Adult Health Test 1 Integumentary part 4

Tumors of the Skin

• Keloids are an overgrowth of collagenous scar tissue at the site of a wound on the skin.
  • More prevalent in African Americans than Caucasians.
  • Skin becomes raised, hard, and shiny.
  • Can be pink, red, or flesh-colored.
  • Treatment options include corticosteroid injections, radiation, cryotherapy, laser surgery, and surgical excision.
  • May recur and be larger after treatment.
• Angiomas are a group of blood vessels that dilate and form a tumor-like mass.
  • Port Wine birthmarks are a common type of angioma.
  • Discoloration is not elevated and may be found on any part of the body.
  • Treatment options include electrolysis and radiation.
• Spider angiomas resemble little spider veins.
  • Also known as telangiectasia.
  • Can be associated with liver disease.
  • Often resolve when liver disease improves.
• Warts, also known as Veruca, are benign viral warty skin lesions.
  • Have a rough papillomatous (nipple-like) growth.
  • Can be singular or in groups.
  • Thought to be contagious.
  • Commonly found on hands, arms, and fingers, but can occur anywhere.
  • Plantar warts are found on the soles of the feet and can be painful.
  • Treatment options include cauterization, solid carbon dioxide (dry ice), liquid nitrogen, and salicylic acid.
  • May take multiple treatments to eliminate.
• Nevi (moles) are non-vascular tumors, also known as birthmarks.
  • Some may be malignant.
  • Raised black nevi are the most threatening and should be removed to prevent malignancy. Clients should self-examine their skin, including their backs, for changes in color, size, texture, bleeding, or purpura.
  • ABCDE: Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, and Elevation or Enlargement should be investigated.

Skin Cancer

• Basal Cell Carcinoma is a type of skin cancer that originates in the basal cell layer of the epidermis.
  • Often found on the face and upper trunk.
  • May be subtle and unnoticed.
  • Can appear as a red, scaling area that comes and goes.
  • Can cause underlying tissue destruction and progress to vital structures.
  • Causes include chemicals, sun exposure, and radiation treatments.
  • Usually presents as a scaling appearance with a pearly papule with a central crater and a waxy pearly border.
  • Early detection and complete removal using the Mohs procedure is recommended for the best outcome. The Mohs procedure involves taking layers of tissue and examining them under a microscope until no further cancer is found.
  • Can reoccur in 40-50% of patients.
• Squamous Cell Carcinoma arises from the epidermis, forming a firm nodular lesion topped with a crust or an ulceration.
  • Found most commonly in sun-exposed areas, such as the head, neck, and lower lip.
  • May also occur in areas of chronic irritation or injury, such as scars, irradiated skin, or leg ulcers.
  • Metastasis occurs in 10% of patients.
• Malignant Melanoma is a cancerous neoplasm that occurs when pigment cells (melanocytes) invade the epidermis, dermis, and sometimes subcutaneous tissue.
  • Can arise in pre-existing moles.
  • Heredity is a factor.
  • Individuals with a large number of moles of varying sizes and colors should have regular dermatologic exams.
  • Sun exposure, chronic skin irritation, family history of unusual moles and melanoma, and personal history of melanoma increase the risk.
  • The four types of melanoma are superficial spreading melanoma, lentigo malignant melanoma, nodular melanoma, and acral lentiginous melanoma.
  • Superficial spreading melanoma is the most common and is characterized by irregular shape and multiple colors.
  • Lentigo malignant melanoma is typically found on the heads and necks of older adults and presents as tan flat lesions with changing shape and size.
  • Nodular melanoma appears as a blueberry-type growth and varies from blue to black or pink. It grows and metastasizes quickly.
  • Acral lentiginous melanoma occurs in areas not exposed to the sun and without hair follicles, commonly on the hands, soles of the feet, and mucous membranes of dark-skinned people.
  • Diagnosis is made through biopsy.
  • Treatment options include wide surgical excision of the lesion, sometimes requiring a skin graft, immunotherapy, chemotherapy, chemo-immunotherapy, and radiation.

Alopecias

• Alopecia is hair loss, often not permanent unless due to aging.
• Hirsutism or Hypertrichosis is excessive hair growth in a masculine distribution pattern.
  • Can be hereditary or acquired due to hormone dysfunction or medications.
  • Treatment methods include dermabrasion, electrolysis, chemical depilation, shaving, tweezing, and rubbing with a pumice stone.
• Hypotrichosis is the absence or decrease in hair growth.
  • Can be caused by various factors, including skin diseases, endocrine problems, and malnutrition.
  • Treatment focuses on addressing the underlying cause.

Nail Disorders

• Onychomycosis is a disorder of the nails.
  • The nails become soft, brittle, and their shape can change as they grow into soft tissue.
  • Includes conditions like ingrown toenails and infections around the nail.
  • Infected nails become painful and may loosen and separate from the tissue.
  • Treatment includes wet dressings, topical antibiotics, and sometimes incision and drainage for infections.

