Integumentary Handouts

Medical and Surgical Nursing
Integumentary System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,MAN 1

LAYERS

A. Epidermis
 Avascular outermost layer
 Stratified squamous epithelium
 Composed of keratinocytes (produce keratin
responsible for formation of hair and nails) and
melanocytes (produce melanin).
MEDICAL AND SURGICAL NURSING  Form the appendages (hair and nails) and glands
 Epidermis
Integumentary System  Stratum basale
 Stratum granulosum
Lecturer: Mark Fredderick R. Abejo RN,MAN  Stratum spinosum
________________________________________________  Stratum lucidum
 Stratum corneum
Integument – Skin
B. Dermis
The skin is the largest organ of the body  Layer beneath the epidermis composed of
As the external covering of the body, the skin performs the connective tissues.
vital function of protecting internal body structures from  Contains lymphatics, nerves and blood vessels.
harmful microorganisms and substances.  Elasticity of the skin results from presence of
collagen, elastin and reticular fibers.
FUNCTIONS:  Responsible for nourishing the epidermis.

1. Protection C. Subcutaneous layer
 Covers and protects the entire body from  Layer beneath the dermis.
microorganisms  Composed of loose connective tissues and adipose
 Protects from UV rays – melanin (pigment in the cells.
skin)  Stores fat.
 Keratin – a protein in the outermost layer of the skin  Important for thermoregulation.
“waterproofs” and “toughens” skin and protects
from excessive water loss, resists harmful APPENDAGES
chemicals, and protects against physical tears
Hair
2. Regulation  Covers most of the body surface (except the palms,
 Maintains normal body temperature by regulating soles, lips, nipples and parts of the external
sweat secretion and regulating the flow of blood genitalia).
close to the body surface.  Hair follicles: tube-like structures, derived from the
 Evaporation of sweat from the body epidermis, from which hair grows.
surface  Functions as protection from external elements and
 Radiation of heat at the body surface due from trauma.
to the dilation of blood vessels close to  Protects scalp from ultraviolet rays and cushions
the skin blows.
 Excessive heat loss causes shivering (contraction of  Eyelashes, hair in nostrils and in ears keep particles
skeletal muscle) increasing heat production and from entering organ.
goosebumps (contraction of arrector pili muscle)  Hair growth controlled by hormonal influences and
pulling hair shaft vertical, creating an insulated air by blood supply.
space over the skin.  Scalp hair grows for 2 to 5 years.
 Approximately 50 hairs are lost each day.
3. Absorption  Sustained hair loss of more than 100 hairs each day
 Absorbs oxygen and carbon dioxide and UV rays usually indicates that something is wrong
 Steroids (hydrocortisone) and fat-soluble vitamins Nails
(ie D) are readily absorbed  Dense layer of flat, dead cells, filled with keratin.
 Topical medications – motion sickness patch etc  Systemic illnesses may be reflected by changes in
the nail or its bed:
4. Synthesis  Clubbing
 Skin produces melanin, keratin, vitamin D  Beau’s line
 Melanin protects the skin from UV rays; determines
skin color Glands
 Keratin helps waterproof the skin and protects from  Eccrine sweat glands are located all over the body
abrasions and bacteria and produce inorganic sweat which participate in
 Vitamin D stimulated by UV light. Enters blood and heat regulation.
helps develop strong healthy bones. Vitamin D  Apocrine sweat glands are odiferous glands, found
deficiency causes Rickets primarily in the axillary, areolar, anal and pubic
areas; the bacterial decomposition of organic sweat
5. Sensory causes body odor.
 Sensory nerve endings tell about environment  Sebaceous glands are located all over the body
 They respond to heat, cold, pressure, touch, except for the palms and soles; produce sebum.
vibration, pain


ASSESSMENT
Effects of Aging in the Skin
Health History  Skin vascularity and the number of sweat and
 Presenting problem sebaceous glands decrease, affecting
 Changes in the color and texture of the skin, thermoregulation.
hair and nails.  Inflammatory response and pain perception
 Pruritus diminish.
 Infections  Thinning epidermis and prolonged wound healing
 Tumors and other lesions make elderly more prone to injury and skin
 Dermatitis infections.
 Ecchymoses  Skin cancer more common.
 Dryness
 Lifestyle practices
 Hygienic practices LABORATORY / DIAGNOSTIC STUDIES
 Skin exposure
 Nutrition / diet  Blood chemistry / electrolytes: calcium, chloride,
 Intake of vitamins and essential nutrients magnesium, potassium, sodium
 Water and Food allergies  Hematologic studies
 Use of medications  Biopsy
 Steroids  Removal of a small piece of skin for
 Antibiotics examination to determine diagnosis
 Vitamins  Nursing Interventions
 Hormones Preprocedure
 Chemotherapeutic drugs - Secure consent
 Past medical history - clean site
 Renal and hepatic disease Postprocedure – place specimen in a
 Collagen and other connective tissue diseases clean container & send to pathology
 Trauma or previous surgery laboratory
 Food, drug or contact allergies - use aseptic technique for biopsy
 Family medical history site dressing, assess site for
 Diabetes mellitus bleeding & infection
 Allergic disorders - instruct px to keep dressing in
 Blood dyscrasias place for 8hrs & clean site daily
 Specific dermatologic problems - instruct the patient to keep
 Cancer biopsied area dry until healing
occur
Physical Examination  Skin Culture
 Color  Used for microbial study
 Areas of uniform color  Viral culture is immediately placed on ice
 Pigmentation  Obtain prior to antibiotic administration
 Redness  Wood’s Light Examination
 Jaundice  Skin is viewed through a Wood’s glass
 Cyanosis under UV
 Vascular changes Nursing Interventions
 Purpuric lesions Preprocedure – darken room
 Ecchymoses Postprocedure – assist px in adjusting to
 Petechiae light
 Vascular lesions  Skin testing
 Angiomas  Administration of allergens or antigens on
 Hemangiomas the surface of or into the dermis to
 Venous stars determine hypersensitivity
 Lesions  Types:
 Color  Patch
 Type  Prick
 Size  Intradermal
 Distribution
 Location
 Consistency DIAGNOSIS
 Grouping
 Annular  Impaired skin integrity
 Linear  Pain
 Circular  Body image disturbance
 Clustered  Risk for infection
 Ineffective airway clearance
 Edema (pitting or non-pitting)  Altered peripheral tissue perfusion
 Moisture content
 Temperature (increased or decreased;
distribution of temperature changes)
 Texture
 Mobility / Turgor


