Integumentary System and Skin Conditions

Glands

• Eccrine glands cover most of the body except nail beds, lip margins, glans penis, and labia minora
• Eccrine glands are most numerous on the palms and soles
• These glands open directly onto the skin surface
• Eccrine glands secrete a weak saline solution known as sweat, assisting in thermoregulation, in response to environmental or psychological stimuli
• Sweat-producing (sudoriferous) glands maintain normal body temperature by controlling the evaporation and resorption of water
• Apocrine glands are located in the axillae and genital areas
• Apocrine glands open into hair follicles and become active during puberty
• Apocrine glands create thicker, milky sweat that mixes with bacterial flora, producing a characteristic musky smell, or “body odor", and functioning decreases with aging
• Sebaceous glands are located throughout the body, except the palms and soles
• Sebaceous glands open into hair follicles and secrete sebum, which is an oil-like substance, assisting the skin with moisture retention and friction protection

Medications & Conditions That Cause Photo Reactions

• Medications like tetracycline, doxycycline, nalidixic acid, voriconazole, amiodarone, hydrochlorothiazide, naproxen, piroxicam, chlorpromazine, and thioridazine can cause phototoxic and photoallergic reactions
• Sun exposure can aggravate skin conditions like lupus erythematosus, erythema multiforme, atopic eczema, psoriasis, viral exanthemata, pemphigus, dermatitis herpetiformis, rosacea and shingles
• Retinols, glycolic acid, and benzoyl peroxide remove the outermost layer of skin, causing photosensitivity to fight fine lines or acne
• Products containing fragrances, preservatives, parabens, imidazolidinyl urea, Quaternium-15, DMDM hydantoin, phenoxyethanol, methylchloroisothiazolinone, and formaldehyde often cause skin irritation and allergies
• Brighteners like vitamin C may decrease melanin in the skin and exacerbate sunburn

Health & Promotion Teaching: Skin Self-Examination

• Skin self-examination aids at-risk lesion identification
• Complete self-examination is vital for immune-suppressed patients or those with a history/ family history of skin cancer through the detection of moles
• A normal mole has solid tan, brown, black, or skin-toned color, is usually round or oval with a flat or dome-like surface, and emerges before 30 years of age
• UV radiation is most intense between 10 am and 4 pm
• UV-A is responsible for photo-aging and wrinkling
• UV-B is likely to cause sunburn with skin cancers
• Broad-spectrum sunscreen is important
• Inspect skin of each body area
• Collect data on rashes, lesions, wounds
• Inspect skin over pressure points and collect data on risk for skin breakdown in immobile patients
• Inspect fingernails and toenails
• Assess hygiene, circulation, and inspect wounds
• Evaluate wound and stage wound healing
• Palpate skin, assess temperature, turgor, and vascularity
• Inspect hair for lesions, nits

Manifestations in Integument of Systemic Disorders

• Flushing is increased permeability of the peripheral capillaries, as with fever; may be normal with exercise and occurs with elevated temperature and hot climate
• Pallor is decreased arterial blood flow of arterial insufficiency and arterial insufficiency of an extremity indications and anemia occur on the face and conjunctiva
• Rubor and brawny skin indicate decreased venous return in venous insufficiency and the skin is cool or cold over areas of decreased circulation with chronic disease, as well as deep-dependent rubor of the right foot, with brawny skin being bronze in color and rough from chronic insufficiency
• Circumoral cyanosis is associated with congestive heart failure or chronic obstructive pulmonary disease
• Bluish skin discoloration occurs in areas of decreased blood flow or poor blood oxygenation, but cyanosis in dark-skinned patients is not readily observed on the skin and can be assessed in buccal mucosa or conjunctivae
• Gastrointestinal disorders lead to thinning of the skin, hair, and nail and hair loss, nutritional deficiencies, inadequate absorption of vitamins A, B6 (riboflavin), and C
• Poor appetite (quality, changes) and gastrointestinal symptoms (taste, hiccups, satiety, nausea, vomiting, indigestion, abdominal pain, bloating, constipation, and diarrhea) can lead to nutritional deficiencies
• Fingernail clubbing indicates disease states with prolonged hypoxia (e.g., emphysema), Rounded and “clubbed” or squared appearance of fingernail can also occur
• Jaundice (yellow discoloration of the skin, sclera, shown; buccal mucosa) indicates Liver disease
• Symptoms of liver disease consist of fatigue, abdominal pain, weight loss, vomiting, fever, pale stools, and dark urine

