Integumentary System

1. Integumentary System

2. RESPONSE TO ALTERED INTEGUMENTARY FUNCTIONUnit Outcomes: Upon completion of this unit of study, the student will be able to: • Safe Effective Care Environment: • 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.). • 2 . Perform thorough dermatological assessment throughout the life span. • Health Promotion and Maintenance: • 3. Identify healthy behaviors by the client and family ( screening exams, limiting risk taking behaviors). • Psychosocial Integrity: • 4. Discuss psychosocial impact of client’s altered dermatological condition ( acne, burns, rashes, tumors). • Physiologic Integrity: • 5. Discuss nursing implications for medications prescribed for clients with dermatologic disorders. • 6. Develop plan of care for client with impaired skin integrity. • 7. Explain the eight parameters of assessing a lesion. • 8. Describe common lesions and rashes utilizing proper terminology. • 9. Describe pre-op and post care of clients receiving dermatological surgical procedures. • 10. Select nursing diagnoses most likely to be utilized with clients with integumentary problems. • 11. Discuss etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and parasitic skin disorders.

3. Introduction: Skin in our Culture • Defining ‘beauty’ • Language • Costs

4. Functions: • Protective Barrier • Injury • Microbial Invasion • Fluid & Electrolyte Balance • Temperature control • Excretion • Sensation • Vitamin D • Identity

5. Topics: • Assessment • Safety and preventive measures • Nursing Implications for Pharmacologic Management • Nursing Implications for Nonpharmacologic Management • Nursing Implications for Surgical Management • Nursing Management of Clients with Alterations - Integument

6. KP’s • Assessment • A. Parameters of General Skin Assessment • B. Lesions • C. Cultural/Ethnic variations • D. Diagnostic Testing

7. Thorough History • Dx & Tx – realm of practice • Difficult due to similarities in lesions and sx • Differential dx requires clues

8. Assessment: Subjective Data • Past Medical History • Trauma • Surgery • Prior skin disease • Jaundice • Delayed wound healing • Allergies • Sun exposure • Radiation treatments

9. Assessment: History Medications • Prescription • OTC • Herbals • Name • Length of usage

10. Assessment: History • Surgery • Cosmetic • Biopsy • Diet • Health Practices • Hygiene, products • Sunscreen, SPF • Complementary & alternative medicine • C/O symptoms • Known exposure to carcinogens, chemical irritants, allergens • Family • Alopecia (bald) • Psoriasis • Skin cancer

11. Assessment: History • Changes • Skin condition • Hair condition • Nail condition • Mucous membranes

12. Assessment • Privacy • Carefully describe: • Obvious changes in color and vascularity • Presence or absence of moisture • Edema • Skin Lesions • Skin integrity • Document properly

13. Parameters of General Skin Assessment • color, temperature, moisture, elasticity, turgor, texture, and odor.

14. Assessment: Inspection • Consider Cultural and Ethnic variations • Dark skin • rates - skin cancer • Difficult to assess flushing; cyanosis; jaundice • Rashes difficult to observe • Pseudofolliculitis • Keloids • Mongolian spots

15. Assessment: Inspection Malnutrition Anorexia nervosa Anxiety Hygiene Depression Hormones Living conditions Circulatory status Chronic disease • Inspection of hair • Distribution • Texture • Quantity • Inspection of nails • Iggy page 474-475; Wilkinson 370 • Grooves • Pitting • Ridges • Curvature • Shape

16. Lesion Description Configuration Annular “relating to, or forming a ring” Linear Concentric rings Clustered Diffuse Effect of pressure • Size • Metric • Shape • Circumscribed • Irregular • Round • Texture • Rough • smooth

17. Lesion Description • Distribution • Asymmetric vs. Symmetric • Confluent • “flowing or coming together; also: run together” • Diffuse • Localized • Solitary • Zosteriform • “resembling shingles” • Satellite

18. Assessment: Palpation Fever C-V status Respiratory status Hormones Hydration Rash/ Lesion Nutritional status • Edema • Moisture • Temperature • Turgor • Texture

19. Skin cancer - most common cancer! • Risk factors • Fair skin • Blue/green eyes • Blond/red hair • History chronic sun exposure • Family history • Living near the equator • Very high/low altitudes • Working outdoors • Age > 60 (damage is cumulative)

20. Non-melanoma Skin Cancers • Basal Cell Carcinoma • Most common type of skin cancer • Easily treated • Doesn’t metastasize • Middle age to older adults • Symptoms • Small slow growing papule • Semi translucent or “pearly” • Erosion/ulceration of center

21. Basal Cell Carcinoma Medical Tx • Excision • Cryosurgery • Radiation • Topical chemotherapy

22. Non-Melanoma Skin Cancer • Squamous cell • Less common than BCC • High cure rate with early detection • Can be aggressive, metastasize & be fatal • Common on lips, mouth, face and hands • Pipe, cigar, & cigarette smoking • Symptoms • Firm nodule • Scaling/ulceration • Opaque

23. Squamous cell carcinoma Medical Tx • Excision • Radiation • Moh’s surgery • (see slide #33) • 5 FU or methotrexate intralesional • (see slide #34)

24. Diagnostic & Surgical Therapy • Simple Excision • Excision • Moh’s micrographic surgery • Microscopically controlled removal of lesion • Removes tissue in thin layers • Can see all margins of specimen • Preserves normal tissue • Produces smallest wound

