Integumentary System Disorders, Conditions, and Diseases PDF

The Integumentary System “Disorders, Conditions, and Diseases”  Objectives Identify the structures and functions of the skin. Differentiate the composition and function of each skin layer: epidermis, dermis, and subcutaneous tissue. Recognize common sk...

The Integumentary System “Disorders, Conditions, and Diseases”  Objectives Identify the structures and functions of the skin. Differentiate the composition and function of each skin layer: epidermis, dermis, and subcutaneous tissue. Recognize common skin eruptions and manifestations associated with systemic disease. Describe the general management of the patient with an abnormal skin condition. Use the nursing process as a framework for caring of the patient with skin disorders  Definitions Disease- an abnormal condition of the body or the mind that causes dysfunction or discomfort. Disorder- a functional abnormality, or disturbance. Condition- a state of being, in health, a disease, such as a heart condition.  Introduction The integumentary system is susceptible to a variety of diseases, disorders, and injuries. These range from annoying but relatively benign bacterial or fungal infections that are categorized as disorders, to skin cancer and severe burns, which can be fatal. Layers of the skin  Layers of epithelial cells The epidermis is composed of keratinized, stratified squamous epithelium. It is made of four or five layers of epithelial cells, depending on its location in the body. It does not have any blood vessels within it (i.e., it is avascular). Skin that has four layers of cells is referred to as “thin skin.” (a) From deep to superficial, these layers are the stratum basale, stratum spinosum, stratum granulosum, and stratum corneum. Most of the skin can be classified as thin skin. “Thick skin” is found only on the palms of the hands and the soles of the feet. (b) It has a fifth layer, called the stratum lucidum, located between the stratum corneum and the stratum granulosum  Epidermis The epidermis is epithelium composed of multiple layers of cells. The basal layer consists of cuboidal cells, whereas the outer layers are squamous, keratinized cells, so the whole epithelium is often described as being keratinized stratified squamous epithelium. Layers of the Epidermis  Dermis The dermis might be considered the “core” of the integumentary system as distinct from the epidermis and hypodermis It contains blood and lymph vessels, nerves, and other structures, such as hair follicles and sweat glands. The dermis is made of two layers of connective tissue that compose an interconnected mesh of elastin and collagenous fibers, produced by fibroblasts Skin Pigmentation  Skin Pigmentation the color of skin is influenced by a number of pigments, including melanin, carotene, and hemoglobin. Recall that melanin is produced by cells called melanocytes, which are found scattered throughout the stratum basale of the epidermis. The melanin is transferred into the keratinocytes via a cellular vesicle called a melanosome  Petechiae & Ecchymoses Round red or purple macule Small: 1–2 mm Secondary to blood extravasation Associated with bleeding tendencies or emboli to skin Ecchymoses Round or irregular macular lesion Larger than petechia Color varies and changes: black, yellow, and green hues Secondary to blood extravasation Associated with trauma, bleeding tendencies  Angioma Cherry Angioma Spider Angioma Papular and round Red, arteriole lesion Red or purple Central body with radiating Noted on trunk, extremities branches May blanch with pressure Noted on face, neck, arms, trunk Normal age-related skin Rare below the waist alteration May blanch with pressure Usually not clinically significant Associated with liver disease, pregnancy, vitamin B deficiency  Telangiectasia (Venous Star) Shape varies: spider-like or linear Color bluish or red Does not blanch when pressure is applied Noted on legs, anterior chest Secondary to superficial dilation of venous vessels and capillaries Associated with increased venous pressure states (varicosities)  Acne Vulgaris Acne vulgaris is a common skin disease that affects 85-100% of people at some time during their lives. It is characterized by non-inflammatory pustules or comedones, and by inflammatory pustules, and nodules in its more severe forms. Acne vulgaris affects the areas of skin with the densest population of sebaceous follicles; these areas include the face, the upper part of the chest, and the back.  