Integumentary System Notes PDF

Integumentar y FA Davis ch. 53, 54, 55 ATI ch. 67, 68, 69 Review of Anatomy & Physiology (FA Davis pg. 1092)  Hair (FA Davis pg. 1093)  Glands (FA Davis pg. 1093)  Effects of Aging (FA Davis pg. 1094)  Physical Assessment (...

Integumentar y FA Davis ch. 53, 54, 55 ATI ch. 67, 68, 69 Review of Anatomy & Physiology (FA Davis pg. 1092)  Hair (FA Davis pg. 1093)  Glands (FA Davis pg. 1093)  Effects of Aging (FA Davis pg. 1094)  Physical Assessment (FA Davis pg. 1096) Inspection and palpation Skin turgor Color Lesions Moisture/dryness Edema Vascular lesions (petechiae or ecchymosis) Integrity Cleanliness 02/02/2025 Integumentary 6  Skin Lesions (FA Davis pg. 1096)  Diagnostic Tests (FA Davis pg. 1099 and ATI pg. 515) Culture Biopsy Three Types: Punch, Shave, and Incisional Wood light examination Allergy Skin testing 02/02/2025 Integumentary 8  Therapeutic Measures FA Davis pg. 1100 Wet Balneother Colloidial apy Tar Baths Dressings baths Topical Topical Intralesiona Dry Application Corticoster l Therapy Dressings s oids Hydrocolloi Gels and Occlusive d Pastes 02/02/2025 Integumentary 9  Dermatitis (FA Davis pg. 1118 and ATI pg. 524) Types Contact Acute or chronic; caused by contact with irritant Atopic Chronic, inherited; may be Associated with respiratory allergies or asthma; Bright red maculas, papules, oozing, and lichenified or hyperpigmented areas Seborrheic Chronic, inflammatory Excessive production sebaceous secretions; can appear as dry, moist, or greasy scales, yellow or pink-yellow crusts, redness, and dry flakiness 02/02/2025 Integumentary 10  Test your Knowledge A nurse is reinforcing teaching with the guardian of a child who has contact dermatitis. Which of the following information should the nurse include? A) Use fabric softener dryer sheets when drying the child's clothing B) Apply a warm dry compress to the rash area C) Place the child in a bath with colloidal oatmeal D) Leave the child's hands uncovered during the night 02/02/2025 Integumentary 11 Therapeutic Interventions (FA Davis pg. 1119 and ATI pg. 524) Antihistamines: monitor for urinary retention Analgesics Antipyretics Steroids: monitor for Adrenal function Colloidal oatmeal baths Wet dressings Topical immunosuppressants: Monitor for erythema, burning sensation Antibiotic creams for infection 02/02/2025 Integumentary 12  Psoriasis (FA Davis pg. 1120 and ATI pg. 521) A chronic inflammatory skin disorder Epidermal cells proliferate abnormally fast Pathophysiology Auto-immune disease, T cells attacking healthy skin cells Abnormal keratin forms loosely adherent cells with dermal inflammation Proliferation of epidermal cells Characterized by exacerbations and remissions 02/02/2025 Integumentary 13  Psoriasis (FA Davis pg. 1121) Signs and symptoms Papules, plaques Silvery scales Itching Complications Infection, fever, chills Arthritis Nail changes Lymphadenopathy Risk Factors for Psoriasis (ATI pg. 521) Stress (overstimulation of immune system) Infection (strep throat, candida, upper respiratory) Genetics Hormone changes Cold weather Skin trauma (surgery, sunburn) Some drugs (lithium, beta blockers) 02/02/2025 Obesity Integumentary 15  Medications (ATI pg. 522) Topical Corticosteroids Tar preparations and baths. Monitor for irritation Vitamin D analogs Vitamin A (contraindicated during pregnancy) Systemic medications: for moderate to severe cases Cytotoxic medications Biologic agents Cyclosporine and azathioprine (immunosuppresants) 02/02/2025 PRESENTATION TITLE 16  Scleroderma Two major types: Localized only affects skin and structures directly under skin. Systemic sclerosis, affects many systems in body Divided into two categories "limited" and "diffuse" No Known cause No cure Goal: relieve symptoms and stop progression of disease 02/02/2025 Integumentary 17  Herpes Simplex Virus (FA Davis pg. 1121) Pathophysiology Viral