Skin: Chapter 50 Student Outline PDF

**[Skin: Chapter 50 Student Outline]** - **Skin facts** - - - - **Anatomy** - The skin is comprised of 3 layers - Epidermis- outer most layer - Dermis -- inner layer - Hypodermis- inner-most layer - **Epidermis** - - - - - Merkel -- associated with the sense of...

**[Skin: Chapter 50 Student Outline]** - **Skin facts** - - - - **Anatomy** - The skin is comprised of 3 layers - Epidermis- outer most layer - Dermis -- inner layer - Hypodermis- inner-most layer - **Epidermis** - - - - - Merkel -- associated with the sense of touch. - Langerhans -- cutaneous (skin) immune system reaction. Process invading antigens and transport the antigen to the lymph system to activate the T lymphocytes - **Dermis** - - - - - - **Hypodermis** - - - **Hair** - - - - - **Nails** - - - - - - **Glands** - - Associated with hair follicles - **Sweat glands** - Heavily concentrated in the palms and soles - Classified as eccrine and apocrine - Eccrine found in all areas of the skin - Apocrine found (larger) in the axillae, anal region, scrotum, and labia majora and become active in puberty - **Skin functions** - - - - - - - **Gerontologic Considerations** - Increased vulnerability to injury and certain diseases - Benign Changes in Skin for Older Adults +-----------------------------------+-----------------------------------+ | Cherry angiomas (bright red | Diminished hair, especially on | | "moles") | scalp and pubic area | +===================================+===================================+ | Dyschromias (color variations): | Neurodermatitis (itchy spots) | | | | | Solar lentigo (liver spots) | | | | | | Melasma (dark discoloration of | | | the skin) | | | | | | Lentigines (freckles) | | +-----------------------------------+-----------------------------------+ | Seborrheic keratoses (crusty | Spider angiomas (network of | | brown "stuck-on" patches) | dilated capillaries radiating | | | from a central arteriole) | +-----------------------------------+-----------------------------------+ | Telangiectasias (red marks on | Wrinkles (a small fold, ridge, or | | skin caused by stretching of the | crease in the skin) | | superficial blood vessels) | | +-----------------------------------+-----------------------------------+ | Xerosis (dryness) | Xanthelasma (yellowish waxy | | | deposits on upper and lower | | | eyelids) | +-----------------------------------+-----------------------------------+ | Ichthyosis (fish scale appearance | Senile purpura (purple or red | | of the skin) | bruises that have an irregular | | | shape) | +-----------------------------------+-----------------------------------+ Structural Changes Associated Physical Findings ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- Thinning at the junction of the dermis and epidermis results in fewer anchoring sites between the two skin layers, which means that even minor injury or stress to the epidermis can cause it to shear away from the dermis Increased vulnerability of aged skin to trauma The epidermis and dermis thin and flatten Wrinkles, sags, and overlapping skin folds Loss of the subcutaneous tissue substances of elastin, collagen, and fat Decreased protection and cushioning of underlying tissues and organs, decreased muscle tone, and loss of the insulating properties of fat Cellular replacement slows as a result of aging, and there is thinning of the dermal layers Skin becomes fragile and transparent The blood supply to the skin also changes with age. Vessels, especially the capillary loops, decrease in number and size Vascular changes are associated with delayed wound healing Sweat and sebaceous glands decrease in number and functional capacity Dry and scaly skin Reduced hormonal levels of androgens Associated with declining sebaceous gland function Hair growth gradually diminishes, especially over the lower legs and dorsum of the feet. Thinning is common in the scalp, axilla, and pubic areas Decreased hair growth, hair loss Photoaging (damage from excessive sun exposure) Profound wrinkling; increased loss of elasticity; mottled, pigmented areas; cutaneous atrophy; and benign or malignant lesions - **Assessment** - - - **History Box 50-3 pg 1586** - - - - - - **Physical Assessment** - Entire skin; including mucous membranes, scalp, hair, and nails - Inspection and palpation are used in a well-lit room - Inspection: Assess the appearance by observing color, temperature, moisture or dryness, skin texture (rough or smooth), lesions, vascularity, mobility and the condition of the hair and nails - Palpation: skin turgor, possible edema, and elasticity - **Color Changes Light and Dark Skin** **Etiology** **Light Skin** **Dark Skin** -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Erythema** Hyperemia: Increased blood flow through engorged arterial vessels, as in inflammation, fever, alcohol intake, blushing Red, bright pink Purplish tinge, but difficult to see because epidermal melanin may alter disease presentation by masking erythema. (Palpate for increased warmth with inflammation, taut skin, and hardening of deep tissues) Polycythemia: Increased red blood cells, capillary stasis Ruddy blue in face, oral mucosa, conjunctivae, hands, and feet Well concealed by