PLANNING AND IMPLEMENTATION  Protecting grafted skin from direct
sunlight for at least 6 months.
 Goals  Protecting graft from physical
 Restoration of skin integrity. injury.
 The patient will experience relief of pain.  Need to report changes in graft.
 The patient will adapt to changes in  Possible alteration in pigmentation
appearance. and hair growth; ability to sweat
 The patient will be free from infection. lost in most grafts.
 Maintenance of effective airway  Sensation may or may not return.
clearance.
 Maintenance of adequate peripheral tissue EVALUATION
perfusion.  Healing of burned areas; absence of drainage,
edema and pain.
 Interventions: Skin Grafts  Relaxed facial expression/body posture.
 Replacement of damaged skin with  Changes into self-concept without negating self-
healthy skin to provide protection of esteem
underlying structures or to reconstruct  Achieves wound healing
areas for cosmetic or functional purposes.  Lungs clear to auscultation
 Sources:  Palpable peripheral pulses of equal quality
 Autograft – patient’s own skin
 Isograft – skin from a genetically
identical person Disorders of the Integumentary System
 Homograft or allograft – cadaver
of same species Primary Lesions of the Skin
 Heterograft or xenograft – skin
from another species Macule is a small spot that is not palpable and is
 Nursing care: Preoperative less than 1 cm in diameter
 Donor site: Cleanse with Patch is a large spot that is not palpable & that is >
antiseptic soap the night before 1 cm.
and morning of surgery as ordered. Papule is a small superficial bump that is elevated
 Recipient site: Apply warm & that is < 1 cm.
compresses and topical antibiotics Plaque is a large superficial bump that is elevated
as ordered. & > 1 cm.
 Nursing care: Postoperative Nodule is a small bump with a significant deep
 Donor site: component & is < 1 cm.
 Keep area covered for 24 to Tumor is a large bump with a significant deep
48 hours. component & is > 1 cm.
 Use bed cradle to prevent Cyst is a sac containing fluid or semisolid material,
pressure and provide greater ie. cell or cell products.
air circulation. Vesicle is a small fluid-filled bubble that is usually
 Outer dressing may be superficial & that is < 0.5 cm.
removed 24 to 72 hours post- Bulla is a large fluid-filled bubble that is superficial
surgery; maintain fine mesh or deep & that is > 0.5 cm.
gauze until it falls of Pustule is pus containing bubble often categorized
spontaneously. according to whether or not they are related to hair
 Trim loose edges of gauze as follicles:
it loosens with healing.  follicular - generally indicative of local
 Administer analgesic as infection
ordered (more painful than  folliculitis - superficial, generally multiple
recipient site).  furuncle - deeper form of folliculitis
 Recipient site:  carbuncle - deeper, multiple follicles
 Elevate site when possible. coalescing
 Protect from pressure through
the use of a bed cradle. Secondary lesions of the Skin
 Apply warm compresses as
ordered. Scale is the accumulation or excess shedding of the
 Assess for hematoma, fluid stratum corneum.
accumulation under graft.  Scale is very important in the differential
 Monitor circulation distal to diagnosis since its presence indicates that the
the graft. epidermis is involved.
 Provide emotional support and  Scale is typically present where there is
monitor behavioral adjustments; epidermal inflammation, ie. psoriasis, tinea,
refer for counseling if needed. eczema
Crust is dried exudate (ie. blood, serum, pus) on the
 Provide client teaching and discharge skin surface.
planning concerning: Excoriation is a loss of skin due to scratching or
 Applying lubricating lotion to picking.
maintain moisture on the surface Lichenification is an increase in skin lines &
of healed graft for at least 6 to 12 creases from chronic rubbing.
months. Maceration is raw, wet tissue.


Fissure is a linear crack in the skin; often very  Activities causes much perspiration should be
painful. avoided.
Erosion is a superficial open wound with loss of  Advise wearing cotton clothing at night
epidermis or mucosa only  Avoid vigorous scratching and nails kept
Ulcer is a deep open wound with partial or trimmed to prevent skin damage and infection
complete loss of the dermis or submucosa

