Week 1 Med Surg Integumentary PDF

Integumentary System Disorders - Skin - 3 layers - Epidermis - Dermis - Subcutaneous tissue - Insulin loves fat! - Epidermis - Keratinocytes = migrate upward; synthesize - Melanocytes = produces pig...

Integumentary System Disorders - Skin - 3 layers - Epidermis - Dermis - Subcutaneous tissue - Insulin loves fat! - Epidermis - Keratinocytes = migrate upward; synthesize - Melanocytes = produces pigment melanin coloring the skin and hair. Protects skin from UV light. - Merkel cells = receptors transmitting stimuli to the axon - Langerhans cells = play in cutaneous immune system reactions - Dermis - Largest portion of the skin. - Provides strength and structure in the form of collagen and fiber. - Contains blood vessels, nerves, sweats and sebaceous glands which produce oil protecting the hair and lastly, hair roots. - Subcutaneous or Hypodermis - Innermost layer of skin composed of adipose and connective tissue. - Cushion between skin layers, muscles, and bones. - Temperature regulation. - Hair - Rate of growth varies. Beard is most rapid followed by scalp, axillae, thighs, and then eyebrows. Growth is also controlled by sex hormones - Hirsutism is excessive hair growth - Alopecia is hair loss. - Glands of the skin - Sebaceous glands = moisten the hair and the skin. - Eccrine glands = sweat - Nails - Transparent plate of keratin on tip of fingers and toes. - Growth is faster in fingernails than toenails and tends to slow with aging. - Regeneration - Fingernails = 6 months - Toenails = 18 months - Assist in grasping small items - Functions of the Skin - Protection, Sensation, Vitamin D responsible for absorption of calcium for strong bones. Fluid balance, temperature regulation, immune response function - Assessing Skin Color - Cyanosis = bluish discoloration from lack of oxygen in the blood - Ecchymosis = Purple, black which fades to green which is sign of healing, yellow, or brown hues over time; most often seen following trauma  - Erythema = redness of the skin caused by dilation of capillaries. - Jaundice = yellowing of the skin. - Primary Skin Lesions - Macule = 1cm - Both nonpalpable and flat - Papule = 0.5 cm - Both palpable and elevated - Nodule = 0.5-2 cm - Tumor = >1-2 cm - Elevated, palpable, solid mass extending deeper than dermis than a papule - Vesicle = 0.5 cm - Circumscribed, elevated, palpable containing serous fluid - Wheal = Elevated mass with transient borders; often irregular; size and color vary. - Pustule = pus-filled vesicle or bulla. - Secondary Skin Lesions - Erosion = loss of superficial epidermis that doesn’t extend to dermis - Ulcer = Skin loss extending past epidermis; necrotic tissue loss. - Fissure = linear crack in the skin that may extend to dermis - Scales = Flakes secondary to desquamated, dead epithelium that may adhere to skin surface. - Crust = Dried residue of serum, blood, or pus on skin surface. - Scar = Skin mark after healing of a wound or lesion - Young scars: red or purple - Mature scars: white or glistening - Keloid = hypertrophied scar tissue secondary to excessive collagen formation during healing. Greater influenced among African American - Atrophy = Thin, dry, transparent appearance of epidermis. - Lichenification = thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, scratching. - Vascular Lesions - Petechia = round red or purple macule 1-2 mm - Ecchymosis = Round or irregular muscular lesion. Larger than petechia. - Cherry Angioma = Noted on trunk, extremities. May blanch with pressure - Spider Angioma = Red, arterial lesion. Noted on face, neck, arms, trunk. Associated with liver disease pregnancy, vitamin B deficiency. - Telangiectasia = Spider Like or linear. Bluish or red. Noted on legs, anterior chest. Associated with increased venous pressure. - Inflammatory Response - Sequence of reaction to cell injury  - To neutralize the bacteria and chemical and dilute the inflammatory agent. Removes necrotic materials. It also establishes an environment suitable for healing and repair. - Inflammation is not similar with infection - Inflammation is always present with infection but infection is not always present with inflammation. - Mediators of Inflammation - Histamine = stored in granules of basophils. Causes vasodilation and increased capillary permeability - Serotonin = stored in platelets, mast cells, GI tract. Same