pigment. (Observe for redness in lips) Carbon monoxide poisoning Bright, cherry red in face and upper torso Cherry red nail beds, lips, and oral mucosa Stasis dermatitis (venous stasis): Poor venous return in the lower extremities causing hemosiderin staining and cracking of the skin (skin breakdown) that causes stasis ulcers or venous ulcers Brown or rusty discoloration of the skin resulting from a buildup of hemosiderin (iron-containing pigment derived from the breakdown of hemoglobin) in the interstitial fluid May be more difficult to detect signs of venous insufficiency such as hemosiderin staining (reddish, brown color) in melanin-rich skin Venous disease Edema, hyperpigmentation surrounding the skin (reddish or brown due to hemosiderin), warmth at feet with palpable pulses (exception if no coexisting arterial disease) Edema, hyperpigmentation surrounding the skin (reddish or brown due to hemosiderin), warmth at feet with palpable pulses (exception if no coexisting arterial disease) **Cyanosis** Increased amount of unoxygenated hemoglobin Dusky blue Dark but dull, lifeless; only severe cyanosis is apparent in skin. (Observe conjunctivae, oral mucosa, nail beds) Central: Chronic heart and lung diseases cause arterial desaturation Bluish discoloration of skin, mucous membranes, and nail beds Peripheral: Exposure to cold, anxiety Nail beds dusky **Jaundice** Increased serum bilirubin concentration (\>2.5--3 mg/dL) due to liver dysfunction or hemolysis, as after severe burns or some infections Yellow first in sclerae, hard palate, and mucous membranes; then over skin Check sclerae for yellow near limbus; do not mistake normal yellowish fatty deposits in the periphery under eyelids for jaundice. (Jaundice is best noted at junction of hard and soft palate, on palms) Carotenemia: Increased level of serum carotene from ingestion of large amounts of carotene-rich foods Yellow-orange tinge in forehead, palms and soles, and nasolabial folds, but no yellowing in sclerae or mucous membranes Yellow-orange tinge in palms and soles Uremia: Kidney failure causes retained urochrome pigments in the blood Orange-green or gray overlying pallor of anemia; may also have ecchymoses and purpura Easily masked. (Rely on laboratory and clinical findings) - Striae (stretch marks) - **Lesions** - Describe clearly and in detail - Size and location - Pattern of eruption - Distribution of the lesions +-----------------------+-----------------------+-----------------------+ | **Primary Lesions** | | | +=======================+=======================+=======================+ | Lesion | Description | Examples | +-----------------------+-----------------------+-----------------------+ | Macule, Patch | Flat, nonpalpable | Freckles, flat moles, | | | skin color change | petechia, rubella, | | | (color may be brown, | vitiligo, port wine | | | white, tan, purple, | stains, ecchymosis | | | red) | | | | | | | |   Macule: less than | | | | 1 cm, circumscribed | | | | border | | | | | | | |   Patch: greater | | | | than 1 cm, may have | | | | irregular border | | +-----------------------+-----------------------+-----------------------+ | Papule, plaque | Elevated, palpable, | Papules: Elevated | | | solid mass with a | nevi, warts, lichen | |  | circumscribed border | planus | | | | | | | Plaque may be | Plaques: Psoriasis, | | | coalesced papules | actinic keratosis | | | with flat top | | | | | | | |   Papule: less than | | | | 0.5 cm | | | | | | | |   Plaque: greater | | | | than 0.5 cm | | +-----------------------+-----------------------+-----------------------+ | Nodule, tumor | Elevated, palpable, | Nodules: Lipoma, | | | solid mass that | squamous cell | | | extends deeper into | carcinoma, poorly | | | the dermis than a | absorbed injection, | | | papule | dermatofibroma | | | | | | |   Nodule: 0.5--2 cm; | Tumors: Larger | | | circumscribed | lipoma, carcinoma | | | | | | |   Tumor: greater | | | | than 1--2 cm; tumors | | | | do not always have | | | | sharp borders | | +-----------------------+-----------------------+-----------------------+ | Vesicle, bulla | Circumscribed, | Vesicles: Herpes | | | elevated, palpable | simplex/zoster, | |  | mass containing | chickenpox, poison | | | serous fluid | ivy, second-degree | | | | burn (blister) | | |   Vesicle: less than | | | | 0.5 cm | Bulla: Pemphigus, | | | | contact dermatitis, | | |   Bulla: greater | large burn blisters, | | | than 0.5 cm | poison ivy, bullous | | | | impetigo | +-----------------------+-----------------------+-----------------------+ | **Primary Lesions | | | | cont.