
Diaper Candidiasis Diagnositics
Usually based on appearance but yeast can be seen on microscope (branching hyphae)
Diaper Candidiasis Treatment
Treat with topical antifungals (Nystatin)
Complication of Diaper Candidiasis
Can move to other regions of the body and can be found in blood if very severe colonization
Diaper Candidiasis Nursing Management
- Keep area clean and dry
- Open to air and sunlight as much as possible
- No rubber pants
- Avoid zinc oxide or other diaper creams
- Can use hair dryer for air drying on low setting
Occurrence/Prevention of other types of diaper dermatitis
- Prevention is the key - some type of barrier cream to diaper area
- Caused by prolonged skin contact with irritating substance
- Ammonia in urine
- Stool
- Detergents
- Soaps or lotions
- Chemicals in baby wipes
Patho of diaper dermatitis
- Inflammatory reaction
- Non-immunologic response to skin irritant that results in skin cell hydration disturbance
- Prolonged exposure to urine/feces leads to changes in skin pH/breakdown
S/Sx of diaper dermatitis
- Starts as a flat, red rash in the skin creases
- May develop papules and become more widespread
- Erythema/macules and papules, erosion, crusting
Diaper Dermatitis Diagnostics
Not used unless progressing to cellulitis or abscess
Diaper Dermatitis Treatment
Using diaper barrier creams or ointments with:
- Vitamin A, E, D, zinc oxide, petroleum
- Boudreaux’s, A and D ointment, Desitin, Aquaphor
- May use hydrocortisone cream if ordered
Complications of diaper dermatitis
- Can develop into abscess or cellulitis with an opportunistic organism
- Pustules, purulent drainage, increasing ulcers
Diaper Dermatitis Nursing Management
- Change wet diapers frequently and stool ASAP
- Avoid harsh soaps and wipes with fragrance/preservatives
- Can use cotton balls or cloths with warm water for each diaper change
- Diaper free - air exposure helps 15 minutes 4 times a day
- No baby powder
Causes of contact dermatitis
- Chemicals in body products - laundry, cosmetics, soaps
- Metals in hardware or jewelry - nickel
- Dyes - found in clothing
- Environmental irritant - poison ivy, poison oak, poison sumac
Contact Dermatitis 2nd Exposure
(Elicitation)
- Contact with antigen (poison ivy resin) makes T-lymphocytes spread rapidly and release inflammatory mediators
- Allergic reaction within 24-48 hours
S/Sx of Contact Dermatitis
- Rash with itching common - varies according to type of exposure and number of times exposed
- May have swelling with blisters present (poison ivy)
- Lesions present along sites that were exposed
Contact Dermatitis Diagnostics
Based on determining source from good H/P assessment
Contact Dermatitis Treatment
- Topical or systemic corticosteroids for rash
- Burow or Domeboro solution for weeping lesions
- OTC calamine lotion to help dry lesions
- Wash lesions daily with mild soap and water
- Mildly debride crusted lesions
- Tepid baths are helpful to relieve itching (avoid hot baths or showers)
Complications of Contact Dermatitis
Scarring if deep scratching present or secondary infections
Poison Ivy Nursing Management
- Heals in 10-14 days
- Can spread from the plant’s oils on clothes, pets, objects
- Soap and water (or IVY BLOCK scrub/soap agent) after contact
Prevention of Contact Dermatitis
- Wear long sleeves/pants in the woods
- Lawn management/weed killers
- Vinyl gloves (not rubber or latex) are an effective barrier
- The plant’s oil residue may be on clothes, pets, garden/sports equipment = wash with soap and water
- If contact occurs, wash vigorously with soap and water within 10 minutes of contact
Occurrence of Eczema (atopic dermatitis)
- 10 - 30% of kids have it
- Genetic tendency
- Atopy family along with asthma and allergic rhinitis
- Develops usually before age 5
Prevention of Eczema (atopic dermatitis)
- Delaying introduction of foods until 6 months
- Breastfeeding 1 year
- Introduction of fish before 9 months of age
Patho of Eczema (atopic dermatitis)
- Chronic disorder with relapsing and remitting nature
- Occurs in response to allergens - food, environmental
- Triggering antigen (mold) causes antigen presenting cells to stimulate the inflammatory process (interleukins)
S/Sx of Eczema (atopic dermatitis)
- Skin begins to feel itchy so the child scratches which makes the rash more apparent
- May also flare with changes in environment (cold/hot) and stressors to the body
- Disrupted sleep, irritability, wiggling, scratching
- Dry, scaly, or flaky skin with hardened/leathery enlarged areas of skin