infection Herpes simplex virus (HSV) 1: Above waist H S V2: Below waist Primary infection Direct contact Fluid exposure Lies dormant Recurs with stress  Herpes Simplex Virus (FA Davis pg. 1122) Therapeutic interventions Antiviral agents (Acyclovir [Zovirax]) Topical Oral Antibiotics for secondary infection Avoid triggers of recurrence 02/02/2025 Integumentary 19  Herpes Zoster Virus (FA Davis pg. 1122) Pathophysiology Acute inflammation/ infection caused by same virus that causes chicken pox. Painful vesicles Follows nerve distribution Usually one-sided Occurs with reduced immune function Elderly AIDS Immunosuppressed Integumentary 20  Herpes Zoster (FA Davis pg. 1122)  Complications (FA Davis pg. 1123) Postherpetic neuralgia Persistent dermatomal pain Hyperesthesia Eyesight Facial and acoustic nerve damage Full-skin necrosis Scarring Systemic infection 02/02/2025 Integumentary 22  Herpes Zoster Virus (FA Davis pg. 1123) Treatment Usually resolves on own in a few weeks (can reoccur) Antiviral agents (acyclovir) Analgesics for pain Anticonvulsants for neuropathic pain (may last for months even years) Cool compresses 02/02/2025 Integumentary 23  Cellulitis (FA Davis pg. 1123) Inflammation of the skin and subcutaneous tissue Methicillin-resistant Staphylococcus aureus (MRSA) Clinical manifestations include warmth, redness, localized edema, pain, tenderness, fever, and lymphadenopathy Diagnostic Tests: Culture and sensitivity Therapeutic Measures: Topical and systemic antibiotics 02/02/2025 PRESENTATION TITLE 24  Fungal Infections (FA Davis pg. 1124) Tinea Pedis (athlete’s foot) Tinea Capitis (Ringworm of Scalp) Tinea Corporis (Ringworm of Body) Tinea Cruris (Ringworm of Groin, Jock Itch) Tinea Unguium (Ringworm of the Nail) Candidiasis (Thrush) 02/02/2025 Integumentary 25  Test your knowledge The nurse is providing care for a patient diagnosed with a fungal infection in the skin folds beneath the breasts. The HCP has prescribed the application of an anti-fungal powder to the affected areas. For which reason does the nurse contact the RN for validation of the prescribed treatment. A) The area of treatment has developed open sores B) The patient has an allergy to cornstarch C) The breasts are heavy and pendulant D) The 02/02/2025 patient has a chronic respiratory disease. Integumentary 26  Acne Vulgaris (FA Davis pg. 1124) Common skin disorder of the sebaceous glands and hair follicles Usually occurs on the face, chest, upper back, and shoulders. Common cause hormonal changes during puberty. Therapeutic Measures: Benzoyl peroxide Antibiotics Vitamin A acid Salicylic or Azelaic acids 02/02/2025 Integumentary 27  Parasitic Skin Disorders (FA Davis pg. 1127) Pediculosis (lice) Three basic types: pediculosis capitis (head lice) pediculosis corporis (body lice) pediculosis pubis (pubic, or crab, lice). Scabies Contagious skin disease caused by the mite Sarcoptes scabiei Ringworm Tinea Capitis, Tinea pedis, Tinea cruris, 02/02/2025 integumentary 28 Benign Skin Lesions (FA Davis pg. 1129) Seborrheic Keratosis Keloid Nevus Wart Cyst Hemangioma Malignant Skin Lesions (FA Davis pg. 1131) Most common type of cancer in the United States Includes basal and squamous cell carcinoma, and malignant melanoma. Risk factors: Overexposure to ultraviolet rays Fair skinned and blue eyed Multiple moles Family history History of x-ray therapy Exposure to certain chemical agents (e.g., arsenic, coal tar) Immunosuppressive therapy 02/02/2025 Integumentary 30  Other Risk Factors Environmental pollutants History of viral illness Scars from a severe burn Chronic Skin Irritations Genetics 02/02/2025 Integumentary 31 Malignant Skin Lesions (FA Davis pg. 1185) Basal Cell Carcinoma Squamous Cell Carcinoma Malignant Melanoma There are three general types of Malignant Melanoma Lentigo maligna, Superficial spreading Nodular Basal Cell Carcinoma (FA Davis pg. 