Integumentary System Flashcards
A severe, life-threatening hypersensitivity reaction caused by an immunoglobulin E (IgE)-mediated reaction to foods, insect stings, and drugs. The main causes are food allergies.
Characterized by acute onset (minutes to several hours) with symptoms such as flushing, hives, angioedema, dyspnea, wheezing, tachycardia or bradycardia, hypotension, hypoxia, or cardiac arrest.
Immediate treatment with epinephrine (1 mg/mL) 0.3 to 0.5 mg IM can be given on the mid-outer thigh. The condition can repeat every 5 to 15 minutes if the response is poor to treatment.
Anaphylaxis (Angioedema, Hives)
In the setting of anaphylaxis, there are no absolute contraindications to epinephrine. Call 911.
Presents with abrupt onset of high fever, chills, severe headache, nausea/vomiting, photophobia, myalgia, and arthralgia followed by a rash that erupts 2 to 5 days after onset of fever. Rash consists of small red spots (petechiae) that start to erupt on the wrist, forearms, and ankles (sometimes the palms and soles). It rapidly progresses toward the trunk until it becomes generalized.
Higher mortality results if not treated during the first 5 days of the infection. More than 60% of cases occur in five states (North Carolina, Oklahoma, Alaska, Tennessee, and Missouri).
Rocky Mountain Spotted Fever (RMSF)
Rocky Mountain Spotted Fever (RMSF) Treatment Plan
First-line treatment is doxycycline (both children and adults).
Use of DEET-containing repellent on skin and permethrin on clothing and gear can repel dog and deer ticks.
Found mostly in the midwestern and southeastern United States. Systemic symptoms include fever, chills, nausea, and vomiting. Deaths are rare but have occurred in young children (younger than age 7 years). Any child with systemic signs should be hospitalized (the condition may cause hemolysis).
Bite may feel like a pinprick (or be painless). The bitten area becomes swollen, red, and tender, and blisters appear within 24 to 48 hours. Central area of bite becomes necrotic (purple-black eschar). When the eschar sloughs off, it leaves an ulcer, which takes several weeks to heal.
Brown Recluse Spider Bites (Loxosceles reclusa)
Classic lesion is an expanding red rash with central clearing that resembles a target. The “bull’s-eye” or target rash usually appears within 7 to 14 days after a deer tick bite (range: 3–30 days). Rash feels hot to the touch and has a rough texture. Common locations are the belt line, axillary area, behind the knees, and groin area. Accompanied by flu-like symptoms. Lesion spontaneously resolves within a few weeks.
Most common in the northeastern regions of the United States. Use of DEET-containing repellent on skin and permethrin on clothing and gear can repel deer ticks.
Erythema Migrans (Early Lyme Disease)
Systemic infection caused by Neisseria meningitidis (gram-negative bacterium) that can progress very rapidly and cause death within several hours.
Symptoms include sudden onset of sore throat, cough, fever, headache, stiff neck, photophobia, and changes in level of consciousness (LOC; drowsiness, lethargy to coma). In some cases, there is abrupt onset of petechial (small red spots) to hemorrhagic rashes (pink to purple colored) in the axillae, flanks, wrist, and ankles (50%–80% of cases). Hypotension and shock are common. In up to 25% of cases, cutaneous hemorrhage and disseminated intravascular coagulopathy (DIC) are seen.
Procalcitonin is usually elevated. Fulminant cases result in death within 48 hours. Mortality rate is about 13%. The risk is higher for those who live in close quarters, such as first-year college students residing in dormitories, nursery or day care, and military barracks; individuals with asplenia (no spleen), defective spleen (sickle cell anemia), HIV infection, or complement immune-system deficiencies; and infants (3 months to 1 year).
Meningococcemia (Meningitis)
Meningococcemia (Meningitis) Treatment Plan
Follow aerosol droplet precautions. Call 911. Prophylaxis should be given as soon as possible after exposure. Rifampin (twice a day for 2 days) and ceftriaxone 250 mg intramuscularly (one dose) are recommended for close contacts.
Sight-threatening condition caused by reactivation of the herpes zoster virus that is located on the ophthalmic branch of the trigeminal nerve (CN: V) Patients report sudden eruption of multiple vesicular lesions (which rupture into shallow ulcers with crusts) that are located on one side on the scalp and forehead and the sides and tip of the nose. If herpetic rash is seen on the tip of the nose, assume it is shingles until proved otherwise. The eyelid on the same side is swollen and red. Patients complain of photophobia, eye pain, and blurred vision. More common in elderly patients.
*Referral to:
Shingles Infection of the Trigeminal Nerve (Herpes Zoster Ophthalmicus)
Refer to an ophthalmologist or the ED as soon as possible.
Dark-colored moles with uneven texture, variegated colors, and irregular borders with a diameter of 6 mm or larger are observed. May be pruritic. Lesions can be located anywhere on the body, including the retina.
Risk factors include family history, extensive/intense sunlight exposure, blistering sunburn in childhood, tanning beds, high nevus count/atypical nevus, and light skin/eyes.