- Dry lesions, weeping papules or vesicles
- Look for s/sx of asthma involvement (wheezing)
Eczema Diagnostics
- Serum IgE levels elevated
2. Skin prick allergy testing for triggers
Eczema Treatment
- Skin hydration
- Topical corticosteroids
- Oral antihistamines
- Antibiotics for secondary infections
Eczema Complications
Secondary infections
Eczema Nursing Management
- Bathe BID with mild soaps to dirty areas only - Cetaphil, unscented Dove
- Limit exposure to chemical containing products - fragrance, dye, perfume
- Pat skin dry (but keep slightly moist) and no rubbing
- Apply topical prescription creams and then moisturizer - Eucerin, Aquaphor
- Humidifiers in winter
- Avoid triggers and scratching
Causes of Urticaria
- Foods
- Drugs
- Animal stings
- Infection
- Environment stimuli
- Stress
Urticaria Patho
- Hives - type 1 hypersensitivity caused by immunology mediated antigen - antibody response of histamine release from mast cells
- Vasodilation and increased vascular permeability result
S/Sx of Urticaria
- Pruritic, red wheals that blanch when pressed
2. SQ edema and warmth
Urticaria Diagnostics
Detailed H/P
Urticaria Treatment
- Identify and remove trigger (stop if med)
- Antihistamine
- Corticosteroids
- Topical antipriritics
Urticaria Complications
Be alert for respiratory s/sx
- SQ epinephrine and IV diphenhydramine and corticosteroids
Urticaria Nursing Management
- Should resolve in a few days OR 6-8 weeks
2. Medical alert bracelets
Occurrence of Acne Vulgaris
In teens 12 - 16, more in males
Acne Vulgaris Patho
- Sebaceous glands enlarge and secrete sebum
- Skin shedding plugs the follicle opening and bacteria grows
- Androgen hormones stimulate sebaceous gland proliferation and production of sebum
S/Sx of Acne Vulgaris
- Non-inflammatory lesions
- Open comodones = blackheads
- Closed comodones = whiteheads
- Inflammatory lesions
- Papules, pustules, nodules, or cysts
- Scarring may be present
- Present of face, chest, and/or back
Acne Vulgaris Diagnostics
- Pregnancy test with Accutane use
2. Cultures if severe (abscess)
Acne Vulgaris Treatment
- Benzoyl peroxide
- Salicylic acid
- Retinoids
- Topical or oral antibiotics
- Accutane - pregnancy prevention program
- Oral contraceptives
- Laser or UV light
- Tea tree oil
Complications of Acne Vulgaris
Scarring
Acne Vulgaris Nursing Management
- Teach to wash face twice daily - do not pick at acne
- Wash hands after eating greasy foods
- Avoid oil based products
Tinea Capitis Patho
Fungus infection that invades hair shafts on the scalp causing central hair loss
S/Sx of Tinea Capitis
- Circular lesions to the scalp
- Papules become crusting papules and scales
- Mildly pruritic
- Patches of scaling in the scalp with central hair loss
Tinea Capitis Diagnostics
- Fungal culture of plucked hair
2. Wood lamp will show with some types not all
Tinea Capitis Treatment
- Oral grisofulvin for 4-6 weeks
- Take with whole milk or high fat foods
- Selenium shampoo may be used to decrease contagiousness (BID for 2 weeks)
- No school or day care for 1 week after treatment initiated
Tinea Capitis Complications
Kerion may form
- Immune reaction
- Red, boggy mass
- Crusted with papules
- Fever
- Lymphadenopathy possible
Tinea Capitis Nursing Management
Must eliminate spores
S/Sx of Tinea Corporis
- RING - circular lesions with raised peripheral scaling and central clearing
- 0.5 - 1 inch across
- Usually on face, trunk, extremities
- May have broken skin or hair loss areas
- Mildly pruritic
Tinea Corporis Diagnostics
- Wood’s lamp (some types)
2. KOH added and look under microscope to see branching hyphae
Tinea Corporis Treatment
Topical antifungals until gone for 1 week (at least 4 weeks)
- Clotrimazole (Lotrimin)
- Miconazole
- Ketoconazole
Tinea Corporis Complications
Scarring
Tinea Corporis Nursing Management
Pets can be the source of infection
Tinea Pedis Patho
- Athlete’s foot
2. Vesicular eruption in interdigital webs
S/Sx of Tinea Pedis
- Fine vesicopustular or scaly lesions
- Pruritic and painful
- See on soles of feet (between toes and under nails)
Tinea Pedis Diagnostics
- Wood’s lamp (some types)
2. KOH added and look under microscope to see branching hyphae
Tinea Pedis Treatment
Topical antifungals - creams, powders, sprays
- Clotimazole (Lotrimin)
- Terbinafine (Lamisil)
Tinea Pedis Complications
Can progress to fissures and maceration
Tinea Pedis Nursing Management
- Good foot hygiene
- Open to air - sandals, alternate shoes to allow to dry
- Change socks daily and wash them with hot water