Distinct Lesions of the Skin SECRETORY DISORDERS

Wheal or hive describes a short lived (< 24 hours), Hydradenitis Suppurativa
edematous, well circumscribed papule or plaque  Abnormal blockage of sweat gland causes recurring
seen in urticaria. inflammation.
Burrow is a small threadlike curvilinear papule that
is virtually pathognomonic of scabies. Seborrheic Dermatoses
Comedone is a small, pinpoint lesion, typically  Excessive production of sebum
referred to as “whiteheads” or “blackheads.”  Two forms:
Atrophy is a thinning of the epidermal and/or - Oily form appears moist or greasy, There may be
dermal tissue. patches of sallow, greasy skin with slightly redness
Keloid overgrows the original wound boundaries - Dry form, consisting of flaky desquamation of the
and is chronic in nature. scalp ( Dandruff )
Hypertrophic scar on the other hand does not  Nursing Management:
overgrow the wound boundaries.  Avoid secondary candidal infection by
Fibrosis or sclerosis describes dermal cleaning carefully the affected areas .
scarring/thickening reactions.  Dandruff Treatment:
Milium is a small superficial cyst containing keratin - Frequent shampooing with medicated
(usually <1-2 mm in size shampoo
- Two or three different type of shampoo
Vascular Skin Lesions should be used in rotation to prevent the
seborrhea from becoming resistance to a
Petechiae is a round or purple macule, associated particular shampoo.
with bleeding tendencies or emboli to skin - The shampoo is left at least 5-10 min.
Ecchymosis a round or irregular macular lesion  Avoid external irritants, excessive heat and
larger than petechiae, color varies and changes from perspiration; rubbing and scratching prolong
black, yellow and green hues. Associated with the disease
trauma and bleeding tendencies.
Cherry Angioma, popular and round, red or purple, Ance Vulgaris
may blanch with pressure and a normal age-related
skin alteration.  Associated with increased production of sebum
Spider Angioma is a red, arteriole lesion, central from sebaceous glands at puberty.
body with radiating branches. Commonly seen on  Lesions include pustules, papules and comedones.
face,neck,arms and trunk. Associated with liver  Primary lesions of acne are comedones:
disease, pregnancy and vitB deficiency. - Close Comedones (whiteheads), formed from
Telangiectasia , shaped varies: spider-like or linear, impacted lipids or oil and keratin that plug the
bluish in color or sometimes red. Does not blanch dilated follicle.
when pressure applied. Secondary to superficial - Open Comedones (blackheads), the content of
dilation of venous vessels and capillaries. ducts are in open communication with the external
environment. The color result not from dirt, but
Pruritus from an accumulation of lipid, bacterial and
epithelial debris.
 General itching  Majority of adolescents experience some degree of
 Scratching the itchy area causes the inflamed cells acne, mild to severe.
and nerve endings to release histamine, which  Lesions occur mostly on face, neck, shoulders and
produces more generating itching. back.
 Usually more severe at night and less frequently  Caused by variety of interrelated factors including
reported during waking hours., probably because the increased activity of the sebaceous glands,
person is distracted by daily activities emotional stress, certain medications, menstrual
 Occurs frequently in elderly as a result of dry skin cycle.
 Treatment:  The inflammatory response may result from the
 Topical corticosteroid as anti- action of certain skin bacteria such as:
inflammatory agent to reduce itching. Propionibacterium Acnes.
 Oral antihistamines
- Diphenhydramine (Benadryl)
- Hydroxyzine (Atarax)
 Nursing Management:
 Tepid bath as prescribed
 Avoid vigorous rubbing of towel to the
affected parts
 Avoid situations that causes vasodilation:
- overly warm environment
- ingestion of alcohol or hot foods/liquids


 Non-infected members of the household
 Assessment findings: should pay special attention to areas of the
Appearance of lesions is variable and skin that have been injured, such as cuts,
fluctuating. scrapes, bug bites, areas of eczema, and
Systemic symptoms absent. rashes. These areas should be kept clean and
Psychologic problems such as social covered to prevent infection.
withdrawal, low self-esteem, feelings of being  In addition, anyone with impetigo should
“ugly.” cover the impetigo sores with gauze and tape.
 Pharmacologic Therapy  All members of the household should wash
Benzoly Peroxide their hands thoroughly with soap on a regular
Oral Antibiotics: Tetracycline, basis.
Doxycycline, Minocycline  It is also a good idea for everyone to keep
Oral Retinoids: Isotretinion (Accutane) their fingernails cut short to make hand
Note: commone side effect, is “cheilitis” washing more effective.
inflammation of lips  Contact with the infected person and his or
Hormone Therapy: Estrogen-progesterone her belongings should be avoided, and the
infected person should use separate towels for
preparation.
bathing and hand washing.
 Elimination of food products associated with a  If necessary, paper towels can be used in
place of cloth towels for hand drying. The
flare-up of acne such as chocolate, cola and
infected person's bed linens, towels, and
fried foods
clothing should be separated from those of
 Milk products should be promoted
 Advise the client to wash face at least twice a other family members, as well.
day with mild soap.  While suffering from impetigo it is best to
stay indoors for a few days to stop any
 Provide positive reassurance, listening actively
bacteria getting into the blisters and making
and being sensitive the feelings of the patient.
 Discuss over-the-counter products and their the infections worse.
effects.
 Patients are instructed to avoid manipulation of
pimples or blackheads. Squeezing merely FOLLICULAR DISEASES
worsens the problem.
Folliculitis