** | | | +-----------------------+-----------------------+-----------------------+ | Wheal | Elevated mass with | Urticaria (hives), | | | transient borders; | insect bites | | | often irregular; size | | | | and color vary | | | | | | | | Caused by movement of | | | | serous fluid into the | | | | dermis; does not | | | | contain free fluid in | | | | a cavity (as, e.g., a | | | | vesicle does) | | +-----------------------+-----------------------+-----------------------+ | Pustule | Pus-filled vesicle or | Acne, impetigo, | | | bulla | furuncles, carbuncles | |  | | | +-----------------------+-----------------------+-----------------------+ | Cyst | Encapsulated | Sebaceous cyst, | | | fluid-filled or | epidermoid cysts | | | semisolid mass in the | | | | subcutaneous tissue | | | | or dermis | | +-----------------------+-----------------------+-----------------------+ | **Secondary Lesions** | | | +-----------------------+-----------------------+-----------------------+ | Erosion | Loss of superficial | Ruptured vesicles, | | | epidermis that does | scratch marks | |  | not extend to dermis; | | | | depressed, moist area | | +-----------------------+-----------------------+-----------------------+ | Ulcer | Skin loss or damage | Stasis ulcer of | | | at or extending past | venous insufficiency, | | | the epidermis. May | pressure ulcer | | | include necrotic | | | | tissue development, | | | | bleeding, or scarring | | +-----------------------+-----------------------+-----------------------+ | Fissure | Linear crack in the | Chapped lips or | | | skin that may extend | hands, athlete foot | |  | | | +-----------------------+-----------------------+-----------------------+ | Scales | Flakes secondary to | Dandruff, psoriasis, | | | desquamated, dead | dry skin, pityriasis | | | epithelium that may | rosea | | | adhere to skin | | | | surface; color varies | | | | (silvery, white); | | | | texture varies | | | | (thick, fine) | | +-----------------------+-----------------------+-----------------------+ | Crust | Dried residue of | Residue left after | | | serum, blood, or pus | vesicle rupture: | |  | | eczema | | | Large, adherent crust | | | | is a scab | | +-----------------------+-----------------------+-----------------------+ | **Secondary Lesions | | | | cont.** | | | +-----------------------+-----------------------+-----------------------+ | Scar (cicatrix) | Skin mark left after | Healed wound or | | | healing of a wound or | surgical incision | | | lesion; represents | | | | replacement by | | | | connective tissue of | | | | the injured tissue | | | | | | | |   Young scars: red | | | | or purple | | | | | | | |   Mature scars: | | | | white or glistening | | +-----------------------+-----------------------+-----------------------+ | Keloid | Hypertrophied scar | Keloid of ear | | | tissue secondary to | piercing or surgical | |  | formation during | | | | healing; elevated, | | | | irregular, red | | | | | | | | In Black skin | | | | fibroblasts are found | | | | to be numerous, | | | | large, and | | | | multinucleated, | | | | explaining the | | | | manifestation of | | | | keloids | | +-----------------------+-----------------------+-----------------------+ | Atrophy | Thin, dry, | Aged skin, arterial | | | transparent | insufficiency | | | appearance of | | | | epidermis; loss of | | | | surface markings; | | | | secondary to loss of | | | | collagen and elastin; | | | | underlying vessels | | | | may be visible | | +-----------------------+-----------------------+-----------------------+ | Lichenification | Thickening and | Contact dermatitis | | | roughening of the | | |  | skin markings that | | | | may be secondary to | | | | repeated rubbing, | | | | irritation, | | | | scratching | | +-----------------------+-----------------------+-----------------------+ - **Wounds** - Wound bed - Inspect for necrotic, slough (yellow, white or grey dead tissue), granulation (new reddish connective tissue that forms on the surface of a wound when the wound is healing, often described as "cobblestone-like" in appearance) or epithelial tissue, exudate, color, and odor. - Wound edges and margins - Observe for undermining (i.e., extension of the wound under the surface skin) or epibole (rolled edges) and evaluate for condition. - Wound size - Measure in centimeters (cm), as appropriate, to determine diameter and depth of the wound and surrounding erythema. - Surrounding skin - Assess for color, suppleness and moisture, irritation, induration (abnormal firmness of tissue), and scaling. - **Diagnostic Evaluation** - Skin biopsy - scalpel excision or by a skin punch. Biopsies are performed on skin nodules, plaques, blisters, ulcers, and other lesions to rule out malignancy and to establish an exact diagnosis. - Patch testing - identify substances to which the patient has developed an allergy, patch testing involves applying the suspected allergens to normal skin under occlusive patches. - The development of redness, fine elevations, or itching is considered a weak positive reaction. - Fine blisters, papules, and severe itching indicate a moderately positive reaction. - Blisters, pain, and ulceration indicate a strong positive reaction - Skin scrapings - Tissue samples are scraped from suspected fungal lesions with a scalpel blade moistened with oil, so that the scraped skin adheres to the blade. The scraped material is transferred to a glass slide, covered with a coverslip, and examined microscopically. The spores and hyphae of dermatophyte infections, as well as infestations such as scabies, can be visualized. - **Clinical photographs** - Photographs are taken to document the nature and extent of the skin condition and are used to determine progress or improvement resulting from treatment. They are sometimes used to track the status of moles to document if the characteristics of the mole are changing.