Burns

• Thermal burns are the most common, caused by flames or scalds (boiling water).
• Non-thermal burns are caused by electricity, chemicals, or radiation.
• The extent of tissue destruction depends on the burning agent, temperature, condition of the skin, and duration of exposure.
• Factors affecting burn severity include:
  • Extent of the burn: Documented as the percentage of body surface area burned.
  • Depth of the burn:
    • Superficial (first-degree): Dry appearance, minimal/no edema, blanches with pressure and refills rapidly. Primarily affects the epidermis.
    • Partial thickness (second-degree): Large moist vesicles that increase in size, blanches with pressure and refills rapidly. Affects the epidermis and dermis.
    • Full thickness (third-degree): Dry, leathery appearance, charred vessels visible, no blanching with pressure. Affects the epidermis, dermis, and subcutaneous tissue.
• Burns exceeding 20% of the total body surface area result in significant evaporative water loss and fluid shifting into the interstitial spaces.
• Chemical Burns: Requires extensive rinsing with cool water for many minutes to remove the chemicals.
• Electrical Burns: Have an entry and exit site, often leading to cardiac arrest. CPR is necessary if a pulse is absent.

Burn Stages and Emergent Phase

• Emergent Phase: Occurs from the time of the burn up to 48 hours.
  • Greatest risk is burn shock (hypovolemic shock) due to fluid evaporation and shifting from the vascular compartment to the interstitial spaces.
  • Treatment includes:
    • Oxygen
    • Intubation if needed
    • Control bleeding
    • Remove non-adherent clothing and jewelry
    • Cover with a sheet or cloth
    • Transport to the hospital
  • Fluid loss is greatest within the first 12 hours.
  • Damaged capillaries dilate, leading to capillary hyperpermeability for about 24 hours, causing edema and blistering.
  • Fluid shift results in:
    • Third spacing: Fluid moves from the vascular space (blood vessels) into the interstitial space (tissues).
    • Burn Shock: Dehydration of cells, leading to hypovolemic shock.
  • Burn shock causes:
    • Hypotension
    • Decreased urinary output
    • Tachycardia to compensate
    • Increased respirations to deliver oxygen
    • Restlessness
  • Laboratory abnormalities:
    • Increased hemoglobin and hematocrit due to fluid loss
    • Decreased sodium
    • Increased potassium due to cell damage.
    • Decreased plasma proteins and electrolytes
  • Smoke Inhalation: Can cause damage to the cilia and mucosa of the respiratory tract and potentially lead to carbon monoxide poisoning.
    • Signs and symptoms include:
      • Singed nasal hairs
      • Soot in the throat
      • Hoarseness
      • Stridor (noisy breathing)
      • Productive cough
      • Agitation
      • Tachypnea (rapid breathing)
      • Flaring nostrils
      • Intercostal retractions (pulling inward between ribs)
      • Brassy cough
      • Grunting or guttural sounds
      • Erythema or edema of the oropharynx or nasopharynx
    • Carbon monoxide poisoning can mimic hypoxia, so ABG's are recommended over pulse oximetry.
    • Signs and symptoms of carbon monoxide poisoning include:
      • Headache
      • Nausea
      • Vomiting
      • Unsteady gait
    • Treatment for carbon monoxide poisoning includes 100% oxygen.

Acute Phase

• Acute phase: Occurs from 48 to 72 hours after the burn.
  • Fluid shifts back from the interstitial space to the vascular space, leading to circulatory overload and increased risk of heart failure.
  • Increased cardiac output and renal perfusion.
  • Signs of fluid shift:
    • Increased urine output
    • Decreased edema
    • Diuresis (increased urine production)
  • Goals of treatment in the acute phase:
    • Treat the burn wound
    • Prevent and manage complications
  • Increased metabolism, urinary output.
  • Vital signs stabilize:
    • Increased blood pressure
    • Decreased heart rate and respiratory rate
    • Improved level of consciousness
  • Common complications:
    • Heart Failure
    • Renal Failure
    • Paralytic Ileus (cessation of bowel sounds)
    • Contractures: Shortening and tension in the muscles, causing limited movement.
    • Curling's Ulcer: Duodenal ulcers that develop 8-14 days after severe burns, indicated by bright red blood in vomit.
  • Laboratory shifts:
    • Decreased hemoglobin and hematocrit
    • Decreased sodium
    • Decreased potassium
    • Increased white blood cells (initially), then decrease with shift
    • Possibly elevated glucose due to stress
    • Slight hypoxia (low oxygen levels) from metabolic acidosis
    • Decreased total protein and albumin due to fluid loss
  • Treatment:
    • Oxygen
    • Fluid resuscitation with lactated ringers
    • Inotropic agents (to increase cardiac output)
    • Osmotic diuretics (to reduce fluid overload)
    • Central line insertion for IV fluids
    • Urinary catheter with hourly urine output measurement
    • G-tube for aspiration prevention
    • Frequent small doses of morphine for pain (monitor respiratory rate)
    • Tetanus booster if not given within the last 5 years
    • Elevate extremities to reduce edema
    • Turn, cough, and deep breathe
    • Topical antimicrobials
    • Nutrition: High caloric, high protein diet, oral supplements as needed
    • Range of motion to prevent contractures
    • Monitor for acute renal failure (BUN, creatinine), heart failure (edema, fluid in the lungs), and infection.
  • Infection is the most common complication after 72 hours, requiring reverse isolation.
  • Signs of infection:
    • Erythema (redness)
    • Odor
    • Green or yellow exudate (drainage)
    • Wound cultures should be obtained
  • Treatment for infection includes antibiotics.
  • Nutrition needs increased protein, calories, vitamins, minerals, and calcium, zinc, magnesium, and iron for skin repair and general nutrition.
  • Encourage small, frequent meals as tolerated.
  • 85 degrees Fahrenheit and 30-50% humidity in the room are recommended.
  • Important to address psychological needs.