Pathophysiology During puberty, androgens stimulate the sebaceous glands, causing them to enlarge and secrete a natural oil, sebum, which rises to the top of the hair follicle and flows out onto the skin surface. In adolescents who develop acne, androgenic stimulation produces a heightened response in the sebaceous glands so that acne occurs when accumulated sebum plugs the pilosebaceous ducts. The color of open comedones (ie, blackheads) results not from dirt, but from an accumulation of lipid, bacterial, and epithelial debris. Although the exact cause is unknown, however an inflammatory response may result from the action of certain skin bacteria, such as Propionibacterium acnes, that live in the hair follicles and break down the triglycerides of the sebum into free fatty acids and glycerin.  Management The goals of management are to reduce bacterial colonies, decrease sebaceous gland activity, prevent the follicles from becoming plugged, reduce inflammation, combat secondary infection, minimize scarring, and eliminate factors that predispose the person to acne Treatment is a regimen of topical creams, and oral antibiotics, and or steroids. Maintenance of good nutrition equips the immune system for effective action against bacteria and infection. Hormone Therapy- Estrogen therapy (including progesterone–estrogen preparations) suppresses sebum production and reduces skin oiliness. Surgical management – - Comedo extraction, - Injections of corticosteroids into the inflamed lesions, - and incision and drainage of large, fluctuant nodular cystic lesions. - Cryosurgery (ie, freezing with liquid nitrogen) - abrasive therapy in which the epidermis and some superficial dermis are removed down to the level of the scars.  Nursing intervention Patient education, particularly in skin care techniques, and managing potential problems related to the skin disorder or therapy Prevention of scarring is the ultimate goal of therapy- - long-term therapy with systemic antibiotic with tetracycline  Psoriasis It can appear anywhere on the body, but it is most commonly found on the elbows, knees, scalp, and lower back. Skin typically becomes red and inflamed and may form white scaly patches. It can be quite painful and may itch, crack, and bleed. While psoriasis may look like just a skin disease, it is in fact a disease of the immune system.  Psoriasis Although the primary cause is unknown, a combination of specific genetic makeup and environmental stimuli may trigger the onset of disease. There is some evidence that the cell proliferation is mediated by the immune system. Periods of emotional stress and anxiety aggravate the condition. Trauma, infections, and seasonal and hormonal changes also are trigger factors. The onset may occur at any age but is most common between the ages of 15 and 50 years. Psoriasis has a tendency to improve and then recur periodically throughout life  Clinical manifestation Lesions appear as red, raised patches of skin covered with silvery scales. The scaly patches are formed by the buildup of living and dead skin resulting from the vast increase in the rate of skin-cell growth and turnover. If the scales are scraped away, the dark red base of the lesion is exposed, producing multiple bleeding points. These Affected areas - scalp, the extensor surface of the elbows, knees, the lower part of the back, and the genitalia, palms and soles, nails Complications - associated with asymmetric rheumatoid arthritis of multiple joints  Management The goals of management are to slow the rapid turnover of epidermis, to promote resolution of the psoriatic lesions, and to control the natural cycles of the disease. There is no known cure. Therapeutic approach - cosmetically acceptable and not too disruptive of lifestyle Treatment is time consuming, expensive, and aesthetically unappealing at times. The most important principle of psoriasis treatment is gentle removal of scales. with baths. Oils (eg, olive oil, mineral oil, Aveeno Oilated Oatmeal Bath) or coal tar preparations (eg, Balnetar) can be added to the bath water and a soft brush used to scrub the psoriatic plaques gently. Followed by the application of emollient creams containing alphahydroxy acids (eg, Lac-Hydrin, Penederm) or salicylic acid will continue to soften thick scales  Eczema Eczema most commonly causes dry, reddened skin that itches or burns, although the appearance of eczema varies from person to person and varies according to the specific type of eczema. Intense itching is generally the first symptom in most people with eczema. Sometimes, eczema may lead to blisters and oozing lesions, but eczema can also result in dry and scaly skin. Repeated scratching may lead to thickened, crusty skin.  Contact Dermatitis The word "dermatitis" means inflammation of the skin. In contact dermatitis, the skin becomes extremely itchy and inflamed, causing redness, swelling, cracking, weeping, crusting, and scaling. Dry skin is a very common complaint and an underlying cause of some of the typical rash symptoms. This is usually occupationally related: hair stylists, medical personnel, photographers, etc.  