as histamine. Stimulates smooth muscle contraction. - Kinins = produced from precursor factor kininogen as a result of activation of Hageman factor. Causes smooth muscle and vasodilation. Result in stimulation of pain. - Complement components = Anaphylatoxic agents generated from complement pathway activation. Stimulate histamine release and chemotaxis. - Prostaglandins and leukotrienes = Found in cell membranes, produced from arachidonic acid. Cause vasodilation. Lots stimulate chemotaxis - Cytokines = Proinflammatory mediator. Promotes proliferation of B cells. Activates T cells, NK cells, and macrophages. - Types of Inflammatory Exudate - Serous (clear) = results from outpouring of fluid. Seen in early stages of inflammation or when injury is mild. Ex. skin blisters, pleural effusion - Serosanguineous (clear and blood) = found during the midpoint in healing after surgery or tissue injury. Composed of RBCs and serous fluid. Ex. Surgical drain fluid - Fibrinous = callous. Occurs with increasing vascular permeability and fibrinogen leakage into interstitial spaces. Fibrin coats tissue surfaces causing them to adhere. Ex, adhesions, gelatinous ribbons seen in surgical drain tubing. - Hemorrhagic = Results from rupture or necrosis of blood vessel walls. Ex. Hematoma, bleeding after surgery - Purulent (pus) = Consists of WBCs, microorganisms (dead and alive), liquefied dead cells, and other debris. Ex. Furuncle (boil), abscess, cellulitis. - Pressure Injury - Ulcers - Localized area of necrotic soft tissue that occurs when pressure applied to the skin usually a bony prominence over a period of time to cause injury - ANA monitors hospital acquired pressure injuries. - Pressure Ulcers - Braden Scale predicts pressure injury risk - Sacrum most common and heels second common - Risk Factors for Pressure Ulcers - Advanced age  - Comorbidities - DM, PVD, Stroke, Cognitive Impairment, Cancer, - Excessive Skin Dryness - Friction, Shearing forces, trauma - High acuity patients (ICU) - History of having recurrent PUs - Immobility, impaired mobility - Loss of protective reflexes, sensory deficit /loss - Malnutrition, hypoproteinemia, anemia, vitamin deficiency - Medical devices (casts, tractions, restraints, nasal cannula) - Medications (sedative, analgesics) - Poor skin perfusion, edema - Pre-existing skin problems on admission - Prolonged hospitalization - Smoking - Prolonged surgery >3 hrs - Pressure Ulcer Stage I - Intact skin with nonblanchable redness of a localized area. - Area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. - Pressure Ulcer Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough - May also present as an intact or open/ruptured serum-filled or serosanguineous-filled blister - Presents as a shiny or dry shallow ulcer without slough or bruising. - Pressure Ulcer Stage III - It will always be this stage if fascia is present. - Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. - May include undermining and tunneling. - Pressure Ulcer Stage IV - Full-thickness tissue loss with exposed bone, tendon, muscle. Slough or Eschar may be present. - Often includes undermining and tunneling - Unstageable  - Full-thickness tissue loss. Depth of ulcer is completely obscured by slough in wound bed - Stable eschar on the heels - Suspected Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister - May further evolve and become covered by thin eschar. - Nursing Interventions - Relieve Pressure - Positioning the patient - Use pressure-relieving devices - Improve mobility - Improve sensory perception - Improve tissue perception - Improve nutritional status - Reduce friction and shear - Minimize moist - Promote pressure injury healing - Factors Delaying Wound Healing - Nutritional Deficiencies - Vitamin = delays formation of collagen fibers - Protein = decreases supply of amino acids for tissue repair - Zinc = impairs epithelialization - Inadequate blood supply = decreases supply of nutrients to injured area, inhibits inflammatory response - Corticosteroid drugs = inhibit wound contraction - Infection - Smoking - Mechanical friction on wound - Advanced age - Obesity - DM - Poor general health - Anemia - Types of Wound Dressing - Gauze = absorption of exudates - Nonadherent = Impregnated with saline - Transparent films = Visualization of the wound  - Foams = hold large amounts of exudate - Hydrocolloids = Flat occlusive dressing that forms a gel on wound surface. - Hydrogels = Rehydrate wound tissue. Minimal drainage - Alginates = Use over irregular-shaped wounds. Moderate to heavy exudates. - Antimicrobials = Silver and iodine. Antibacterial properties. Partial or full thickness wounds - Types of Debridement - Autolytic debridement = covers a wound and allows enzymes to self-digest sloughed skin - Chemical or Enzymatic debridement = drugs are applied topically to dissolve necrotic tissue and then covered with moist dressing. - Mechanical debridement = removes devitalized tissue with mechanical force - Surgical debridement = quick method to prevent, control, or remove infection. - Negative Pressure Wound Therapy - Treat acute and chronic wounds - Vacuum source creates continuous or intermittent negative pressure inside the wound to remove fluid exudates, and infectious materials to prepare the wound for healing and closure. Pulls excess fluid from the wound, reduces bacterial load, and encourages blood flow to the wound base. - Complications of Wound Healing - Adhesion - Contractions - Dehiscence - Evisceration - Excess Granulation Tissue (Proud Flesh) - Fistula Formation - Infection - Hemorrhage - Hypertrophic Scars - Keloid Formation - Hidradenitis Suppurativa - Caused by the blockage and infection of the sweat glands. Occurs from folliculitis of the perianal, axillar, and genital areas or under the breasts. A pea sized nodule that causes discomfort.  - Management - Warm compresses - Loose-fitting clothes over the nodules or lesions - NSAIDs to relieve pain - Oral antibiotic - Incision and drainage of large suppurating areas - Acne Vulgaris - Commonly on face, neck, torso, and upper arms. - Excessive sebaceous glands stimulation causing pill sebaceous ducts plugging - Management - Nutrition - Avoid sugary food products - Hygiene - Washing twice a day with soap and water - Phototherapy - Surgical Management - Medication - Benzoyl peroxide - Topical retinoids - Topical antibiotics - Oral isotretinoin + oral ATB - Impetigo - Bacterial infection of superficial layers of skin. - Bullous - Spread via towels, hands, clothing, nasal discharge, droplets - Clinical findings - history - pruritus - Weakness, fever, diarrhea with bulbous impetigo - Clinical findings - physical examination - Nonbullous = 1-2 mm - Bullous - Lesions common on face, hands, necks, extremities perineum - Regional lymphadenopathy - Clinical findings - diagnostic studies - Gram stain/culture if needed - Management - Topical antibiotics if superficial  - Oral antibiotics for multiple lesions - Bullous impetigo in infant - Obtain culture if no response in 7 days - Hygiene education - Exclude from day care until treated 24 hrs - Complications - Skin becomes burn due to infection - Cellulitis - Lymphangitis - Staphylococcal scalded skin syndrome - Folliculitis and Furuncle - Clinical findings - physical examination - Discrete, erythematous 1-2 mm papules on inflamed base near follicle - Pruritus papules, pustules, deep red/purple nodules in areas under swimsuit. - Management - Warm compresses - Topical keratolytics - Topical antibiotics - Avoid shaving and have proper hygiene - Herpes Simplex - Clinical findings - physical examination - HSV-2 - Grouped vesicopustules/ulceration - Diagnostic studies - Tzanck smear - Viral cultures - PCR tests - Contagious infections an be severe - Direct contact with secretions/mucocutaneous lesions - Incubation days to weeks - HSV type 1 - oral mucosa - HSV type 2 - neonatal infection - Management - Burrow solution compresses - Acyclovir to help shorten course - Topical acyclovir for initial genital HSV - Antibiotics for secondary infection - Oral anesthetic for comfort  - Complications - eczema herpeticum, erythema multi forms - Herpes Zoster (Shingles) - Considered contagious!!!! - Recurrent varicella infection - Findings - history - burning stinging pain, hyperesthesia, tingling - Findings - diagnostic studies - Clinical diagnosis - Tzack smear or viral culture if needed - Management - Soothing baths that are warm - Antihistamines for comfort - Moisturizing ointment - Antiviral medications - Complications - Initial finding in AIDS - Rare except in immunocompromised children - Fungal (Mycotic) Skin Infections - Tinea barbae - Tinea capitis - Tinea corporis - Tinea cruris - Tinea pedis - Tinea unguium