Dermatologic Problems/ Integumentary System

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Dermatologic Problems/ Integumentary System
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Physical Examination

• Obtain history
• WHATS UP
• Inspection
• Palpation
• Gloves are worn during examination

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Physical Examination

• Observe for
• Color
• Temperature
• Moisture
• Dryness

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Physical Examination

• Skin texture (rough-smooth)
• Lesions
• Vascularity
• Mobility
• Texture of hair and nails
• Skin turgor

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Physical Examination

• Color
• Varies from person to person
• Ivory-deep brown
• Pigmentations r/t
• Sun exposure
• Fevers
• Sunburn, inflammation-
• Pink or
• Reddish hue
• Pallor
• Decreased skin tones

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Physical Examination

• Color
• Vascularity
• Observed in
• Conjunctivae
• Mucous membranes
• Bluish hue
• Cyanosis cellular hypoxia
• Jaundice
• Yellow pigment
• sclera
• mucous membrane

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Physical Examination

• Color
• Dark skinned persons
• Have reddish base and undertones
• Buccal mucosa, tongue, lips,nails normally appear
  pink
• Cyanosis-skin assumes grayish cast
• Age related changes

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Physical Examination

• Types of dressings
• Wet-dry dressings
• Moisture-retentive dressings
• Already impregnated with moisture
• Occlusive dressings
• Cover wound

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Physical Examination

• Topical medications
• Lotions, suspensions
• Clear solutions, liniment,
• Powders, creams,
• Gels, pastes,
• Ointments, sprays,
• Corticosteroids etc.

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Wounds

• Abrasion skin is rubbed or scraped off
• Lacerations torn, ragged, irregular edges made
  by blunt objects
• Avulsions the tearing away of tissue from a
  body part
• Incisions cuts made by sharp cutting
  instruments
• Punctures caused by objects that penetrate
  tissue while leaving a small surface opening 
• Amputations traumatic is the nonsurgical
  removal of a limb from the body

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Wound Healing

• 1st intention
• 2nd intention
• 3rd intention

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Diagnostic Tests/Treatments

• Cultures
• Skin biopsy
• Woods light examination
• Skin testing (allergies)
• Open wet dressing/other dressings
• Therapeutic baths
• Topical meds

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Herpes Zoster Shingles

• Acute inflammatory and infectious disorder
• Painful vesicular eruption
• Bright red edematous plaques along the nerve from
  one or more posterior ganglia

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Herpes Zoster Shingles contd

• Eruption follows the course of the nerve
• Almost always unilateral

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Herpes Zoster Shingles contd

• Cause
• Varicella-zoster virus (like chicken-pox)
• Incubation period 7-21 days
• Vesicles appear in 3-4 days
• Occur posteriorly
• Progress anteriorly peripherally
• Along dermatome
• Duration 10 days to 5 weeks

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Herpes Zoster Shingles contd

• Occurs most frequently in
• Elderly
• Immunosuppressed
• Malignancy or injury to spinal or cranial nerve

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Herpes Zoster Shingles contd

• Complications
• Facial and acoustic nerve involvement
• Hearing loss
• Tinnitus
• Facial paralysis
• Vertigo
• painful

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Herpes Zoster Shingles contd

• Complications
• Full thickness skin necrosis and scarring
• Systematic infection from scratching, causing
  virus to enter blood stream

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Herpes Zoster Shingles contd

• Medical treatment
• Control outbreak
• Reduce pain and discomfort
• Prevent complications
• Acyclovir (Zovirax) IV, PO, topically
• Corticosteroids
• Antihistamines
• Antibiotics

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Herpes Zoster Shingles contd

• Nursing Care
• Cool compresses two-three times per day
• Help cleanse and dry lesions
• Measures to decrease itching
• Medication

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Parasitic Skin Infections (PSI)

• Higher risk situations?
• Poor hygiene
• Living in close quarters

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Pediculosis- Lice (PSI)

• Infestation by human lice
• Pediculosis capitis-head
• Pediculosis corporis-body
• Pediculosis pubis- pubic or crab

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Pediculosis (PSI)

• Parasite
• Approximately 2-4 mm
• Female lays eggs-hundreds-nits
• Deposit on hair shaft base

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Pediculosis (PSI)

• Symptoms
• Pruritus
• Excoriation
• Vectors of other diseases
• Typhus
• Recurrent fever