Tinea Pedis- Athletes’ Foot Athlete's foot is a very common skin infection of the foot caused by fungus.. When the feet or other areas of the body stay moist, warm, and irritated, this fungus can thrive and infect the upper layer of the skin.. Athlete's foot is caused by the ringworm fungus ("tinea" in medical jargon). Athlete's foot is also called tinea pedis. The fungus that causes athlete's foot can be found on many locations, including floors in gyms, locker rooms, swimming pools, nail salons, and in socks and clothing. The fungus can also be spread directly from person to person or by contact with these objects.  Urticaria Hives (medically known as urticaria) are red, itchy, raised areas of skin that appear in varying shapes and sizes. They range in size from a few millimeters to several inches in diameter. Hives can be round, or they can form rings or large patches. Wheals (welts), red lesions with a red "flare" at the borders, are another manifestation of hives. Hives can occur anywhere on the body, such as the trunk, arms, and legs.  Rosacea Rosacea (roz-ay-sha) is a very common benign skin disorder that affects many people worldwide. The main symptoms of this facial condition include red or pink patches, visible broken blood vessels, small red bumps, red cysts, and pink or irritated eyes. Many patients may just assume they blush easily or have gotten sunburned.  Albinism is a genetic disorder that affects (completely or partially) the coloring of skin, hair, and eyes. The defect is primarily due to the inability of melanocytes to produce melanin. Individuals with albinism tend to appear white or very pale due to the lack of melanin in their skin and hair. Individuals with albinism tend to need more protection from UV radiation, as they are more prone to sunburns and skin cancer. They also tend to be more sensitive to light and have vision problems due to the lack of pigmentation on the retinal wall. Treatment of this disorder usually involves addressing the symptoms, such as limiting UV light exposure to the skin and eyes.  Vitiligo Vitiligo (vit-ill-EYE-go) is a pigmentation disorder in which melanocytes (the cells that make pigment) in the skin are destroyed. As a result, white patches appear on the skin in different parts of the body. Similar patches also appear on both the mucous membranes (tissues that line the inside of the mouth and nose), and the retina (inner layer of the eyeball). The hair that grows on areas affected by vitiligo sometimes turns white.  Impetigo Impetigo is a skin infection that can spread from one person to another. Impetigo causes one or more "sores" on the skin that are often covered by a thick dry honey-colored crust. The sores don't hurt, but may be tender if touched. They may also be itchy. Any skin area can be affected, but sores are usually on arms or legs, the face (mainly around the mouth, nose, or ears), and sometimes on the scalp. Anyone can get impetigo, but it most often occurs in children 2 to 6 years old. The disease is most common during summer and fall, but can occur anytime.  Boils A boil, also referred to as a skin abscess, is a localized infection deep in the skin. A boil generally starts as a reddened, tender area. Over time, the area becomes firm and hard. Eventually, the center of the abscess softens and becomes filled with infection-fighting white blood cells that the body sends via the bloodstream to eradicate the infection. This collection of white blood cells, bacteria, and proteins is known as pus.  Carbuncles A skin abscess, a collection of pus that forms inside the body. Antibiotics are often not very helpful in treating abscesses. The main treatments include hot packs and draining ("lancing") the abscess, but only when it is soft and ready to drain.  Ringworm Ringworm is not, as its name suggests, caused by a worm. Characterized by round lesions (rings) and early belief that the infection was caused by a parasite (worm), the term ringworm was born. Further confusion comes from the medical term for ringworm, tinea, which is Latin for 'growing worm.' While the condition is actually the result of a fungal infection, the name 'ringworm' has stuck.  Warts Common warts are local growths in the skin that are caused by human papillomavirus (HPV) infection. Although they are considered to be contagious, it is very common for just one family member to have them. They often affect just one part of the body (such as the hands or the feet) without spreading over time to other areas.  Keloid A keloid is a scar that doesn't know when to stop. When the cells keep on reproducing, the result is an overgrown (hypertrophic) scar or a keloid. A keloid looks shiny and is often dome-shaped, ranging in color from slightly pink to red. It feels hard and thick and is always raised above the surrounding skin.  