25. Drug Therapy: Topical Fluorouracil (5-FU) • Selective toxicity for sun damaged cells (cytotoxic) • Indications • Premalignant skin disease (esp. actinic keratosis) • Systemic absorption minimal It causes painful eroded area within 4 days and must use 1-2 times daily 2-4 weeks. Healing up to 3 weeks after med stopped Is photosensitizing - avoid sunlight during treatment Will look worse before it gets better

26. Non-Melanoma Skin Cancers • Actinic Keratosis (AKA Solar keratosis) • Most common precancerous lesion • Premalignant form of squamous cell carcinoma • Symptoms • Hyperkeratotoc papules/plaques on sun exposed areas • Varied appearance • Irregular shape • Flat • Indistinct borders • Overlying scale

27. Actinic Keratosis (AKA Solar keratosis) Medical Tx: • Cryosurgery • (see slide #37) • 5 FU • Surgical removal • Retin A • Chemical peels

28. Cryosurgery • Subfreezing temps for surgery (liquid nitrogen) • Lesion becomes red & swollen, blisters, then scabs; falls off in 1-3 weeks • Minimal scarring • Indications • Genital warts • Seborrheic keratosis • Actinic keratosis

29. Malignant Melanoma • 1/3 of all melanoma occur in existing nevi or moles • Any sudden or progressive change in size, color or shape of a mole should be checked

30. Malignant Melanoma • Can metastasize anywhere • Most deadly of skin cancers • Causes • UV radiation • Skin sensitivity • Genetic • Hormonal • Sun exposure • Mutation of gene (B-RAF) 70%

31. A B C D’s of Melanoma Asymmetry Border irregular, edges ragged Color varied pigmentation • Tan, brown, black, red Diameter > 6mm

32. Melanoma Medical Tx Depends on site, stage, age and general health of client • Surgery • Chemotherapy • Biologic Therapy • Interferon, interleukin • Radiation therapy

33. Prevention/Education • Sunscreen • Limit exposure • Hat/clothes/sunglasses • Shade • Inspect skin regularly

34. Sunburn: Education(Protect, Protect, Protect) • Same precautions as for skin cancer. • Don’t let clouds or cool air fool you – Florida sun is damaging then too. • Get out of the sun before you turn red! • Cool skin off. Immediately! • Hydrate!

35. Sunburn • Superficial burn • Excessive exposure to ultraviolet rays injures dermis. • Dilated capillaries = red, tender, edema, blisters • Large area = nausea, fever

36. Sunburn • Redness & pain begin within a few Hours. • Intensity may increase before subsiding. • 3-5 days to heal • Tx: cool bath; soothing lotions; topical corticosteroids; fluids

37. Insects/Pests/Parasites • Spiders • Fire Ants • Lice/Scabies • Mosquitoes • Scorpions • “Sand fleas”

38. Infestations: Pediculosis • Head, body or pubic lice (“crabs”) • Parasite excrement and eggs on skin • Nits in hair • Waxy, don’t fall off easily • Symptoms • Tiny red points to papular wheal-like lesions • Pruritis – check hairline • Secondary excoriation

39. Pediculosis Medical tx • Pyrethrins (Rid), Permethrin (Nix) or if all other agents fail…Benzene hexachloride (Kwell) • Contact screening • l

40. Infestations: Scabies • Skin reactions due to eggs, feces, & mite parts • Transmitted by direct contact • Symptoms • Severe itching especially at HS • Usually not on face • Presence of burrows esp. interdigital webs & flexor surface of wrists • Redness, swelling, vesiculation

41. Scabies Medical tx • Topical Scabicide • Antibiotics for 2ndary infection • Treat those in close proximity • Clothing & linens – hot water and detergent

42. Drug Therapy: Antiparasitics • Pediculicides • Pyrethrins (RID) • Permethrin (NIX) • Scabicide & Pediculicide • Lindane (Kwell, Scabene) • Cream, lotion • Shampoo • nit comb • Adverse effects • Rash, rare CNS toxicity

43. Plants in FL that irritate skin • Poinsettia, Croton • Milky sap can cause skin irritation • Oleander • Touching the plant is not dangerous, but prolonged contact can irritate the skin. • Poison Ivy , Brazilian Pepper • Touching the leaves or oil from the plant can cause an itchy rash with blisters.

44. Brazilian Pepper

45. Virginia Creeper • Poison Ivy:

46. Drug Therapy • Topical Corticosteroids • Anti-inflammatory, antipruritic • Low potency (hydrocortisone) • Slower acting • Can be used longer without serious side effects • Ointment most efficient • Higher potency, long term, systemic use is different tx

47. CorticosteroidsTriamcinolone (Kenalog) • Intralesional • Reservoir of med effects lasts several weeks to months • Indications • Psoriasis • Alopecia • Cystic acne • Hypertrophic scars and keloids • Systemic • Undesirable adverse effects – Lilley 6th ed. Page 869 • Short term therapy – poison ivy • Long term therapy – chronic bullous diseases

48. Bases for Topical Medications • Powder • Promotes dryness • Good for antifungals • Lotion • Cooling and drying with residual powder film • Good for pruritic eruptions • Cream • Emulsion of oil and water • Lubrication and protections • Ointment • Oil with water in suspension • Lubrication • Most efficient delivery system • Paste • Mixture of powder and ointment • Drying • Moisture absorption

49. Nursing Management:RN as skin “symptomologist” • Dry skin • Elderly; Infants • Itchy skin • Broken skin • Prevention of secondary infections

50. Nursing Management: Dry skin • Manifestations • Interventions: • Elder – • Fewer total baths • Lotions & Mild soaps • Hydrate!