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Pediculosis Capitis (PSI)

• More common in women
• Sides and back of scalp
• Assess for
• Visible white flecks (nits)
• Matting and crusting of scalp
• Foul odor

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Pediculosis Capitis (PSI)

• Treatment
• Pediculicides
• Hand pick or comb nits out
• Launder bed linens vacuum
• Seal items in plastic bags for 14 days
• Repeat above in 10-14 days

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Pediculosis Corporis (PSI)

• Lice live and lay eggs in clothing
• Itching
• Assess for
• Excoriation on
• Trunks
• Abdomen
• Extremities

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Pediculosis Pubis (PSI)

• Intense pruritis
• Vulvar region
• Peri-rectal
• More compact
• Crab-like appearance

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Pediculosis Pubis (PSI)

• Contracted from
• Infested bed linens
• Sexual intercourse
• May also infest
• Axilla
• Eyelashes
• Chest

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Pediculosis (PSI)

• Treatment
• Chemical killing
• Clean linens with hot water and soap
• Dry-clean
• Fine-tooth comb
• Treat social contacts

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Scabies (PSI)

• Contagious skin disease
• Mite infestation
• Transmitted by
• Close-prolonged contact with
• Infested companion
• Infested bedding

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Scabies (PSI)

• Characterized by
• Epidermal curved or linear ridges
• Follicular papules
• Pruritus Palms
• More intense and unbearable at night
• White visible epidermal ridges by
• Mite burrowing into outer layers of skin

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Scabies (PSI)

• Hypersensitivity reaction
• Excoriated erythematous papules
• Pustules, crusted lesions
• Elbows
• Axillary folds
• Lower abdomen
• Buttocks, thighs
• Between fingers
• Genitalia

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Scabies (PSI)

• Treatment
• Topical sulfur preparations
• One-two applications daily
• Launder personal items
• No disinfectant

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Ringworm (PSI)

• Ringworm - an infection caused by a fungus
• Jock itch form of ringworm on groin area
• Athletes foot fungal infection of foot (feet)
• Fungus
• live and spread on the top layer of the skin and
  on the hair
• grow best in warm, moist areas,
• contagious via skin-to-skin contact with a person
  or animal that has it or when you share things
  like towels, clothing, or sports gear.
• You can also get ringworm by touching an infected
  dog or cat, although this form of ringworm is not
  common.

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Psoriasis

• Lifelong disorder
• Exacerbations
• Remissions
• Cannot be cured

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Psoriasis

• Pathophysiology
• Scaling disorder
• Underlying dermal inflammation
• Abnormality in proliferation of epidermal cells
  in outer skin layers
• Normal 28 days to shed cells
• Psoriasis Cells shed every 4-5 days

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Psoriasis

• Cause-unknown
• Genetic predisposition
• Environmental factors
• May appear after skin trauma
• Sunburn
• Surgery

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Psoriasis

• Improves in warmer climates
• Aggravated by
• Infections
• Streptococcal throat infection
• Candida infections
• Hormonal changes
• Psychological stress

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Psoriasis

• Assessment
• History
• Family history
• Age at onset
• Disease progression
• Pattern of recurrences
• Gradual or sudden

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Psoriasis Vulgaris Ordinary/Common

• Most common
• Thick erythematous papules or plaques
• Surrounded by silvery white scales

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Psoriasis Vulgaris Ordinary/Common

• Common sites
• Scalp
• Elbows
• Trunk
• Knees
• Sacrum
• Extensor surfaces of limbs

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Skin Cancers

• Overexposure to sunlight
• Common skin cancers
• Squamous cell carcinoma
• Basal cell carcinoma
• Melanoma

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Actinic Keratosis

• Pre-malignant lesions
• Cells of epidermis
• Chronically sun-damaged skin
• Can lead to squamous cell carcinoma

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Squamous Cell Carcinoma

• Malignant neoplasms of epidermis
• Invade locally
• Potentially metastic
• Ear
• Lip
• External genitalia
• Cause
• Repeated irritation or injury

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Basal Cell Carcinoma

• Basal cell layer of epidermis
• Lesions go unnoticed
• Metastasis rare
• Underlying tissue destruction progresses to
  underlying vital structure

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Melanomas

• Pigmented malignant lesions
• Originate in melanin-producing cells of epidermis

