medical

1. INTEGUMENTARY SYSTEM DISORDERS

2. • The integumentary system consists of the skin and its accessory structures,
including the hair, nails, sebaceous glands, and sweat glands.
• The skin is the exterior covering of the body. It weighs more than 6 pounds
in the average adult, and covers more than 3,000 square inches.
• It is the largest organ of the body. It is supplied with blood vessels and
nerves.

3. Skin
• one of the largest organ in our body
• Forms barrier b/n internal external environment
• Participate in many function of the body
• Continuous in external opening of the body
• provide noninvasive window to observe the body’s level of functioning
• Covers the body

4. • The skin consists of 3 layers:
– Epidermis- non vascular outermost layer, continuously dividing cells
– Dermis- takes the largest portion of the skin and provides strength and
structure. It consists of glands (sebaceous, sweat), hair follicle, blood
vessels, and nerve endings
– Subcutaneous tissue (hypodermis)- the inner most layer. contains
major vascular networks, fat, nerves, and lymphatics

5. Factors influencing skin integrity
• Immobility is the major factor leading to pressure sore development .
• The pt who is confined to bed & unable to change position is at
greatest risk .
• Trauma most likely occur
– over the prominent areas
– weight bearing areas

6. 6
Epidermis
Dermis
Subcutaneous tissue
Skin appendage
Layer of the skin

7. 7
Epidermis
 The most outer layers of stratified and squamous epithelium
 Consists of four layers
Stratum cornium
Stratum lucidum/ granulosum
Stratum germinativum/ spinosum
Basel layer
 Thickness – range from o.lmm to 1mm/1.6mm
 Regenerates almost every 3-4 wks

8. 8
cells of epidermis
Keratinocyte
Melanocyte
Merkel cell
Langerhans cells

9. 9
Basement membrane of the skin
Separate dermis from epidermis
Rate ridge ( undulated furrows)
 Anchors epidermis
Found at junction of dermis and epidermis
Permit free exchange of essential nutrients
It is finger print on finger tips

10. 10
Dermis
• Largest portion of the skin
• It consists of
• Blood vessels
• Lymphatic
• Nerves
• smooth muscle
• Cells
• fibroblast
• Macrophage
• Mast cell

11. 11
Subcutaneous tissue
• Below the dermis
• Attaches skin to muscle & bone
• Stores fat
• Regulates temperature
• Provides shock absorption

12. 12
Glands of the skin
Sebaceous glands
• Found every where on the dermis except on palmar and
plantar surface
• Secretion stimulated by sex hormones
Sweat glands
• Eccrine sweat glands
• Apocrine sweat glands
Ceruminous glands

13. 13
Nails
• Composed of keratinized and horny layer
• Color ranges from pink to yellow or brown depending on skin color
• Pigmented bands in nail bed is normal for dark skinned people
• Protects ends of fingers and toes

14. 14
Hair
Grows over most of body except lips, palms & soles
Color is inherited & depends on amount of melanin
Protects and warms the head

15. Function Of Skin
• Protection- protection of underlying structures from invasion by bacteria, noxious
chemicals and foreign matter.
• Sensory perception- transmits pain, touch, pressure, temperature, itching, etc.
• Fluid balance (excretion)- absorption of fluids and evaporation of excess.
• Temperature regulation- produced heat released through skin by radiation,
conduction, and convection
• Vitamin synthesis- skin exposed to ultra violet light can convert substances
necessary for synthesizing vitamin D3 (cholecalciferol).
• Aesthetic- provides beauties and appearance

16. ASSESMENT OF CLTENTS WITH SKIN PROBLEMS
16
1. History
2. Physical examination
3. Diagnostic evaluations

17. History
17
• Identification/biographic data
• Onset of symptoms
• Location of symptoms
• Medicament history
• General medical history
• Travel history
• Family or house hold contacts

18. History cont’d
18
Presence of symptoms and It’s characteristics
Sever itch
Scabies
Atopic eczema
Contact dermatitis
Mid itch
Psoriasis
Drug eruption
Bullus pemphigoid
Pain -vasculitis and pemphigus ( large bulla)

19. Physical
examination
19
Technique
Inspection
Palpation
Observation
Requirements
Good light
Pen light
Warm and private room
Done glove
Drape

20. 20
Inspection
Inspect the skin for
1. Color of the skin
2. Vascular changes
3. Skin lesions