Melanoma
Most common type of melanoma in African Americans and Asians. Dark brown-to-black lesions are located on the nail beds (subungual), palmar and plantar (sole of foot) surfaces, and rarely the mucous membranes. Subungual melanomas look like longitudinal brown-to-black bands on the nail bed.
Acral Lentiginous Melanoma
Most common type of skin cancer in the United States. Looks like a pearly or waxy skin lesion with an atrophic or ulcerated center that does not heal. Lesion could be white, light pink, brown, or flesh colored. It may bleed easily with mild trauma. More common in fair-skinned individuals with long-term daily sun exposure. An important risk factor is severe sunburns as a child.
Basal Cell Carcinoma
*Pearly or waxlike (shiny) appearance with telangiectasia, may have central ulceration
Older-to-elderly fair-skinned adults complain of numerous dry, round, and red-colored lesions with a rough texture that do not heal. Lesions are slow growing. Most common locations are sun-exposed areas, such as the cheeks, nose, face, neck, arms, and back. In some cases, a precancerous lesion of squamous cell carcinoma is a possibility. Patients with early-childhood history of severe sunburns are at higher risk for skin cancer (squamous cell carcinoma, BCC, melanoma).
Actinic Keratosis
*Appear as a crusty/scaly growth that slowly enlarges over time – precancer of squamous cell carcinoma
Direct trauma to the nail bed results in pain and bleeding that is trapped between the nail bed and the fingernail/toenail. If hematoma involves >25% of the area of the nail, there is a high risk of permanent ischemic damage to the nail matrix if the blood is not drained.
One method of draining (trephination) is to straighten one end of a steel paperclip or use an 18-gauge needle and heat it with a flame until it is very hot. The hot end is pushed down gently (90-degree angle) until a 3- to 4-mm hole is burned on the nail. The nail is pressed down gently until most or all of the blood is drained or suctioned with a smaller needle. Blood may continue draining for 24 to 36 hours.
Subungual Hematoma
Lesions appear like a target (or a “bull’s-eye”). Multiple lesions start erupting abruptly and can include hives, blisters (bullae), petechiae, purpura, and necrosis and sloughing of the epidermis. Extensive mucosal surface involvement (eyes, nose, mouth, esophagus, and bronchial tree) is observed. There could be a prodrome of fever with flu-like symptoms 1 to 3 days before rashes appear.
Most common triggers are medications such as allopurinol, anticonvulsants (lamotrigine, carbamazepine, phenobarbital), sulfonamides, and oxicam nonsteroidal anti-inflammatory drugs (NSAIDs).
Risk factors include HIV infection (100-fold higher risk), genetics, lupus, and malignancies. HIV-infected patients have a 40-fold increased risk from trimethoprim–sulfamethoxazole compared to the general population.
Stevens–Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
SJS is less severe (involves <10% body skin) compared with TEN (involves >30% body skin).
Mortality rate ranges from 10% (SJS) to 30% (TEN).
The skin has three layers—epidermis, dermis, and subcutaneous.
Epidermis: No blood vessels; gets nourishment from the dermis. Consists of two layers:
Top layer consists of keratinized cells (dead squamous epithelial cells).
Bottom layer is where melanocytes reside and vitamin D synthesis occurs.
Dermis: Consists of blood vessels, sebaceous glands, and hair follicles
Subcutaneous layer: Composed of fat, sweat glands, and hair follicles
Apocrine glands: Type of sweat gland located mainly in the axilla and groin.
Eccrine glands: Major sweat glands of the body, helps with heat dissipation and thermoregulation.
Anatomy of the Skin
Urticaria and wheals can appear paler than surrounding skin (palpate for induration and warmth). Very dry dark skin can appear ashy to gray in color (check arms and legs).
Skin Examination: Darker Colored Skin
Vitamin D Synthesis: Darker Skin
People with darker skin require longer periods of sun exposure to produce vitamin D. A deficiency in pregnancy results in infantile rickets (brittle bones, skeletal abnormalities).
Distal portions of the limbs (i.e., the hand or feet [acral melanoma])
Acral
Ring-shaped (ringworm, or tinea corporis)
Annular
Cutaneous rash
Exanthem
The skin area that is outside of the joint (e.g., front of knee, back of elbow)
Extensor
The area of the skin on top of the joint with skin folds (e.g., back of knees, antecubital space)
Flexor
Skin flexures are body folds (eczema affects flexural folds)
Flexural
An area where two skin areas touch or rub each other (e.g., axilla, breast skin folds, anogenital area, between the fingers/digits)
Intertriginous
Rash with color (usually pink to red) with small bumps that are raised above the skin (viral rashes)
Maculopapular rash
Rash that resembles measles (pink rash with texture)
Morbilliform
Coin-shaped, round (nummular eczema)
Nummular
Bleeding into the skin; small bleeds are petechial (RMSF), and larger areas of bleeding are ecchymoses or purpura (meningococcemia)
Purpura
