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Integumentary System

Integumentary System. Fall 2010 C. Matthews MSN, RN Ignatiavicius references are for 6 th ed. RESPONSE TO ALTERED INTEGUMENTARY FUNCTION Unit Outcomes: Upon completion of this unit of study , the student will be able to:. Safe Effective Care Environment:

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Integumentary System

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  1. Integumentary System Fall 2010 C. Matthews MSN, RN Ignatiavicius references are for 6th ed.

  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 • Every RN 4. Psychosocial Integrity: Discuss psychosocial impact of client’s altered dermatological condition. C. Matthews MSN, RN

  4. Costs: • $$ - Skin care and tx • “skincare market including both mass and prestige to reach $7.2 billion by 2010” (The US Market for Skin Care Products, 2005) • “In the U.S., 2.5 million pressure ulcers are treated each year in acute care facilities, and the cost of treating these potentially deadly wounds has been estimated at $11 billion a year.” (Groch, 2006) 4. Psychosocial Integrity: Discuss psychosocial impact of client’s altered dermatological condition. C. Matthews MSN, RN

  5. Costs: • “…quadriplegic actor Christopher Reeve died at the age of 52 from complications reportedly associated with an infected pressure ulcer. Once established, these wounds are notoriously hard to treatand are associated with adverse health outcomes and high treatment costs…” (Groch, 2006) 4. Psychosocial Integrity: Discuss psychosocial impact of client’s altered dermatological condition. C. Matthews MSN, RN

  6. Multiple layers within the integumentary system form a wall of protection http://www.chinapictures.org/photo/travel/great-wall-of-china/31222141525419/ Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.). C. Matthews MSN, RN

  7. Anatomy review • See illustration – Iggy’s text (6th ed. - page 461 and/or Lilly text (6th ed.) page 864 • FYI http://www.middlesexcc.edu/faculty/Barbara_Bogner/preworkshop5.html C. Matthews MSN, RN

  8. Skin Layers http://www.brighterblooms.com/planting-directions/ Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention (sun exposure, environmental toxins, etc.). C. Matthews MSN, RN

  9. Functions: • Protective Barrier • Injury • Microbial Invasion • Fluid & Electrolyte Balance • Temperature control • Excretion • Sensation • Vitamin D • Identity Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention. Psychosocial Integrity: 4. Discuss psychosocial impact of client’s altered dermatological condition. C. Matthews MSN, RN

  10. 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 C. Matthews MSN, RN

  11. KP’s • Assessment • A. Parameters of General Skin Assessment • B. Lesions • C. Cultural/Ethnic variations • D. Diagnostic Testing Physiologic Integrity: 6. Develop plan of care for client with impaired skin integrity. C. Matthews MSN, RN

  12. Thorough History • Dx & Tx – realm of practice • Difficult due to similarities in lesions and sx • Differential dx requires clues Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  13. Assessment: Subjective Data Chart 26 -2 page 466 • Past Medical History • Trauma • Surgery • Prior skin disease • Jaundice • Delayed wound healing • Allergies • Sun exposure • Radiation treatments Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  14. Assessment: History Medications • Prescription • OTC • Herbals • Name • Length of usage Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.). Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders. C. Matthews MSN, RN

  15. 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 Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.). Health Promotion and Maintenance: 3. Identify healthy behaviors by the client and family (screening exams, limiting risk taking behaviors). C. Matthews MSN, RN

  16. Assessment: History • Changes • Skin condition • Hair condition • Nail condition • Mucous membranes Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  17. Assessment • Privacy • Carefully describe: • Obvious changes in color and vascularity • Presence or absence of moisture • Edema • Skin Lesions • Skin integrity • Document properly Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  18. Parameters of General Skin Assessment • color, temperature, moisture, elasticity, turgor, texture, and odor. Wilkinson page 366 - 370 Physiologic Integrity: 7. Explain the parameters of assessing a lesion. C. Matthews MSN, RN

  19. Assessment: Inspection • Consider Cultural and Ethnic variations • Dark skin (Iggy page chart 26-3 page 476) • rates - skin cancer • http://www.cdc.gov/cancer/skin/statistics/race.htm • wrinkles • Difficult to assess flushing; cyanosis; jaundice • Rashes difficult to observe • Pseudofolliculitis • Keloids (page 509) • Mongolian spots Iggy - Chart 26-3 pg. 476 Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  20. 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 Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. Physiologic Integrity: 11. Discuss etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and parasitic skin disorders. C. Matthews MSN, RN