21. 1.Color of the skin
Increased pigmentation…deposition of Melanin
Loss of pigmentation…… leprosy
Redness ……allergy
Yellow …….carotenoids
Brown ……. melanin
Blue ……. ..reduced hemoglobin
Red ………. ..oxygenated hemoglobin
21

22. 22
2.Pallor
Absence or decreased normal skin tone and
vasculature
Best observed from conjunctive, mm, palm and sole
Cause – anemia, DHN

23. Pallor

24. 24
3.Cyanosis
 Bluishness of the skin
 Best observed from
lips
bucal mucosa
Tongue
Type
Central cyanosis
Peripheral cyanosis

25. Cyanosis
25

26. 26
Possible causes of;
Peripheral cyanosis
• Anxiety
• Cold exposure
• CHF

27. 27
Possible cause of central cyanosis
CHF
Venous obstruction
Advanced lung disease
Congenital heart disease
Respiratory obstruction
Indicates
Cellular hypoxia

28. 28
4.Jaundice
 Yellowish Ness of the skin
 Occurs due to increased blirubin
 Noted from- sclera and mucus membrane
 Suggests
liver disease
Excessive hemolysis of RBC

29. Jaundice
29

30. 30
Palpation
Palpate the skin for;
• Moisture
• Temperature.
• Texture
• Mobility and turgor
• Tenderness
• Edema

31. • Moisture
 Dryness may indicates hypothyroidism
 Oiliness may indicates acne, sweating
Temperature
• Generalized warmth occurs in fever, hyperthyroidism
• Generalized coolness as in hypothyroidism
• Local warmth as in inflammation
Texture
• roughness or smoothness
31

32. 32
Skin lesion
The most prominent characteristics of dermatological problems
80-100% of persons living with HIV/AIDS develop dermatological
conditions
May be very disabling, disfiguring and even life-threatening
Vary in shape and size
Classified according to appearance and origin
Assessment of skin lesions

35. Herpes vircilla virus

36. Tinea pedis

37. acne

38. Adverse effect of topical corticosteriods

39. pso

40. Assessing the general appearance of the skin
• The general appearance of the skin is
assessed by observing (Inspection) color,
skin lesions, and vascularity.
• On palpation skin turgor and mobility,
possible edema, temperature, moisture,
dryness, oiliness, tenderness, and skin
texture (rough and smooth).

41. Color change: can be hyperpigmentation,
hypopigmentation or depigmentation
1. Redness- fever, alcohol intake, local
inflammation due to increased blood flow to
the skin.
2. Bluish color (cyanosis) - decreased oxygen
supply due to chronic heart and lung disease,
exposure to cold, and anxiety

42. Cont’ed…
3. Yellowish color (jaundice) - increased serum bilirubin
concentration due to liver disease or red blood cell
haemolysis
- Uremia- renal failure
4. Brown-tan- Addison’s disease: cortisol deficiency
stimulates increased melanin production
- Birth mark, chloasma of pregnancy (face patches), and
sun exposure
5. Pale: Albunism- total absence of pigment melanin
• Vitiligo- destruction of the melanocytes in
circumscribed areas of the skin

43. Benign skin condition-vitiligo

48. Diagnostics test
• Skin biopsy: removal of a piece of skin by
shave, punch, or excision technique for a
microscopic study of the skin to determine the
histology of cells to rule out malignancy and to
establish an exact diagnosis.
• Patch testing: performed to identify
substances to which the patient has developed
an allergy.
• Potassium hydroxide test (KOH): helps to
identify fungal skin infection

49. Diagnostics test…
• Gram stain and culture with sensitivity test:
helps to identify the organism responsible for
an underlying infection with the effective drug
identification
• Slit Skin Smear (SSS): to identify the
causative agent of leprosy (mycobacterium
leprea)

50. Disorder of the skin
I . Inflammatory and allargic skin disorders
– Acne
– Psoriasis
– Atopic dermatitis (eczema)
– Contact dermatitis
II. Bacterial infections
– Impetigo
– Boil (furuncle)
– Carbancle
– Cellilitis

51. Disorder of the skin…
III. fungal infections
– Candidiasis
– Tinea captis
– Tinea corporis
– Tinea pedis (atlet's foot)

52. Disorder of the skin…
IV.Viral infections
– Herpes simplex (cold - sore)
– Herpes zoster (shingles)
– Warts

53. Inflammatory and allergic
condition
A. Eczema/Dermatitis
- It is a chronic pruritic inflammatory disorder
affecting the epidermis, and dermis
commencing in infancy, often persisting
throughout child hood but eventually remitting
and some times recurring in adult life.
• They are a non-infectious inflammation of the
skin and it can be acute, sub-acute or chronic.