 Is the inflammation of one or more hair follicles.
BACTERIAL INFECTIONS
 Folliculitis starts when hair follicles are damaged by
friction from clothing, an insect bite, blockage of
Impetigo
the follicle, shaving or too tight braids too close to
the scalp traction folliculitis.
 Is a superficial bacterial skin infection most
 In most cases of folliculitis, the damaged follicles
common among children 2 to 6 years old.
 It is primarily caused by Staphylococcus aureus, are then infected with the bacteria Staphylococcus
 Symptoms:
and sometimes by Streptococcus pyogenes
 rash (reddened skin area)
 Impetigo generally appears as honey-colored scabs
 pimples or pustules located around a hair
formed from dried serum, and is often found on the
arms, legs, or face. follicle
o may crust over
 The infection is spread by direct contact with
o typically occur on neck, axilla, or
lesions or with nasal carriers.
groin area
 The incubation period is 1–3 days. Dried
streptococci in the air are not infectious to intact o may be present as genital lesions
 itching skin
skin. Scratching may spread the lesions.
 spreading from leg to arm to body through
 The lesions begin as small, red macules which
improper treatment of antibiotics
quickly become discrete, thin-walled vesicles that
soon ruptured and become coved with a loosely
adherent honey-yellow crust. Furuncles (Boils)
 Medical Management:
 Is a skin disease caused by the infection of hair
 Topical or oral antibiotics are usually
prescribed: follicles, resulting in the localize accumulation of
- Benzathine penicillin pus and dead tissue.
 The symptoms of boils are red, pus-filled lumps that
- Penicillinase-Resistant- cloxacillin
are tender, warm, and extremely painful. A yellow
- Penicillin-Allergic- erythromycin
 Treatment may involve washing with soap and or white point at the center of the lump can be seen
water and letting the impetigo dry in the air. when the boil is ready to drain or discharge pus.
 In a severe infection, multiple boils may develop
 Mild cases may be treated with bactericidal
and the patient may experience fever and swollen
ointment, such as fusidic acid, mupirocin,
chloramphenicol or neosporin, which in some lymph nodes. A recurring boil is called chronic
countries may be available over-the-counter. furunculosis.
 In some people, itching may develop before the
lumps begin to form.
 Good hygiene practices can help prevent
 Boils are most often found on the back, stomach,
impetigo from spreading. Those who are
infected should use soap and water to clean underarms, shoulders, face, lip, eyes, nose, thighs
and buttocks, but may also be found elsewhere.
their skin and take baths or showers regularly.


 Sometimes boils will exude an unpleasant smell, VIRAL SKIN INFECTION
particularly when drained or when discharge is
present, due to the presence of bacteria in the Herpes Zoster (Shingles)
discharge.
 The cause are bacteria such as staphylococci.  Commonly known as shingles, is a viral disease
Bacterial colonization begins in the hair follicles characterized by a painful skin rash with blisters in
and can lead to local cellulitis and abscess a limited area on one side of the body, often in a
formation. stripe.
 The infection is caused by varicella zoster virus.
Carbuncles  Symptoms

 Is an abscess larger than a boil.  The earliest symptoms of herpes zoster,
 It is usually caused by bacterial infection, most which include headache, fever, and
commonly Staphylococcus aureus. malaise.
 The infection is contagious and may spread to other  These symptoms are commonly followed
areas of the body or other people. by sensations of burning pain, itching,
 A carbuncle is made up of several skin boils. The hyperesthesia (oversensitivity), or
infected mass is filled with fluid, pus, and dead paresthesia ("pins and needles": tingling,
tissue. Fluid may drain out of the carbuncle, but pricking, or numbness).
sometimes the mass is so deep that it cannot drain  The pain may be extreme in the affected
on its own. dermatome, with sensations that are often
 Carbuncles may develop anywhere, but they are described as stinging, tingling, aching,
most common on the back and the nape of the neck. numbing or throbbing, and can be
 Men get carbuncles more often than women. interspersed with quick stabs of agonizing
 Things that make carbuncle infections more likely pain.
include friction from clothing or shaving, generally  After 1–2 days (but sometimes as long as
poor hygiene and weakening of immunity. 3 weeks) the initial phase is followed by
 Nursing Management the appearance of the characteristic skin
 Carbuncles usually must drain before they will rash.
heal. This most often occurs on its own in less  Later, the rash becomes vesicular,
than 2 weeks. forming small blisters filled with a serous
 Placing a warm moist cloth on the carbuncle exudate, as the fever and general malaise
helps it to drain, which speeds healing. continue.
 The affected area should be soaked with a  The painful vesicles eventually become
warm, moist cloth several times each day. cloudy or darkened as they fill with blood,
 The carbuncle should not be squeezed, or cut crust over within seven to ten days, and
open without medical supervision, as this can usually the crusts fall off and the skin
spread and worsen the infection. heals: but sometimes after severe
 Treatment is needed if the carbuncle lasts blistering, scarring and discolored skin
longer than 2 weeks, returns frequently, is remain.
located on the spine or the middle of the face,  Medical management:
or occurs along with a fever or other Analgesics
symptoms. Corticosteroids
 A doctor may prescribe antibacterial soaps and Acetic acid compresses
antibiotics applied to the skin or taken by Acyclovir (Zovirax)
mouth.  Nursing interventions:
 Deep or large lesions may need to be drained  Apply acetic acid compresses or white
by a health professional. petrolatum to lesions
 Proper excision under strict aseptic conditions  Administer medications as ordered.
will treat the condition effectively.  Analgesics for pain
 Proper hygiene is very important to prevent the  Systemic corticosteroids:
spread of infection. monitor for side effects of
 Hands should always be washed thoroughly, steroid therapy.
preferably with antibacterial soap, after  Acyclovir: antiviral agent which
touching a carbuncle. reduces the severity when given
 Washcloths and towels should not be shared or early in illness.
reused. Clothing, washcloths, towels, and
sheets or other items that contact infected areas
should be washed in very hot (preferably Herpes Simplex Virus
boiling) water.
 Bandages should be changed frequently and  Assessment findings:
thrown away in a tightly-closed bag.  Clusters of vesicles, may ulcerate or crust
 If boils/carbuncles recur frequently, daily use  Burning, itching, tingling
of an antibacterial soap or cleanser containing  Usually appears on lip or cheek.
triclosan, triclocarban or chlorhexidine, can  Nursing interventions:
suppress staph bacteria on the skin.  Keep lesions dry.
 Apply topical antibiotics or anesthetic as
ordered.