Pressure Injuries

• Stage 1: Non-blanchable erythema of intact skin
• Stage 2: Partial-thickness skin loss with exposed dermis
• Stage 3: Full-thickness skin loss with epibole
• Stage 4: Full-thickness skin and tissue loss
• Unstageable: Obscured full-thickness skin and tissue loss
• Deep tissue pressure injury: Persistent non-blanchable deep red marron or purple discoloration
• Non-pressure ulcers: Neuropathic ulcers/ loss of sensation, impairing the ability to detect pressures on the feet
• Venous ulcer (vascular): Developed from chronic pulling of blood in the extremities, usually between ankle and knee
• Arterial ulcer: Results from chronic ischemia and arterial circulation to an extremity and is located distally on toes or fingers

Cultural Variations & Health Disparities

• Skin color is the most noticeable difference among racial groups; shape of eyes, nose, and lips and cranium/neck shape and size also varies
• Hypothyroidism and hyperthyroidism are more common in assigned females and hypothyroidism is especially common in older assigned females; females are more likely to have goiter
• African Americans have a 54% lower prevalence of hypothyroidism and threefold higher risk of hyperthyroidism compared to Whites
• Thyroid cancer impacts all ages/races/ethnicities/sexes, but more females than males are diagnosed and the rate of thyroid cancer by race/ ethnicity is highest in Asian/Pacific Islanders and Whites

Assessment of Risk Factors

• Past medical history of thyroid tumor
• Lifestyle and personal habits, including diet
• Medications are taken
• Family history of thyroid disorder
• Teaching & Health Promotions
  • Reducing injury risk by promoting early detection of masses and emphasizing the importance of wearing helmets
  • Preventing thyroid disorders complications
• Need for regular exams, especially for pregnant individuals
• Risk factors for cancer include male gender, age over 50, alcohol use, and and tobacco consumption

Auscultation

• If the thyroid is enlarged, either unilaterally or bilaterally, auscultate over each lobe for a bruit using the bell of the stethoscope
• Acromegaly: Overproduction of growth hormone in adults results in thickening of the skin/ subcutaneous tissue and facial bones and coarsening of facial features
• Bell's palsy paralysis: usually unilateral paralysis of the facial nerve 12 can be transient or permanent
• Cushing syndrome: excessive exogenous adrenocorticotropic hormone production
• Parkinson's disease: degenerative neurological disease with mask-like facial appearance
• Cerebral vascular accident: stroke embolism, hemorrhage, or spasm in the brain
• Scleroderma: presents with shinning taut in eMobile skin, which may make it difficult to speak
• Goiter: enlarged thyroid glands
• Myxedema: severe hypothyrodism with swelling and edema of the face, hands, and feet

Visual fields

• Tests static confrontation (finger # test) and kinetic confrontation (finger wiggle test)
• Cornea light reflex shines light on the bridge of the nose and light must reflect exactly in the same spot in both eyes
• Visual fields must be covered and the patient must focus on a distant object, then move the cover from one eye to another to observe eye movement
• Accommodation: Pt must focus on the nurse's finger and move towards the patient’s nose

Assessment of Risk Factors for Eyes

• Assess past and family history of eye problems and cataracts
• Patient history of eye surgery and eye health (last EXAM) needs assessed
• Corrected prescriptions and exposure to viruses, such as diagnosed congenital syphilis, needs checked
• Lifestyle and personal factors related to eye exposure to toxins is important
• Eye protection needs to be assessed
• Medication & allergies that include the use of artificial tears or allergies, needs assessed

Extraocular Muscle Movements

• Cornea light reflux examines the shinning of light on the bridge of the nose and light must reflect exactly in the same spot in both eyes
• Covered test is covering patient eye and having the patient focus on distant object then move cover from one eye to another/ observe eye movement