1131) Squamous Cell Carcinoma (FA Davis pg. 1132) Malignant Melanoma (FA Davis pg. 1132) Lentigo Maligna Melanoma  Kaposi’s Sarcoma 02/02/2025 Integumentary 37  Malignant Skin Lesions (FA Davis pg. 1132) Prevention Limit exposure to U V rays Use sunscreen Wear protective clothing Report changes in moles Diagnostic tests Examination Biopsy Lactic dehydrogenase aminotransferase 02/02/2025 Integumentary 38  Diagnostic tests and other Cancers Biopsies of lesions or tumors CA-125 test Alpha fetoprotein and beta human chorionic gonadotropin Lactic dehydrogenase and aminotransferase 02/02/2025 Integumentary 39  Therapeutic 1132) Measures (FA Davis pg. Mohs surgery Grafting Chemotherapy Radiation therapy Cryosurgery Curettage Electrodessication 02/02/2025 Integumentary 40  Test your knowledge A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse’s priority? A) Document the client's history of skin allergies. B) Identify when the client first noticed the lesion C)Photograph the lesion for the client's medical record. D)Instructing the client on the use of daily sunscreen products. 02/02/2025 Integumentary 41  Burns (FA Davis pg. 1138 and ATI pg. 527) Wounds caused by an energy transfer from a heat source Heat denatures cellular protein and interrupts blood supply. The amount of skin damage is related to: (1)the temperature of the burning agent (2)burning agent (3)duration of exposure (4)conductivity of tissue (5)thickness of the involved dermal structures. 02/02/2025 Integumentary 42  Burns (ATI pg. 527) Alterations in normal skin function Loss of protective functions Impaired ability to regulate temperature Risk of infection Sweat and sebaceous gland function Changes in sensory function Loss of fluids Impaired skin regeneration Impaired secretory and excretory functions 02/02/2025 Integumentary 43  Test your Knowledge The nurse is assisting with the care of an older adult who is hospitalized for second-degree burns of the legs and feet acquired when a deep fryer tipped over. Which factor has the least impact on the condition and recovery of the patient. A) The normal condition of the patient's skin B) The nature of the substance causing the burns C) The patient has a history of diabetes mellitus D) The patient wearing light weight cotton pajamas when burned 02/02/2025 PRESENTATION TITLE 44  Systemic Response to Burns (FA Davis pg. 1138) Alterations in functional capacity of skin in response to a burn affects virtually all major body systems. Fluid Balance: Damaged cells release inflammatory mediators. Cardiac Function:decrease in cardiac output. Metabolic Changes: Severe catabolism begins early Gastrointestinal: gastric dilation, peptic ulcers, and 02/02/2025 Integumentary 45 Systemic Response to Burns (FA Davis pg. 1139) Renal Function: acute renal insufficiency Pulmonary Effects: mostly related to smoke inhalation. hyperventilation may occur with moderate to major burn injury. Immune Function: With skin destroyed, body loses first line of defense against infection Depressed immunoglobulin (Ig)A, IgG, and IgM. 02/02/2025 Integumentary 46  Degrees of Burns (FA Davis pg. 1139) First degree: skin intact, reddened, painful Second degree: partial thickness, broken skin, pain, pink/red blisters Third degree: full thickness, often painless, white/black eschar, leathery or waxy skin Fourth degree: muscle and/or bone exposed, (common with electrical burns) 02/02/2025 Integumentary 47  Stages of Burns (FA Davis pg. 1142) Two Emerge Acute Phases: nt 02/02/2025 Integumentary 48  Severity of Burns (FA Davis pg. 1139 and ATI pg. 527) Percentage of total body surface area (BSA), Rule of Nines Depth of burn, superficial, partial, full and deep full thickness Body location of burn more damage to areas of body that have thinner skin Young and older adults have less reserve capacity Causative agent, thermal, chemical, electrical or radioactive 