Condition Description Illustration Tinea Pedis - soles of feet have - Soak feet in
“athletes scaling and mild vinegar and water
foot” redness with solution.
maceration in toe webs - Resistant
Infection infection:
occurs when griseofulvin or
the virus terbinafine
comes into - Lamisil daily for
Herpes labialis 3 months
contact with
oral mucosa
or abraded
skin. Tinea - Nails thicken, - Itraconazole
Ungum crumble easily and (sporanox)
(toenails) luck cluster
- whole nail maybe
When destroyed
symptomatic,
the typical Nursing Management
manifestation  Keep feet dry as much as possible, including area
of a primary between the toes.
HSV-1 or  Wear clothing and socks should be made of cotton
HSV-2  Anti-fungal powder may applied twice a day to keep
genital feet dry.
Herpes infection is  Instruct the patient to always use a clean towel and
genitalis clusters of washcloth daily
inflamed  Each person should have separate comb and
papules and hairbrush to prevent spread of tinea capitis..
vesicles on  Household pets should be examined.
the outer
surface of the
genitals PEDICULOSIS
resembling
cold sores.  Parasitic infestation
 Adult lice are spread by close physical contact such
as sharing combs, clips, caps, hats, etc.
 Occurs in school-age children particularly those
FUNGAL INFECTION with long hair.
 Medical management:
Types and Clinical Treatment  Special medicated shampoos (Lindane).
Location Manifestation  Use of fine-tooth comb to remove nits.

 Assessment findings:
Tinea - Oval, scaling, - Griseofulvin for 6  White eggs (nits) firmly attached to base of
Capitis erythematous patches weeks hair shafts.
( Head) - small papules or - Shampoo hair 2  Pruritus of scalp.
pustules in scalp or 3 times with
- brittle hair Nizoral or  Nursing interventions:
Selenium sulfide  Institute skin isolation precautions.
shampoo  Use special shampoo and comb the hair.
 Provide client teaching and discharge planning
concerning:
Tinea - Begins with red - Mild condition:  How to check self and other family members
Corporis macule, which spreads Topical antifungal and how to treat them.
(Body) to a ring of papules creams  Washing of clothes, bed linens, etc.;
- lesions found in discouraging sharing of brushes, combs and
cluster -Severe condition: hats.
- very pruritic Griseofulvin or
Terbinafine Contact Dermatitis

 Irritation of the skin from a specific substance
Tinea - Begins with small, - Mild condition: which came in contact with the skin.
Cruris red scaling patches Topical antifungal  Usually caused by irritants and allergens
(Groin) which spread to form creams  Contact dermatitis is a localized rash or irritation of
circular elevated the skin caused by contact with a foreign substance.
plaques. -Severe condition:  Only the superficial regions of the skin are affected
- very pruritic Griseofulvin or in contact dermatitis. Inflammation of the affected
Terbinafine tissue is present in the epidermis (the outermost


layer of skin) and the outer dermis (the layer  Nursing Interventions:
beneath the epidermis)  Apply occlusive wraps over prescribed
 Symptoms of both forms include the following: topical steroids.
Red rash. This is the usual reaction. The  Protect areas treated with coal tar
rash appears immediately in irritant preparation from direct sunlight for 24
contact dermatitis; in allergic contact hours.
dermatitis, the rash sometimes does not  Administer methotrexate as ordered, assess
appear until 24–72 hours after exposure to for side effects.
the allergen.  Provide client teaching and discharge
Blisters or wheals. Blisters, wheals planning concerning:
(welts), and urticaria (hives) often form in Feelings about changes in appearance of
a pattern where skin was directly exposed skin (encourage client to cover arms
to the allergen or irritant. and legs with clothing if sensitive about
Itchy, burning skin. Irritant contact appearance).
dermatitis tends to be more painful than Importance of adhering to prescribed
itchy, while allergic contact dermatitis treatment and avoidance of
often itches. commercially advertised products.

 Nursing Interventions:
 Apply wet dressings of Burrow’s solution
for 20 minutes, 4 times a day to help clear
oozing lesions. Vitiligo
 Provide relief from pruritus.
 Administer topical steroids and antibiotics  Is a chronic disorder that causes depigmentation in
as ordered. patches of skin.
 Allowing crusts and scales to drop off  It occurs when the melanocytes, the cells
skin naturally as healing occurs. responsible for skin pigmentation which are derived
 Avoidance of wool, nylon, or fur fibers on from the neural crest, die or are unable to function.
sensitive skin.  Unknown caused, but there is some evidence
 Need to use gloves if handling irritant or suggesting it is caused by a combination of
allergenic substances. autoimmune, genetic, and environmental factors.
 Provide client teaching and discharge  Symptom of vitiligo is depigmentation of patches of
planning concerning: skin that occurs on the extremities. Although
Avoidance of causative agent. patches are initially small, they often enlarge and
Preventing skin dryness: change shape.
Use mild soaps.  When skin lesions occur, they are most prominent
Soak in plain water for 20 to 30 on the face, hands and wrists.
minutes.  Depigmentation is particularly noticeable around
Apply prescribed steroid cream body orifices, such as the mouth, eyes, nostrils,
immediately after bath. genitalia and umbilicus
Avoid extremes of heat and cold.

Psoriasis
Skin Cancer
 Is a chronic, non-contagious autoimmune disease
which affects the skin and joints.  Types of skin cancers:
 It commonly causes red scaly patches to appear on  Basal cell epithelioma – most common type
the skin. The scaly patches caused by psoriasis, of skin cancer; locally invasive and rarely
called psoriatic plaques, are areas of inflammation metastasizes; most frequently located between
and excessive skin production. the hairline and upper
 Skin rapidly accumulates at these sites and takes on lip.
a silvery-white appearance.  Risk factors:
 Plaques frequently occur on the skin of the elbows - UV rays
and knees, but can affect any area including the - May take several forms: nodular,
scalp and genitals. ulcerative, pigmented ad superficial
 Predisposing factors:  Hx and Assessment:
Stress - Usually asymptomatic unless
Trauma secondarily infected in advanced
Infection disease
Changes in climate - Pearly-colored PAPULE
Excessive alcohol consumption - External surface - fine
Smoking telangiectasia and is translucent
 Treatment:
Familial factors
- Curettage
 Medical management:
- Surgical
 Topical corticosteroids
- Cryosurgery
 Coal tar preparations
- Radiation
 Ultraviolet light
- prevention
 Antimetabolites (methotrexate)
- Mohr’s micrographic surgery