Cranial Nerves

• Optic nerve II (VISUAL ACUITY, FIELDS, FUNDUS, SCOPIC EXAMINATION)
• Ocular motor III (CARDINAL FIELDS OF GAZE EYE LID INSPECTION, PUPIL REACTION)
• Trochlear IV (Cardinal fields of gaze) and Abducens VI ( Cardenal fields of gaze)

Visual Acuity

• Distant vision examined using Snellen or Allen chart
• Near vision examined with Jaeger test 14 in away from patient's view
• Color vision examined with Ishihara cards

Hearing & Hearing Difficulties

• Hearing: the external ear channels sound waves into the external auditory canal through the TM, to ossicles in the middle ear via the oval window, then to the cochlea basilar membrane vibrates the receptor hair cells of the organ of Corti, which transfer the signal into electrical impulses for the auditory nerve
• Conductive Hearing Loss: blockage of external canal due to cerumen or fluid in the middle ear
• SNHL: results from a problem somewhere beyond the middle ear/ from inner ear to auditory cortex
• Presbycusis: degeneration of nerves & hair cells of the organ of corti
• Tinnitus: buzzing or a ringing in both ears

Personal Habits

-Important to ask about how one protects skin in the sun -Medications ( prescription or OTC) as well as allergies

• Family HX of hearing problems or ear issues also important

Otoscopic Evaluation

• Inspects the external meatus and canal Several sizes of speculum are usable on Otoscope; select the correct one suited to the patient
• Otoscope evaluation: holding the patient's ear at the helix to help align canal for best visualization of tympanic membrane
• Exam the inside of the patient’s ear for redness, swelling, drainage/ discharge

Rinne Test

• rinne test measures the differences between BC and AC
• Using tuning forks by grasping and tapping to help place handle against surface
• Next ,place handle of the tuning fork patient surface area along with time in place
• AC=is longer by 2xs in comparison to BC
• Webers: Used when there's an indication of potential hearing loss
• Place at midline on top of skull to differentiate if patient hears equally
• Pt hears equally when done properly

Common Findings (Ears)

• sudden hearing loss/obstruction
• trauma to ear
• vertgio- vertigo & is often causes vertigo with different triggers
• tinnitus: an constant internal noise
• Otalgia( ear dysfunction , external)
• Possible ear infection - Otorrhea ( redness, swelling, drainage)

Equilibruim

• Assessed by using the Romberg test found in Chap23 Patient is standing up w/ eyes closed
• Looking for balance/or if pt looks to be dizzy

Nose

• Allow's passage of hair to allow into the respiratory system
• 4 Sinuses : Hollow cavity in the face to allow air
• In sinuses are
• Frontal: above eyebrows
• Ethmoid: between orbital socket
• Maxillary- bottom area of eyes on the cheek bone and above the teeth
• Normal /clear muscous- to allow a protective factors for filtering and protect
• When these aren't working efficiently or one component / factor is off

Signs / Symptoms -Nose ,Mouth,Throat

• Facial pressure/pain or HA ( H/A)
• Sleep Apnea or snoring
• Nasal congestion
• Bleading -Epitaxis
• Halitosis
• anosmia (decreased)
• Oral and voice complications or changes

Mouth Assessment

• External- inspect ,lips- palpating, moist , color , lesions to check competence
• Inside the M.- inspect for lesions / inflammation and swelling along with pinkness
• Mucosa-Use light and apply tongue separator(non-domo) with dom-hand to allow proper assessment
• UVULA- Uvula Rises properly for testing ,(Aaaahh)
• Soft And hard pallet, check color And check for tumor growth and or abnormalities
• Tongue- color , smooth with no abnormal it seems that don't need to occur

Hypothesis (Nose, Mouth) What are the potential causes for abnormalities :

• Diagnose Air way obstruction , clearing. Allergies, trauma or smoking
• What does this mean:
  • Patient education is a major importance for methods and prevent aspirating of foreign bodies
• Swallowing Problems What are some ways to reduce or what could cause the following effects here ?

Test your knowledge of the integumentary system, including gland functions, skin conditions, and medication-related skin issues. Questions cover eccrine and apocrine glands, sebaceous glands, photosensitivity, and pressure injuries. Identify stages of pressure injuries and nail conditions related to hypoxia.