Eschar Management and Skin Grafting

• Eschar is black, leathery tissue that forms over burned areas.
  • Harbor microorganisms that can cause infection.
  • Can cause circulatory constriction and hinder breathing.
  • Treatment:
    • Escharotomy: A surgical procedure that uses a scalpel to make an incision through the eschar to relieve pressure and allow for chest expansion.
• Temporary Skin Substitutes:
  • Integra: A synthetic skin substitute that stimulates the regeneration of the dermis and skin layer.
    • Used in surgical debridement to promote healing.
    • Removed after it has stimulated tissue growth and replaced with a client's own skin graft.
• Traditional Treatment:
  • Daily debridement (removal of eschar) to cleanse the wound and promote regeneration.
  • Pain medications 30 minutes before debridement
  • Topical antibiotics applied after debridement
  • Dressing changes twice daily
  • Hydrotherapy to soften eschar
• Dressing Options:
  • Open Dressing: Wounds are left open after debridement and cleansing
  • Closed Dressing: Wounds are closed with a dressing after treatment
• Fluidized Beds: Used to decrease pressure on burns and promote healing.
• Bed Cradles: Used to keep linens off of the burned skin.

Skin Grafting

• Autografting: Skin is taken from another part of the client's body and placed on the burned area.
• Homograft: Skin is taken from another person or a cadaver.
• Heterograft: Skin is taken from another species, such as a pig or cow.
• Synthetic Skin Substitutes: Man-made graft substitutes are also available.
• Post-Graft Care:
  • Minimize movement to allow the graft to adhere
  • Moistened with lotion daily for 6-12 months
  • Protected from direct sunlight with sunscreen for at least 6 months
  • Report any changes in the graft, hematoma, or fluid collection
  • Elastic stockings worn for 4-6 months for grafts on lower extremities

Nutrition and Rehabilitation Phase

• Nutrition for Burn Patients:
  • Increase protein and calorie intake due to high energy requirements (1.5-2grams per kilogram of protein, 2000-6000 calories per day)
  • Offer high-calorie foods frequently
  • Supplements like Ensure may be given
  • Small, frequent meals due to decreased appetite
  • Vitamin C and Zinc are essential for wound healing
• Rehabilitation Phase:
  • Goal is to increase independence
  • Mobility is a major concern, requiring physical therapy (PT) assistance
  • Address psychosocial needs due to changes in body image
  • Focus on achieving independence in daily activities
  • Monitor for complications.

Additional Definitions

• Blanching: When skin becomes pale after pressure is applied
• Erythema: Redness of the skin.
• Exudate: Drainage from a wound.
• Hyperpermeability: Increase in the permeability (leakage) of the capillaries.
• Hypovolemia: Decreased blood volume.
• Hypoxia: Low oxygen levels in the blood.
• NPO: Nothing by mouth.
• Intratracheal Tube: A breathing tube inserted into the trachea to assist breathing.
• Osmotic Diuretics: Medications that help excrete fluid from the body.
• Paralytic ileus: A condition in which bowel sounds are absent.
• Stridor: A noisy breathing sound.
• Tetanus Shot: A vaccine to prevent tetanus.
• Topical Antimicrobials: Medications applied to the skin to prevent infection.
• ABG: Arterial blood gas (a blood test that measures oxygen and carbon dioxide levels)
• BUN: Blood urea nitrogen (a measure of kidney function)
• Creatinine: A measure of kidney function
• H&H: Hemoglobin and hematocrit, which measure the concentration of red blood cells in the blood.
• Albumin: A protein found in the blood that helps to maintain fluid balance.

Home Care Considerations

• Bathe twice a day with mild soap.
• Test water temperature before bathing as skin is sensitive.
• Clean the tub thoroughly before each bath.
• For severe itching, use a lukewarm bath with alpha-Keri lotion.
• Do not use lotions containing lanolin or alcohol as they can cause blisters.
• Avoid direct sunlight.
• Wear light clothing to cover burned areas.
• Discoloration and scarring are normal during healing.
• Scars may remain red for 6-12 months before softening and changing color.
• Normal skin color may take several months to return.
• Report any signs of infection to the healthcare provider (e.g., fever greater than 101°F, inability to cope).
• Schedule follow-up appointments with the provider for burn and wound progress checks.
• Multiple return visits are needed to monitor healing.