 Squamous cell carcinoma (epidermoid) – BURNS
grows more rapidly than basal cell carcinoma
and can metastasize; frequently seen on Direct tissue injury due to:
mucous membranes, lower lip, neck and o Thermal: scald, hot grease, sunburn,
dorsum of the hands. contact with flames
 Risk factors: o Electrical
- UV rays o Chemical
- Radiation o Smoke inhalation: fumes, gasses, smoke
- Actinic keratosis
- Immunosuppression I. TYPES
- Industrial carcinogens A. Full thickness
 History and Assessment: 1. First degree burns (superficial)
- Slowly evolving  Epidermis
- Assymptomatic  Common cause is thermal burn
- Occassionaly bleeding and pain  (+) blanching upon pressure and
- Exophytic nodules w/ varying erythema
degree of scaling or crusting  (+) pain
 Diagnosis: 2. Second degree burns (deep burn)
- Biopsy- irregular masses of  Chemical
anaplastic epidermal celss  (+) very painful
proliferating down to the dermis  (+) erythema or fluid filled blisters
 Treatment B. Partial thickness
- Surgical excision 1. Third to fourth degree burns
- Mohr’s micrographic surgery  Affect all layers of skin, muscle and
- Radiation bones
 Electrical burns
 Malignant melanoma – least frequent of skin  Less painful than 1st and 2nd degree
cancers, but most serious; capable of invasion burns
and metastasis to other organs.  Dry, thick, leathery texture
 Risk factors:  Eschar – devitalized tissue
- Sun exposure
- Fair skin
- Positive family history A description of the traditional and current
- Presence of dysplastic nevi classifications of burns.
 Hx and Assessment:
- Usually asymptomatic until late
- Pruritus or mild discomfort
Traditional Clinical
- Recent changed in a previous skin Nomenclature Depth
nomenclature findings
lesion
asymetry
border irregularity
color variation Erythema,
diameter(large) Superficial Epidermis minor pain,
 Diagnosis: thickness
First-degree
involvement lack of
- Biopsy- melanocytes w/ marked blisters
cellular atypia and melanocytic
invasion of the dermis
 Treatment:
- Surgical excision Partial Superficial Blisters,
- Chemotherapy- metastasis thickness – Second-degree (papillary) clear fluid,
superficial dermis and pain
 Precancerous lesions:

 Leukoplakia – white shiny patches in the Partial Deep
mouth or on the lip. Whiter
thickness – Second-degree (reticular)
 Nevi (moles) – junctional nevus may become deep dermis
appearance
malignant; compound and dermal nevi
unlikely to become cancerous.
 Senile keratoses – brown, scale-like spots on
older individuals. Dermis and Hard,
underlying leather-like
Third- or
 Nursing interventions: Full thickness Fourth-
tissue and eschar,
 Limitation of contact with chemical irritants. degree*
possibly purple fluid,
 Need to report lesions that change fascia, bone, no sensation
characteristics and/or those that do not heal. or muscle (insensate)
 Protection against UV rays from the sun
 Wear thin layer of clothing.
 Use sunblock or lotion
containing PABA.


C. STAGES 2. Wound care:
1. Emergent – removal of client from source of Hydrotherapy
burn Debridement (enzymatic or surgical)
 Thermal – smother burn beginning 3. Drug therapy:
with the head. Topical antibiotics
 Smoke inhalation – ensure patent Systemic antibiotics
airway. Tetanus toxoid or hyperimmune human
 Chemical – remove clothing that tetanus globulin
contains chemical; lavage are with Analgesics
copious amounts of water. 4. Surgery: excision and grafting
 Electrical – note victim position,
identify entry and exit routes; maintain F. NURSING MANAGEMENT
airway.
 Wrap in dry, clean sheet or blanket to 1. Administer medications as ordered
prevent further contamination of  Tetanus toxoid
wound and to provide warmth.  Burn surface area is a good source of
 Assess how and when burn occurred. microbial growth
 Provide IV route if possible.  CLOSTRIDIUM TETANY
 Transport immediately.
 Tetanospain
2. Shock phase (24-48 hours) – shifting of fluids  Tatanolysin
from intravascular to interstitial   Narcotic analgesics – morphine
hypovolemia  Systemic antibiotics
 Elevated HCT  Cephalosporins
 Tachycardia  Penicillin
 Metabolic acidosis  Tetracyclines
 Low serum sodium  Topical antibiotics
 Low serum potassium  Silver sulfadiazide
 Hypotension  Silver nitrate
3. Diuresis Phase/Fluid remobilization phase –  Povidone iodine
characterized by the return of fluids from
interstitial to intravascular 2. Provide relief/control of pain:
 Assessment findings:  Administer morphine sulfate and
 Elevated blood pressure, increased monitor vital signs closely.
urine output.  Administer analgesics/narcotics 30
 Hypokalemia, hyponatremia, minutes before wound care.
metabolic acidosis  Position burned areas in proper
alignment.
4. Convalescent/Recovery phase – characterized
by continuous wound healing 3. Monitor alterations in fluid and electrolyte
 Healing starts immediately after balance:
injury  Assess for fluid shifts and electrolyte
 Assessment findings: alterations.
 Elevated blood pressure, increased  Administer IV fluids as ordered.
urine output.  Monitor Foley catheter output hourly
 Hypokalemia, hyponatremia, (30 ml/hr desired).
metabolic acidosis
4. Monitor alterations in fluid and electrolyte
balance:
D. ASSESSMENT FINDINGS  Weigh daily.
1. Rule of 9’s  Monitor circulation status regularly.
 Head and neck = 9  Administer/monitor
 Anterior chest = 18 crystalloids/colloids/water solutions.
 Posterior chest = 18
 Upper extremity = 9 x 2 5. Formula in IVF administration:
 Lower extremity = 18 x 2
 Genital = 1  Evans Formula:
 Colloids: 1 ml x wt (kg) x % BSA
2. Severity of burns: burned
 Major: partial thickness greater than 25%;  Electrolytes (saline):
full thickness greater than or equal to 1 ml x wt (kg) x % BSA burned
10%.  Glucose (D5W): 2000 ml for
 Moderate: partial thickness 15%-25%; full insensible loss.
thickness less than 10%. Day 1: half to be given in 1st 8 hours;
 Minor: partial thickness less than 15%; remaining half over next 16 hours.
full thickness less than 2%. Day 2: half of previous day’s colloids and
electrolytes; all of insensible fluid replacement.
E. MEDICAL MANAGEMENT: Maximum of 10 L over 24 hours.
1. Supportive therapy: IV fluid management,
catheterization