  21. Lesion Description Page 467- 472 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 Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. Physiologic Integrity: 7. Explain the eight parameters of assessing a lesion. 8. Describe common lesions and rashes utilizing proper terminology C. Matthews MSN, RN

  22. Lesion Description Page 467-472 • Distribution • Asymmetric vs. Symmetric • Confluent • “flowing or coming together; also: run together” • Diffuse • Localized • Solitary • Zosteriform • “resembling shingles” • Satellite Safe Effective Care Environment: 2.Perform thorough dermatological assessment throughout the life span. Physiologic Integrity: 7. Explain the eight parameters of assessing a lesion. 8. Describe common lesions and rashes utilizing proper terminology C. Matthews MSN, RN

  23. Inspection See slides 129 - 133 at the end of the slide show See Iggy text illustrations on pages 467-472 for “primary” and “secondary” lesions

  24. Pause for photos C. Matthews MSN, RN

  25. Table 26-4, page 472 Assessment: Palpation Fever C-V status Respiratory status Hormones Hydration Rash/ Lesion Nutritional status • Edema • Moisture • Temperature • Turgor • Texture Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  26. Skin problems common in Florida • Skin cancer • Sunburn • Insects • Plants • Water sports C. Matthews MSN, RN

  27. Skin cancer • http://www.cdc.gov/cancer/skin/statistics/state.htm Iggy text, page 509-512 C. Matthews MSN, RN

  28. 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) Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.). Health Promotion and Maintenance: 3. Identify healthy behaviors by the client and family. C. Matthews MSN, RN

  29. 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 Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  30. Basal Cell Carcinoma Medical Tx • Excision • Cryosurgery • Radiation • Topical chemotherapy See illustration, page 510 Physiologic Integrity: 8. Describe common lesions and rashes utilizing proper terminology. C. Matthews MSN, RN

  31. 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 Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  32. Squamous cell carcinoma Medical Tx • Excision • Radiation • Moh’s surgery • (see slide #33) • 5 FU or methotrexate intralesional • (see slide #34) Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders. C. Matthews MSN, RN

  33. 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 Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures. C. Matthews MSN, RN

  34. 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 Lilley 6th ed. page 871 - 872 Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders. C. Matthews MSN, RN

  35. 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 Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  36. Actinic Keratosis (AKA Solar keratosis) Medical Tx: • Cryosurgery • (see slide #37) • 5 FU • Surgical removal • Retin A • Chemical peels Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders. C. Matthews MSN, RN

  37. 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 Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures. C. Matthews MSN, RN

  38. 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 Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  39. 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% Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.). C. Matthews MSN, RN

  40. Malignant Melanoma • 4 Types occur different areas of body • Superficial Spreading Melanoma (SSM) • Most common type • Most curable • Frequently from preexisting moles • Lentigo Maligna Melanoma (LMM) • Acrallentiginous melanoma (ALM) • Nodular melanoma (NM) C. Matthews MSN, RN

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

  42. Melanoma Medical Tx Depends on site, stage, age and general health of client • Surgery • Chemotherapy • Biologic Therapy • Interferon, interleukin • Radiation therapy Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures. C. Matthews MSN, RN

  43. Pause for Photos

  44. Prevention/Education • Sunscreen • Limit exposure • Hat/clothes/sunglasses • Shade • Inspect skin regularly Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.). Health Promotion and Maintenance: 3. Identify healthy behaviors by the client and family. C. Matthews MSN, RN

  45. 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! Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.). C. Matthews MSN, RN

  46. Sunburn • Superficial burn • Illustration page 522 • Excessive exposure to ultraviolet rays injures dermis. • Dilated capillaries = red, tender, edema, blisters • Large area = h/a, nausea, fever Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span. C. Matthews MSN, RN

  47. 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 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. C. Matthews MSN, RN

  48. Insects/Pests/Parasites • Spiders • Fire Ants • Lice/Scabies • Mosquitoes • Scorpions • “Sand fleas” • Chiggers • AKA harvest mites or red bugs 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. C. Matthews MSN, RN

  49. Spider bites • http://assets.aarp.org/external_sites/adam/html/2/19570.html • http://www.badspiderbites.com/brown-recluse-spider-bite/ 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. C. Matthews MSN, RN

  50. 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 Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span. 11. Identify etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and parasitic skin disorders. C. Matthews MSN, RN

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