02/02/2025 Integumentary 49 02/02/2025 PRESENTATION TITLE 50  Severity of Burns Superficial burn: Erythema Partial thickness burn: Blistering Full thickness burn: leathery, waxy, or yellow skin with edema Deep partial thickness: Red in color with eschar present Deep full thickness: black in color and pain absent 02/02/2025 Integumentary 51  Classification of Burns (FA Davis pg. 1140) Superficial- partial-thickness- first to second degree burn Partial thickness- second degree burn Full thickness- third to fourth degree burn 02/02/2025 Integumentary 52  Nursing Care (ATI pg 530) Respiratory system Cardiovascular Fluid replacement Pain management Thermoregulation Gastrointestinal Urinary Infection prevention 02/02/2025 Integumentary 53  Nursing Care cont. (ATI pg. 530) Nutritional Support Restoration of mobility Psychosocial support 02/02/2025 Integumentary 54  Nutritional Support (ATI pg. 531) Within 4 to 6 hours of injury nasogastric enteral feeding shown to reduce incidence of mortality and infectious morbidity. Goals of nutritional support are to (1)meet metabolic needs (2) promote wound healing (3) promote resistance to infection (4) reduce protein loss Loss of 10% or more of body weight indicates need for additional caloric intake Indirect calorimetry (IC) utilized to determine caloric needs 02/02/2025 Integumentary 55  Nutritional Support (ATI pg. 531) Hypermetabolic and hypercatabolic state 5,000 calories a day Caloric needs double or triple 4-12 days 50-60% of intake high carbohydrates to reduce protein catabolism Parenteral nutrition (IV) reserved Combination of antioxidant vitamins  Restoration of Mobility (ATI pg. 531) Correct body alignment Splint extremities Active and Passive ROM Ambulation Pressure dressings Prevent pressure sores 02/02/2025 Integumentary 57  Psychosocial Effects (FA Davis pg. 1146) A burn affects the patient’s psychosocial status. Magnitude related to: Age (young and elderly have less reserves) Location of the burn (e.g., face, hands) Changes in body image Cause of the injury Ability to continue at the pre-burn level of function Disruption of role function Treatment involves patient and family members Referrals to support groups, counselors, and psychiatrists are important 02/02/2025 Integumentary 58  Medications (ATI pg. 532) Silver nitrate: bacteriostatic, reduces fluid evaporation Silver sulfadiazine: effective against gram-negative and gram- positive bacteria and yeast Mafenide acetate: twice daily, bacteriostatic, penetrates eschar, can cause metabolic acidosis Polymyxin B-bacitracin: every 2-8 hrs., bacteriostatic against gram-positive bacteria Gentamicin topical: aminoglycoside anti-infective agent, nephrotoxic and ototoxic Mannitol: used for electrical burns when obstruction of renal tubules with protein myoglobin hinders urine output 08/21/2023 Integumentary 59  Therapeutic Procedures (ATI 532) PRE-MEDICATE Wound care Types of Debridement Hydrotherapy: in a tub with warm water, use warm running water to cleanse wound, gently using mild soap or detergent, rinse with room temperature water Mechanical: scissors and forceps used to cut away dead tissue, can be done during hydrotherapy Chemical: topical enzyme (Collengenase) to break down and remove dead tissue 02/02/2025 Integumentary 60  Therapeutic Procedures (ATI pg. 448) PRE-MEDICATE Escharotomy Fasciotomy Excision of wound Skin coverings Biologic Synthetic Biosynthetic Wound grafting: Autograft, Artificial and Cultured epithelium 02/02/2025 Integumentary 61  Escharotomy (FA Davis pg. 1145) 02/02/2025 Integumentary 62  Skin Graft (FA Davis pg. 1145) 02/02/2025 Integumentary 63 02/02/2025 PRESENTATION TITLE 64  Complications (ATI pg. 534) Airway injury: major cause of morbidity and mortality Sepsis most common cause of death Fluid imbalances: can lead to heart failure Impaired muscle and joint mobility Compartment Syndrome Paralytic ileus