55. Con’ted
….
• Causes
– The exact cause is unknown
– Imbalance of the immune system with an increase
in the immunoglobulin “E” activity and deficient
of cell mediated delayed hypersensitivity.
• Can be exacerbated by infection, bites, pollen,
wool, silk, fur, ointments, detergents,
perfume, certain foods, temperature
extremes, humidity, sweating and stress

56. Hypersensitivity reactions
HA(MSN) 56

57. Sign and
symptom
• An acute stage eczema shows redness,
swelling, papules, blisters, oozing and crusts.
• In the sub-acute stage the skin is still red but
becomes drier and scalier and may show
pigment change.
• In the chronic stage
-lichenification,
-excoriation,
-scaling and cracks are seen

58. Types of eczema
Atopic eczema
- is a chronic relapsing skin disorder that usually
begins in infancy and is characterized principally
by dry skin and pruritis, consequent rubbing and
scratching lead to lichenification
• This patient has a genetic predisposition for
hypersensitivity reactions such as asthma, allergic
rhinitis, and chronic urticaria.
– The eczema comes and goes
– The eczema triggered by dryness of the skin,
infections, heat, sweating, contact with allergens or
irritants and emotional stress.

59. Atopic eczema…
• Mostly affected sites are elbow and knee
folds, wrists, ankles, face, and neck; in some
cases it can be generalized

60. Atopic dermatitis

61. Atopic dermatitis

62. Seborrhoic
eczema
- is a very common chronic dermatitis
characterized by redness and scaling that
occurs in regions where the sebaceous
glands are most active, such as:
–Scalp, border of forehead/scalp
–Behind ears, above and in between
eyebrows
–In nasolabial folds, Sternum
–In between the shoulder blades, in axillae
–Groin , Perianal area

63. Seborrhoic eczema…
–Under the breast , umbilicus and in body
folds
–Pts often complains of oily skin
–The eczema comes and goes
–In HIV patients, the eczema can become very
widespread and easily super infected

64. Infective
eczema
• which occurs as a response to an oozing skin
infection.
• Common sites are the foot, and ankle region
• Causative organisms are usually staphylococci/
streptococci
• Vaseline use aggravates this condition

65. Contact eczema:
• is caused by contact of the skin with an
irritant or an allergen.
• Vaseline commonly causes: Vaseline
dermatitis.
• Common causes of irritant contact eczema on
hands, arms and legs are excessive use of H2O,
soap (especially if not washed off properly)
detergents, chemicals, sunlight, jewellery,
dyes, bleaches, perfume, nail polish/remover,
etc

66. Contact dermatitis

67. Sign and symptom of
eczema/
dermatitis
(general)
• Itching
• Redness, dry skin, lichenification, excoriation,
scaling skin
• Papules, blisters, oozing and crusts
• Color change

68. Management (general)
• Stop the use of irritants (contact eczema)
• Mild topical steroid such as hydrocortisone 1%
cream twice daily until lesions clear.
• In severe itching use antihistamines
E.g.: promethazine 25mg at night,
chlorphenaramine 4mg at day time/night

69. Mgt cont…
• In bacterial super infection use KMNO4
solution, Betadine solution, antibiotics
• Explain to the Patient, and Parents that not
serious and will disappear in time.
• Keep finger nails short and covered at night
• Use non greasy or non moisturizers
(seborrhoic eczema)

70. Mgt cont…
• An imidazole cream twice daily/ketaconazole
200 mg/d 1-3 weeks (seborrhoic eczema)
• The vicious circle of itch – scratch –
lichenification – itch needs to be broken , (atopic
eczema)- conscious effort to stop scratching
• In photo allergies – sun protection by wide rim
sun hat, long sleeves, high collar, sunglasses, stay
indoor, sunscreen, umbrella, etc
• Keep the site clean