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Melanomas

• Risk factors
• Genetic predisposition
• Excessive exposure to UV light
• Precursor lesions resembling unusual moles
• Highly metastatic
• Survival depends on early diagnosis and treatment

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Skin Cancers

• Incidence/Prevalence
• Light skinned persons
• Outside work
• Higher altitudes
• Chemical carcinogens

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• Type I - Often burns, rarely tans. Tends to have
  freckles, red or fair hair, and blue or green
  eyes.
• Type II - Usually burns, sometimes tans. Tends to
  have light hair, and blue or brown eyes.
• Type III - Sometimes burns, usually tans. Tends
  to have brown hair and eyes.
• Type IV - Rarely burns, often tans. Tends to have
  dark brown eyes and hair.
• Type V - Naturally black-brown skin. Often has
  dark brown eyes and hair.
• Type VI - Naturally black-brown skin. Usually has
  black-brown eyes and hair.

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Skin Cancers

• Prevention
• Avoid exposure to sunlight
• Use of sunscreen SPF30 or greater

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Skin Cancers

• Assessment
• Age
• Race
• Family history
• Removal of skin growths

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Skin Cancers

• Assessment
• Change in
• Size, Color, Sensation
• Of any
• Mole, Birthmark, Wart, Scar
• Hair-bearing areas of body

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Skin Cancers

• Interventions Radiation therapy
• Elderly
• Large, deeply invasive basal cell tumors
• Poor risk for surgery
• Malignant melanoma resistant
• May be used in combination with systemic
  chemotherapy

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Skin Cancers

• Interventions Surgery
• Cryosurgery
• Local application of liquid nitrogen
• Cell death
• Tissue destruction
• Hemorrhagic blister formation x 1-2 days
• Nursing Care
• Clean site with hydrogen peroxide
• Topical antibiotic may be ordered

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Skin Cancers

• Interventions Plastic or reconstructive surgery
• Wound flaps
• Pressure wounds

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Skin Flap vs. Skin Graft

• Skin Flap
• Segment of tissue attached on one end while other
  end is moved to new site
• Nursing Care
• Assess for infection
• Assess circulation of tissue

• Skin Graft
• Section of skin detached transferred
• Nursing Care
• Keep affected part immobilized
• Inspect dressing
• After 2-3 weeks, massage with oil
• No heating pads or sun exposure

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Pressure Ulcers

• Etiology

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Pressure Ulcers

• Etiology
• Immobility
• Impaired sensory perception or cognition
• Decreased tissue perfusion
• Decreased nutritional status
• Friction and shear
• Increased moisture

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Pressure Ulcers

• Stages

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Pressure Ulcers

• Stages
• Stage I
• Non-blanchable erythema
• Tissue swelling
• C/O discomfort
• Stage II
• Break in skin
• Epidermis
• Dermis
• Necrosis

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Pressure Ulcers

• Stages
• Stage III
• Subcutaneous tissue
• Deep crater
• With undermining
• Without undermining
• Stage IV
• Underlying structures
• May have large undermined area

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Pressure Ulcers

• Nursing Care
• Relieve pressure
• Proper positioning
• Improve mobility
• Improve sensory perception
• Improve tissue perfusion
• Improve nutritional status
• Reduce friction and shear
• Minimize moisture

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Burns

• 1st degree partial-thickness (superficial)
• 2nd degree partial-thickness (deep)
• 3rd degree full-thickness

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• Chemical burns
• Electrical burns
• Thermal burns
• Sunburn

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Burns

• Extent of burn injury
• Rule of nines
• Stages of care
• I Emergent
• II Acute
• III - Rehabilitation

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Burns

• Tests
• Wound cultures
• CBC, BUN, glucose, electrolytes, urine studies
• Interventions
• IV fluid replacement
• Antibiotic/antimicrobial agents
• Analgesics

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Burns

• Treatment
• Debridement cleaning
• Mechanical, chemical, surgical
• Escharotomy
• Dressing
• Open, closed, biological, synthetic
• Skin grafts
• Autograft
• Split-thickness
• Full-thickness

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Burn Care

• Impaired gas exchange
• Impaired skin integrity
• Deficient fluid volume
• Pain
• Ineffective peripheral tissue perfusion
• Risk for sepsis

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QUESTIONS?