PTSD 08/21/2023 Integumentary 65  Rehabilitation (FA Davis pg. 1145( Starts in acute phase Prevent contractures Risk for infection 02/02/2025 PRESENTATION TITLE 66  Impaired Gas Exchange Impaired Skin Integrity Deficient Fluid Volume Acute Pain Impaired Physical Mobility Ineffective Peripheral Tissue Perfusion Risk for Infection Altered Body Image 02/02/2025 Integumentary 67  Test your knowledge While changing the dressing on a burned arm, the patient informs the nurse of feeling cold and having extreme pain. However, the patient asks the nurse to not apply so much pressure when wrapping gauze around the limb. Which conclusion does the nurse draw from the patient’s statements? A) All nerve endings are damaged. B) Free nerve endings in the arm are injured. C) Encapsulated nerve endings in the arm are intact. D) Encapsulated nerve endings in the arm are injured 02/02/2025 Integumentary 68  Pressure Injuries (FA Davis pg. 1107) Risk factors Immobility Impaired circulation Friction Shearing Impaired sensory perception Elderly Very thin or obese 02/02/2025 Integumentary 69  Pressure Injuries (FA Davis pg. 1114) Stage One: skin intact, non-blanchable redness Stage Two: partial thickness loss of skin Stage Three: full thickness skin loss extends to dermis and subcutaneous tissue Stage Four: full thickness skin loss, muscle and bone undermining and tunneling, eschar or slough may be present Unstageable: wound completely covered by eschar or slough, unable to determine depth/thickness Deep Tissue Injury: injury to sub-Q tissue under intact skin, dark purple or brown 02/02/2025 PRESENTATION TITLE 70  Prevention (FA Davis pg. 1108) Valid assessment tool Lubricate/Moisturize daily Clean incontinence promptly Use moisture barrier as needed Do not massage reddened areas Maintain Mobility Reduce Pressure, Friction, and Shear Damage 02/02/2025 71  Prevention (FA Davis pg. 1108) Cleanse skin Prevent damage from Incontinence Avoid Massaging Bony Prominences Maintain Mobility Protect Bony Prominences from Pressure Elevate Heels and Avoid Pressure on Calves Prevent Ischemia Protect Skin Contact Surfaces Use Pressure-Redistributing Mattresses and Cushions Prevent Malnutrition and Dehydration Turn/Reposition 02/02/2025 every 2 hours Integumentary 72  Therapeutic Interventions (FA Davis pg. 1112) Remove all pressure Debridement: Mechanical Enzymatic Autolytic Surgical Cleanse 4 to 15 lbs per square inch with 18 bore needle and 30 cc syringe 02/02/2025 Integumentary 73  Therapeutic Interventions (FA Davis pg. 1113) Dressings Types Hydrogel Polyurethane film Hydrocolloid wafer Biological Alginate Gauze Moist environment Open wet dressings (No longer than 72 hours) Non adherent 02/02/2025 Integumentary 74  Therapeutic Interventions (FA Davis pg. 1101) Wet dressings Baleneotherapy Colloidal baths Medicated tar baths Bath oils Topical Medications Dry dressings Occlusive Plastic wrap Hydrocolloid dressings Nonadherent 02/02/2025 Integumentary 75 Negative Pressure Wound Therapy (FA Davis pg. 1114)  Jackson Pratt https://my.clevelandclinic.org 02/02/2025 PRESENTATION TITLE 77  Hemovac https://swrwoundcareprogram.ca 02/02/2025 PRESENTATION TITLE 78  Stages of Wound Healing https://www.ncbi.nlm.nih.gov Hemostasis Inflammation Proliferation Remodeling Primary Intention Secondary Intention 02/02/2025 Integumentary 79  Test your knowledge The nurse is providing care for a patient with a large skin abrasion to the outer thigh. The HCP has ordered daily dressing change without disturbance of the healing crusts that have formed in the area. Which dressing material will the nurse select? A) Gauze 4x 4s with paper tape to seal the edges of the dressing. B) A non-adherent dressing for cover and gauze for wrapping C) Thick abdominal pad for protection with an elastic wrap D) A thin dressing wrapped around the thigh and taped securely. 02/02/2025 Integumentary 80