71. Acn
e
- Is a common disorder of the sebaceous gland
associated with excess production of sebum
and blockage of the duct resulting in a
variety of inflammatory manifestations.
• Common in puberty and usually regresses in
early adult hood
• Patient complain of oiliness of the skin.
- Occurs on the face, upper trunk and
shoulders
- Appears to be multiple inflammatory papules,
pustules and nodules

72. Acne
…
• It can be very mild to be very severe: - they
blend together to form large inflammatory
areas with cysts and scar formation.
Cause-genetic, hormone and bacteria play a role

74. Cont.
.
Sign and symptom
• Red nodules, cyst , red papules, scars,
pustules, keloids
• There may be mild soreness, pain or itching
• Inflammatory papules, pustules, pores acne cyst,
scarring
Diagnosis
• Clinical
– Cyst formation, slow resolution, scarring
– Common at puberty and common of all skin conditions

75. Management
• Stop the use of vaseline, oil, ointment, greasy
cosmetics which further blocks sebaceous
ducts.
• Benzoyl per oxide 5-10% gel or tretinoin 0.01-
0.1% cream or gel apply at night.
• Salicylic acid 1-10% in alcoholic solution for
removal of excess sebum.
• For pustular/inflammatory lesions use topical
clindamycin 1% solution, erythromycin 2%
lotion

76. Management …
• In severe cases use systemic long term
antibiotics like doxycycline 100mg twice daily
until substantial improvement followed by
100mg once daily until acceptable.
• Surgical treatment – extraction of comedones,
incision and drainage of large fluctuant,
nodulocystic lesions

77. Psoriasis
• Is a chronic recurrent, hereditary, non infectious
disease of the skin caused by abnormally fast
turn over of the epidermis
• The turn over may be up to 40 times than
normal and as a result the epidermis is not able
to develop normally, therefore it doesn’t allow
formation of the normal protective layer of the
skin.

78. Psoriasis…
• Skin become red, inflamed, and the scales are
thicker than normal
• It produces a so called candle-wax
phenomenon, when you scratch such a patch it
becomes silvery white.
• Sites can be extensor areas of extremities
especially elbow, knees, buttocks, shoulder and
scalp

80. Generalized psoriasis

82. • Cure is there but it reoccurs
• Occurs at any age but 10-35 years is common
mostly.
• Periods of emotional stress and anxiety
aggravate the condition.
Sign and symptom.
• May itch severely in body folds covered with
silvery scales
• Finger and toenails may show pitting and
thickening
• Associated arthritis

83. Management
• Explain to the Pt the recurrent nature of the
disease.
• Salicylic acid 2-10% ointment twice daily to
reduce scaling
• Moisturizers (Vaseline, paraffin oil, or cream)
• Treat any super infection with KMNO4 , or
antibiotics if necessary
• Psoriatic arthritis NSAIDS E.g.: Ibuprofen,
Indomethacin, and ASA
• Methotrexates as a last option in sever cases.

84. Dermatitis
• Inflammation of the skin as a result of contact with an irritating
substance such as a chemical, foreign substance, medication, or
contact with a plant, such as poison ivy.
• The skin may become reddened, irritated, and itchy. The usual causes
are allergic reactions.

85. • Often the patient has a history or a family history of asthma, allergy,
or eczema. Some later symptoms may be the result of scratching of
the skin. Often the cause may be a drug reaction, the body’s immune
system reacting to a medication.

86. SIGNS AND SYMPTOMS
• Rash on the affected skin area from contact with the offending
substance
• Pruritis from histamine release from mast cells
• Erythema and edema
• Vesicles where the substance came in contact with the skin
• Hyperpigmentation from irritation from scratching

87. INTERPRETING TEST RESULTS
• RAST testing may be done to determine allergens.
• Patch testing

88. Treatment
• Treatment involves determining, if able, the triggers that began the
flare, and avoidance of the same.
• Treatment aimed at each symptom will help to decrease discomfort.
• If the dermatitis is widespread, IV medications, steroids, or
antihistamines may be necessary to resolve the flare.
• Topical corticosteroid cream, gel, or lotions will decrease the
symptoms.

89. NURSING INTERVENTION
• Avoid irritants that caused the dermatitis to prevent recurrence.
• Allow for healing and prevent bacterial infections.
• Cool compresses.
• Use protective gloves and clothing.
• Wash hands often.
• Explain to patient:
• Keep the skin moist.
• Keep nails short to diminish scratching.
• Warm, not hot, showers.
• Use mild soap.
• Apply moisturizers