- No cornstarch
S/Sx of Tinea Cruris
- Erythema, scaling, maceration in the inguinal creases and inner thighs
- Pruritic pink papules on inner thighs, groin, scrotum, and buttocks
- Usually does not affect penis or scrotum
Tinea Cruris Diagnostics
- Wood’s lamp (some types)
2. KOH added and look under microscope to see branching hyphae
Tinea Cruris Treatment
Antifungal topical creams until clear 1 week (at least 4-6 weeks)
Tinea Cruris Complications
Self-esteem issues
Tinea Cruris Nursing Management
- More common in adolescents
2. Avoid tight clothing to allow ventilation
Black Widows
- Shiny black spider with red hourglass
- Only females bite
- Mild sting initially
- Puncture site becomes swollen, red, pruritic
- Venom causes multiple body systems failure without antidote
S/Sx of Black Widow Venom
- Dizziness
- Headache
- Abdominal Pain
- Weakness
- Tremors
- Progression to delirium
- Paralysis
- Seizures
- Death
Black Widow Treatment
- Cleanse bite area
- Hospitalize children
- Give anti-venom (if not allergic to horse serum)
- IV calcium gluconate no longer recommended
- Morphine
- Muscle relaxants
- Tetanus prophylaxis PRN
Black Widow Bite Complications
Death can occur in severe cases
Black Widow Bite Nursing Management
- Keep wound site clean and dry
2. Pain control
Brown Recluse
- Common in SE US
- Yellow to red brown with fiddle shaped marking on head
- Wear protective clothing and be cautious in wooded areas
- Look in shoes before putting on
Brown Recluse Patho
- Initial sting
- Erythema, pain, and blistering develop
- Venom is necrotoxic
S/Sx of Brown Recluse Bite
- Becomes edematous
- Red with purpura
- Can expand to large ulcerated area in 7-14 days
- Fever
- Malaise
- N/V
- Joint pain
Brown Recluse Diagnostics
- Don’t always see the spider
2. Identification of spider or based on bite site and S/Sx
Brown Recluse Treatment
- Analgesics
2. Tetanus prophylaxis
Brown Recluse Complications
- Scarring may develop
2. Skin grafts may be needed
Brown Recluse Nursing Management
- Cool compresses
- Immobilize extremity
- Healing can take months
Bee Sting Patho
- Venom contains histamines and foreign proteins
2. Hypersensitivity response occurs (IgE)
Bee Sting S/Sx
- Pain, swelling, redness, and itching
- One percent have systemic symptoms
- Nausea
- Generalized edema
- Respiratory difficulty
- Shock
Bee Sting Diagnostics
None routinely used
Bee Sting Treatments
- Antihistamines
2. Corticosteroids for swelling
Bee Sting Complications
Anaphylaxis - airway closure
Bee Sting Nursing Management
- Remove restrictive clothing if on extremity
- Clean with soap and water
- Scrap away stinger if still present
- Apply ICE intermittently
- Need:
- ID bracelet
- Epi pen - Baking soda
- ASA paste or Adolph’s meat tenderizer
Pediatric Burns Incidence
- Higher morbidity and mortality rates in children less than 6 years
- Scalds and contact burns most common in kids under 10 years
- Under age 6 has highest incidence of burns
- Age 10-18 burns tend to be flame related from cooking
- Abuse accounts for 10-20% of burns in children
Burn Prevention
- Keep hot water heater below 120 degrees
- Test bath water
- Pot handles not near edge
- Teach older children how to safely get out of the house in case of fire
- Practice fire drills
- Teach children to “stop, drop, and roll”
Signs of Child Abuse-Induced Burns
- Inconsistent history given when caregivers are interviewed separately
- Delay is seeking treatment by caregiver
- Uniform appearance of the burn, with clear delineation of burned and non-burned area (as with a hot object applied to the skin)
- Lack of spattering (force immersion)
- Flexor-sparing burns or burns that involve the dorsum of the hand
Superficial Burn Care at Home
- Run cool water over the burned area until the pain lessens
- Do NOT apply ice to the skin
- Do not apply butter, ointment, or cream
- OTC pain meds
- Cool compresses
- Lotions with aloe
- Cover the burn lightly with a clean, non-adhesive bandage
- Have the child see by the physician or nurse practitioner within 24 hours
- Teach to watch for signs of infection
Extensive Burn Care at Home
- Call 911
- Remove clothing only if it come off easily or if it is still smoldering
- Check the child’s ABC’s and perform CPR if necessary
- Cover the burn with a clean, lint-free bandage or sheet
- Avoid applying large, wet sheets, as this can cause the child to become too cold
- Do not attempt to break any blisters
- If the child appears to be in shock, elevate the legs while protecting the burn and call 911