MRSA- Staph Infection MRSA stands for methicillin resistant Staphylococcus aureus (S. aureus) bacteria. This organism is known for causing skin infections, in addition to many other types of infections. It is also found to be more prevalent in hospital settings and is highly contagious. Most MRSA infections are skin infections that produce the following signs and symptoms:･cellulitis (infection of the skin or the fat and tissues that lie immediately beneath the skin, usually starting as small red bumps in the skin),･ ･･boils (pus-filled infections of hair follicles),･･･abscesses (collections of pus in under the skin).  Gangrene Gangrene may result when blood flow to a tissue is lost or not adequate to keep the tissue alive. There are two types of gangrene: wet and dry. All cases of wet gangrene are infected by bacteria. Most cases of dry gangrene are not infected. If wet gangrene goes untreated, the patient may die of sepsis and die within hours or days. Dry gangrene usually doesn't cause the patient to die. Symptoms of dry gangrene include numbness, discoloration, and mummification of the affected tissue. Wet gangrene symptoms include swelling, pain, pus, bad smell, and black appearance of the affected tissue. Treatment depends upon the type of gangrene and how much tissue is compromised by the gangrene.  Harlequin Type Icthyosis A skin disease, characterized by a thickening of the keratin layer in fetal human skin. In sufferers of the disease, the skin contains massive, diamond-shaped scales, and tends to have a reddish color. In addition, the eyes, ears, mouth, and other appendages may be abnormally contracted. The scaly keratin greatly limits the child's movement. Because the skin is cracked where normal skin would fold, it is easily pregnable by bacteria and other contaminants, resulting in serious risk of fatal infection.  Scleroderma Scleroderma is an autoimmune disease of the connective tissue. Autoimmune diseases are illnesses which occur when the body's tissues are attacked by its own immune system. Scleroderma is characterized by the formation of scar tissue (fibrosis) in the skin and organs of the body. This leads to thickness and firmness of involved areas.  Alopecia Areata Alopecia areata is a hair-loss condition which usually affects the scalp. It can, however, sometimes affect other areas of the body. Hair loss tends to be rather rapid and often involves one side of the head more than the other. Alopecia areata affects both males and females. This type of hair loss is different than male-pattern baldness, an inherited condition. Current evidence suggests that alopecia areata is caused by an abnormality in the immune system. In alopecia areata, for unknown reasons, the body's own immune system attacks the hair follicles and disrupts normal hair formation.  HERPES ZOSTER Herpes zoster, also called shingles, is an infection caused by the varicella- zoster virus, a member of a group of DNA viruses. The viruses causing chickenpox and herpes zoster are indistinguishable, hence the name varicella-zoster virus. The disease is characterized by a painful vesicular eruption along the area of distribution of the sensory nerves from one or more posterior ganglia It is assumed that herpes zoster represents a reactivation of latent varicella virus infection and reflects lowered immunity. After a case of chickenpox runs its course, it is thought that the varicella zoster viruses responsible for the outbreak lie dormant inside nerve cells near the brain and spinal cord. Later, when these latent viruses are reactivated, they travel by way of the peripheral nerves to the skin, where the viruses multiply and create a red rash of small, fluid-filled blisters.  Clinical Manifestations The eruption is usually accompanied by pain (burning, lancing, stabbing, or aching) Itching and tenderness may occur over the area. Malaise and gastrointestinal disturbances precede the eruption The blisters are usually confined to a narrow region of the face or trunk over a 1- 3 weeks period. The goals of herpes zoster management are to relieve the pain and to reduce or avoid complications, which include infection, scarring, and eye complications Treatment-analgesics, corticosteroids Triamcinolone (Aristocort, Kenacort, Kenalog) injected subcutaneously under painful areas is effective as an anti-inflammatory agent Oral antiviral agents such as acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir) are administered within 24 hours of the initial eruption  Nursing Management The nurse assesses the patient’s discomfort and response to medication and collaborates with the physician to make necessary adjustments to the treatment regimen. The patient is taught : - how to apply wet dressings or medication to the lesions - Proper hand hygiene techniques to avoid spreading the virus Diversionary activities and relaxation techniques are encouraged to ensure restful sleep and to alleviate discomfort  Burns Burns are categorized by severity as first, second, or third degree. First degree burns are similar to a painful sunburn, causing redness and swelling to the tissues. The damage is more severe with second degree burns, leading to blistering and more intense pain. Damage is found in deeper tissues. The skin turns white and loses sensation with third degree burns. The entire depth of tissue is affected. Scarring is permanent, and depending on the extent of the burning, may be fatal. Burn treatment depends upon the location, total burn area, and intensity of the burn. 1st Degree Burn 2nd Degree Burn 3rd Degree Burn  Skin Grafting In its most basic sense, skin grafting is the transplanting of skin and, occasionally, other underlying tissue types to another location of the body.  