Second and third-degree burns Administer analgesics before
exceeding 50% BSA calculated on application.
basis of 50% BSA Assess for metabolic acidosis/renal
function studies.
 Administer gentamicin as ordered: assess
 Brooke Army Formula: vestibular/auditory and renal functions at
Colloids: 0.5 ml x wt (kg) x % BSA regularly intervals.
burned
Electrolytes (lactated Ringer’s): 7. Promote maximal nutritional status:
1.5 ml x wt (kg) x % BSA burned  Diet high in CHO, CHON, VIT C
Glucose (D5W): 2000 ml for  Monitor tube feedings/TPN if ordered.
insensible loss  When oral intake permitted, provide high-
Day 1: Half to be given in first 8 hours, calorie, high-protein, high carbohydrate
remaining half over next 16 hours. diet with vitamin and mineral
Day 2: Half of colloids, half of electrolytes, all supplements.
of insensible fluid replacement.  Serve small portions.
Second and third-degree burns  Schedule wound care and other treatments
exceeding 50% BSA calculated on at least 1 hour before meals.
basis of 50% BSA
8. Prevent GI complications:
 Parkland/Baxter Formula:  Assess for signs and symptoms of
Lactated Ringer’s: paralytic ileus.
4 ml x wt (kg) x % BSA burned  Assist with insertion of NGT to
Day 1: Half to be given in first 8 hours; half to prevent/control Curling’s/stress ulcer;
be given over next 16 hours. monitor patency/drainage.
Day 2: Varies; colloid is added.  Administer prophylactic antacids through
NGT and/or IV cimetidine or ranitidine.
 Consensus Formula:  Monitor bowel sounds.
Lactated Ringer’s:  Test stools for occult blood.
2-4 ml x wt (kg) x % BSA burned
Half to be given in first 8 hours after burn; 9. If (+) to burn of the head and neck and face
remaining fluid to be given over next 16 hours.  Assist in intubation
10. Assist in hydrotherapy
6. Prevent wound infection. 11. Assist in surgical wound debridement
 Place the patient in a controlled sterile  Analgesics before debridement
environment. 12. Prevent complications
 Maintain strict aseptic technique  Infections
 Use hydrotherapy for no more than 30  Septicemia
minutes to prevent electrolyte loss.  Paralytic ileus
 Observe wound for separation of eschar  Curling’s ulcers (H2 receptor
and cellulitis. antagonists)
 Apply mafenide (sulfamylon) as ordered: 13. Assist in surgical procedure
Administer analgesics 30 minutes
before application. 14. Provide client teaching and discharge planning
Monitor acid-base status and renal concerning:
 Care of healed burn wound
function studies.
Assess daily for changes.
Provide daily tubbing for removal of
previously applied cream. Wash hands frequently during
dressing change.
 Apply silver sulfadiazine as ordered. Wash area with prescribed solution
Administer analgesics 30 minutes or mild soap and rinse well with
before application. water; dry with clean towel.
Observe and report hypersensitivity Apply sterile dressing.
reactions.  Prevention of injury to burn wound.
Store drug away from heat.  Avoid trauma to area.
 Avoid use of fabric softeners or
harsh detergents (might cause
 Apply silver nitrate as ordered.
irritation).
Handle carefully: solution leaves
 Avoid constrictive clothing over burn
gray or black stain on skin, clothing
wound.
and utensils.
 Adherence to prescribed diet.
Administer analgesics 30 minutes
 Importance of reporting formation of local
before application.
trophic changes.
Keep dressings wet with solution;  Methods of coping and resocialization.
dryness increases the concentration
and causes precipitation of silver
salts in the wound.

 Apply povidone-iodone solution as
ordered.