Skin Cancer Skin cancer is the most common form of cancer. More than one million skin cancers are diagnosed annually internationally. One in five Americans will develop skin cancer in the course of a lifetime. Basal cell carcinoma (BCC) is the most common form of skin cancer; about one million of the cases diagnosed annually are basal cell carcinomas. basal cell carcinomas are rarely fatal, but can be highly disfiguring Squamous cell carcinoma (SCC) is the second most common form of skin cancer. More than 250,000 cases are diagnosed each year, resulting in approximately 2,500 deaths. Basal cell carcinoma and squamous cell carcinoma are the two major forms of non-melanoma skin cancer. Between 40 and 50 percent of Americans who live to age 65 will have either skin cancer at least once. About 90 percent of non-melanoma skin cancers are associated with exposure to ultraviolet (UV) radiation from the sun. Up to 90 percent of the visible changes commonly attributed to aging are caused by the sun.  Basal Cell Carcinoma Basal cell cancer most often appears on sun-exposed areas such as the face, scalp, ears, chest, back, and legs. The most common appearance of basal cell cancer is that of a small dome-shaped bump that has a pearly white color. Blood vessels may be seen on the surface. Basal cell cancer can also appear as a pimple-like growth that heals, only to come back again and again. A very common sign of basal cell cancer is a sore that bleeds, heals up, only to recur again.  Squamous Cell Carcinoma A firm, red nodule on your face, lower lip, ears, neck, hands or arms. A flat lesion with a scaly crust on your face, ears, neck, hands or arms. A new ulceration or raised area on a pre- existing scar or ulcer. An ulcer or flat, white patch inside your mouth. A red, raised patch or ulcerated sore in the anus or on your genitals.  Melanoma A highly malignant type of skin cancer that arises in melanocytes, the cells that produce pigment. Melanoma usually begins in a mole. A popular method for remembering the signs and symptoms of melanoma is the mnemonic "ABCD": Asymmetrical skin lesion. Border of the lesion is irregular. Color: melanomas usually have multiple colors. Diameter: moles greater than 6mm are more likely to be melanomas than smaller moles.  Moh’s Surgery Initially developed by Dr. Frederic E. Mohs, the Mohs procedure is a state-of-the-art treatment that has been continuously refined over 70 years. With the Mohs technique, physicians can see beyond the visible disease, to precisely identify and remove the entire tumor layer by layer while leaving the surrounding healthy tissue intact and unharmed. It relies on the accuracy of a microscopic surgical procedure to trace the edges of the cancer and ensure complete removal of all tumors down to the roots during the initial surgery.  Assessment Assessment of the dermatology patient includes obtaining a detailed dermatological history as this may provide clues to diagnosis, management and nursing care of the existing problem, with careful observation and meticulous description and should cover the following areas: a history of the patient's skin condition a general assessment a specific skin assessment consideration of the skin as a sensory organ assessment of the patient's knowledge about his or her skin condition  Primary lesions are those present at the initial onset of the disease Macule - a flat mark; circumscribed area of colour change: brown, red, white or tan. Example: vitiligo Papule - elevated 'spot'; palpable, firm, circumscribed lesion generally less than 5 mm in diameter. Example: scabies/insect bites Nodule - elevated; firm; circumscribed; palpable; can involve all layers of the skin; larger than 5 mm in diameter. Example: erythema nodosum Plaque - elevated, flat topped, firm, rough, superficial papule greater than 2 cm in diameter. Papules can coalesce to form plaques. Example: psoriasis Wheal - elevated, irregular-shaped area of cutaneous oedema; solid, transient, changing, variable diameter; red, pale pink or white in colour. Example: urticaria Primary lesions are those present at the initial onset of the disease Wheal - elevated, irregular-shaped area of cutaneous oedema; solid, transient, changing, variable diameter; red, pale pink or white in colour. Example: urticaria Vesicle - elevated, circumscribed, superficial fluid filled blister less than 5 mm in diameter. Example: herpes simplex/pompholyx Bulla - vesicle greater than 5 mm in diameter. Example: bullous pemphigoid Pustule - elevated, superficial, similar to vesicle but filled with pus. Example: impetigo  Secondary lesions Are the result of changes over time caused by disease progression, manipulation (scratching, rubbing, picking) or treatments. Scale - heaped-up keratinised cells; flaky exfoliation; irregular; thick or thin; dry or oily; variable size; silver, white or tan in colour. Example: psoriasis Crust - dried serum, blood or purulent exudate; slightly elevated; size variable. Examples: impetigo discoid pattern atopic eczema Excoriation - loss of epidermis; linear area usually due to scratching. Example: atopic eczema Lichenification - rough, thickened epidermis; accentuated skin markings caused by rubbing or scratching. Examples: chronic eczema, lichen simplex  Management Nurses, when assessing the dermatology patient- It is vital to not only listen, but also hear; not only to look, but also see. educate patients about their skin condition management help control the skin condition by providing physical care, and maintaining the integrity of the through the administration of drugs, especially topical treatments maintain comfort of the patient by tackling distressing symptoms and effects such as itch, soreness, dryness, bleeding and pain monitor and educate about specific medication, use and side effects adapt skin care regimes to suit individual patients and their families support patients - support groups, coping strategies, stress management, counselling, listening and talking provide time for the patient provide continuity of care  Dengue - Overview Dengue (break-bone fever)- viral infection that spreads from mosquitoes to people. Transmitted by Aedes mosquitoes - Known for their aggressive daytime biting behavior It is more common in tropical and subtropical climates. Some people develop severe dengue and need care in a hospital. In severe cases, dengue can be fatal. You can lower your risk of dengue by avoiding mosquito bites especially during the day. Dengue is treated with pain medicine as there is no specific treatment currently.  Causes of Dengue Mosquito Bite Mother to unborn Child - can be fatal for the child Sharing of Medical Essentials-use of shared needles and syringes - The individual can also be affected due to blood transfusion and organ transplant.  Symptoms Mild or no symptoms last 1–2 weeks. Dengue can be severe and lead to death. If symptoms occur within 4–10 days after infection and last for 2–7 days.  Symptoms may include: high fever (40°C/104°F) severe headache pain behind the eyes muscle and joint pains nausea vomiting swollen glands rash. Severe dengue – repeated infection symptoms often appears after the fever has gone restlessness blood in vomit or stool severe abdominal pain being very thirsty persistent vomiting pale and cold skin rapid breathing feeling weak. bleeding gums or nose fatigue After recovery, people who have had dengue may feel tired for several weeks.  Severe dengue – repeated infection symptoms often come after the fever has gone : severe abdominal pain persistent vomiting rapid breathing bleeding gums or nose fatigue restlessness blood in vomit or stool being very thirsty  Diagnostics and treatment There is no specific treatment for dengue. Rest; Hydrate; Use acetaminophen (paracetamol) for pain; Avoid non-steroidal anti-inflammatory drugs, like ibuprofen and aspirin; and Watch for severe symptoms and contact your doctor as soon as possible if you notice any.  Platelets - dengue Dengue fever can cause a dramatic drop in platelet count. Normal Range: 150,000 - 450,000 /µL. Dengue Patients: 10,000 /µL or even lower. Thrombocytopenia. Platelets are responsible for blood clotting; - a low platelet count can increase the risk of bleeding and hemorrhage.  Why does the blood platelet count lower in dengue? The dengue virus directly affects the bone marrow, where platelets are produced, leading to decreased production. The virus can cause increased destruction of platelets in the bloodstream. The immune response triggered by dengue infection can also contribute to the drop in platelet levels. The platelets start dropping after the 4th or 5th day of the illness, Resulting feel weak and low the whole day.  How to increase the platelet count during dengue? Blood transfusion - enhance dengue's low blood platelet count, and allows quick recovery of the patient The platelet count may resume the original baseline after at least 72 hours. The doctor may recommend the procedure for a few days depending on the patient's situation. Foods such as leafy veggies, iron-rich foods, lentils, pumpkin seeds, papaya, dairy products, and many other beneficial fruits and vegetables help naturally increase the blood platelet count.