Wound Healing Process C. Proliferative Phase
 Wound healing, or wound repair, is an intricate
process in which the skin (or some other organ) Fibroblasts begin to enter the wound site, marking
repairs itself after injury. the onset of the proliferative phase even before the
 In normal skin, the epidermis (outermost layer) and inflammatory phase has ended.
dermis (inner or deeper layer) exists in a steady- Angiogenesis occurs concurrently with fibroblast
stated equilibrium, forming a protective barrier proliferation when endothelial cells migrate to the
against the external environment. area of the wound.
 Once the protective barrier is broken, the normal The tissue in which angiogenesis has occurred
(physiologic) process of wound healing is typically looks red (is erythematous) due to the
immediately set in motion presence of capillaries
 The classic model of wound healing is divided into Fibroblasts mainly proliferate and migrate, while
three or four sequential, yet overlapping, phases: later, they are the main cells that lay down the
(1) hemostasis collagen matrix in the wound site.
(2) inflammatory, Fibroblasts begin secreting appreciable collagen.
(3) proliferative and Collagen deposition is important because it
(4) remodeling increases the strength of the wound; before it is laid
down.
Formation of granulation tissue in an open wound
A. Homostasis allows the reepithelialization phase to take place, as
epithelial cells migrate across the new tissue to form
Within minutes post-injury, platelets (thrombocytes) a barrier between the wound and the environment
aggregate at the injury site to form a fibrin clot.
This clot acts to control active bleeding D. Remodeling Phase
(hemostasis)
When the levels of collagen production and
B. Inflammatory Phase degradation equalize, the maturation phase of tissue
repair is said to have begun.
The maturation phase can last for a year or longer,
When tissue is first wounded, blood comes in
depending on the size of the wound and whether it
contact with collagen, triggering blood platelets to
was initially closed or left open.
begin secreting inflammatory factors.
During Maturation, type III collagen, which is
Platelets, release a number of things into the blood,
prevalent during proliferation, is gradually degraded
including ECM proteins and cytokines, including
and the stronger type I collagen is laid down in its
growth factors.Growth factors stimulate cells to
place
speed their rate of division.
Platelets also release other proinflammatory factors
like serotonin, bradykinin, prostaglandins,
prostacyclins, thromboxane, and histamine, which Primary Intention:
cause blood vessels to become dilated and porous.
The main factor involved in causing vasodilation is When wound edges are directly next to one another
histamine. Histamine also causes blood vessels to:
Increased Capillary Permeability causes hyperemia Little tissue loss
that leads to redness (rubor) and presence of heat Minimal scarring occurs
(calor) and Most surgical wounds heal by first intention healing
Fluid and cellular exudation that causes edemaand Wound closure is performed with sutures, staples,
presence of exudates or adhesive at the time of initial evaluation
Within an hour of wounding, polymorphonuclear
neutrophils (PMNs) arrive at the wound site and Secondary Intention:
become the predominant cells in the wound for the
first two days after the injury occurs.They also
cleanse the wound by secreting proteases that break The wound is allowed to granulate
down damaged tissue. Surgeon may pack the wound with a gauze or use a
Neutrophils usually undergo apoptosis once they drainage system
have completed their tasks and are engulfed and Granulation results in a broader scar
degraded by macrophages Healing process can be slow due to presence of
The macrophage's main role is to phagocytise drainage from infection
bacteria and damaged tissue and it also debrides
damaged tissue by releasing proteases. Wound care must be performed daily to encourage
Macrophages also secrete a number of factors such wound debris removal to allow for granulation
tissue formation
as growth factors and other cytokines, especially
during the third and fourth post-wounding days.
These factors attract cells involved in the Tertiary Intention (Delayed primary closure):
proliferation stage of healing to the area


The wound is initially cleaned, debrided and observed, typically 4 or 5 days before closure
Pressure Ulcer

• Lesion from unrelieved pressure causing damage of Skin breaks
underlying tissue or a localized area of cellular Stage II Abrasion, blister or shallow crater
necrosis resulting from vascular insufficiency in Edema persists
tissues under pressure Ulcer drains
• Occurs with limited mobility Infection may develop
• Once formed, pressure ulcers are slow to heal
• Result from mechanical forces Ulcer extends into subcutaneous tissue
• Occurs most often over bony prominences Stage III Necrosis and drainage continue
Infection develops

Ulcer extends to underlying muscle and
Stage IV bone.
Deep pockets of infection develop
Necrosis and drainage continue

Pressure Ulcers: Key Things to Remember

• Pressure relieving/reducing devices do not take the
place of observation of skin color, integrity, and
Pressure Points temperature at intervals to determine capillary blood
flow.
• Mechanical Forces • In some clients pressure can occur in less than 2
– Pressure hours– the actual turning/repositioning schedule
– Friction should be individualized based upon assessment
– Shear data

Risk Factors for Developing Pressure Ulcer Pressure Ulcers: Nursing Diagnosis

 Prolong pressure on tissue • Impaired skin integrity
 Immobility, compromised mobility • Pain
 Loss of protective reflexes • Disturbed body image
 Poor skin perfusion • Ineffective coping
 Edema • Imbalanced nutrition: less than body requirements
 Malnutrition • Deficient knowledge
 Friction
 Shearing forces Nursing Intevention
 Trauma
 Incontinence of urine and feces  Prevention of Pressure:
 Altered skin moisture o Turned and repositioned at 1-2 hours
 Excessively dry skin interval
 Advance age o Encourage to shift weight actively every
 Equipment: cast,traction and restraints
15 minutes
o Pressure relief and reduction devices:
Pressure Ulcers: Wound Assessment Dynamic vs. Static

• Appearance changes with the depth of injury  Frequent monitoring of ulcer progress
• Assess for:  Avoid massaging reddened areas, because this may
– Location, size, color increase the damage
– Extend of tissue involvement  To avoid shearing forces when repositioning the
– Condition of surrounding tissue patient, the nurse lifts and avoid dragging the
– Presence of foreign bodies patient across a surface
 Increase protein intake, iron, vitamin C
 Prevention of infection and wound extension
Stages of Ulcer o Be alert for classic signs of wound
infection
o Prevent further pressure damage
Area of erythema  Maintaining a safe environment
Erythema does not blanch with pressure o Meticulous local wound care
Stage I Skin temperature elevated o Minimize cross-contamination with
Tissue are swollen pathogens
Patient complains of discomfort o Standard precautions
Erythema progresses to dusky blue-gray o Thorough handwashing before and after
dressing changes


Anatomy of the Skin

Hair / Hair Growth


Nail Skin Testing Wood’s Light Examination

Skin Grafting

Secondary Skin Lesion


Burn Rule of Nine

Phases of Wound Healing

Integumentary Handouts

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