NURSING CARE OF CLIENTS WITH INTEGUMENTARY PROBLEMS: NURSING CARE OF CLIENTS WITH INTEGUMENTARY PROBLEMS


The Skin: The Skin Epidermis- Epithelial cells Melanocytes- provides difference in skin color Keratinocytes-fibrous, water-repellent protein that gives the epidermis its tough, protective quality Dermis- Second, deeper layer Blood cells, nerve fibers, and lymphatic vesicles Hair follicles, sebaceous glands, and sweat glands


The Skin: The Skin Subcutaneous tissue Below the dermis & not part of the skin Attaches skin to muscle & bone Stores fat Regulates temperature Provides shock absorption


The Skin: The Skin Sebaceous glands Contain sebum to soften and lubricate the skin and hair Secretion stimulated by sex hormones Sweat glands Eccrine glands-forehead, palms, and soles Apocrine sweat glands- axillary, anal, and genital Ceruminous glands-external ear canal for cerumen


The Skin: The Skin Nails- Nail bed Color ranges from pink to yellow or brown depending on skin color Pigmented bands in nail bed normal for dark skinned people Protects ends of fingers and toes


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


Functions of the Skin: Functions of the Skin Protect underlying tissue Barrier against pathogens & excessive water loss Controls heat regulation Provides sensory perception (pain, heat, cold, touch, pressure & vibration Mirrors emotion, e.g. anger or embarrassment


Assessment: Assessment Past medical history involving skin (jaundice, delayed wound healing, pallor, bruising) Skin reactions to foods, insect bites, medications Exposure to ultraviolet light (sun, radiation, tanning beds) Use of sunscreen Changes in skin, hair or nails Family history of skin diseases (alopecia, psoriases, cancer) Tobacco use


The Skin: The Skin Health Assessment Describe itching? When did you see a change in the mole? Any new hair products or skin products? Allergies? Any new medications How do you care for your skin? Intake in the last 24 hours Is your scalp oily or dry? Do you perspire heavily? Describe your activities in the past 24 hours? How much sleep do you get? Any changes in your hair or nails Any recent hair loss? Nails changed shape or color?


The Skin: The Skin Health Assessment Color Lesions Pearly-edged nodules with a central ulcer are seen in basal cell carcinoma Dark, asymmetric, multicolored patches with irregular edges appear in malignant melanoma Circular lesions can be ringworm Urticaria-hives Psoriasis-scaly red patches Temperature


The Skin: The Skin Health Assessment Moisture Tugor tenting Edema Hair Hirsutism – increased hair growth on face or trunk Alopecia – absence of hair Scalp lesions Ring worm – Tinea capitius Furnicles- red swollen hair follicles Lice- Pediculosis


The Skin: The Skin Health Assessment Nails Curvature Color Thickness Pseudomonas and Candida infections can cause the nail to separate and to be darker or red Normal Older Adult Variations of the skin Dry, itchy, decreased melanocytes, liver spots decrease in Subcutaneous fat, increased wrinkling, sagging, bruising, hair loss in outer third of eyebrows, thick, ridged nails


Common Assessment Abnormalities: Common Assessment Abnormalities Alopecia- absence of hair Comedo – blackheads & whiteheads Cyst – fluid filled sac d/t obstructed duct or gland Ecchymosis – bruise Erythema – redness occurring in patches Hematoma – extravasion of blood causing swelling d/t trauma


Common Assessment Abnormalities: Common Assessment Abnormalities Hirsutism – male distribution of hair in women Keloid – hypertrophied scar beyond margin of trauma Mole – benign overgrowth of melanocytes Petechiae – pinpoint deposits of blood under the skin Telangiectasia – dilated, superficial small blood vessels found on face & thighs


Primary Skin Lesions: Primary Skin Lesions Macule – flat, nonpalpable, less than 1 cm Papule – elevated, solid, palapable, less than 0.5 cm Vesicle – circular, superficial collection of serous fluid, less than 1 cm. Plaque – elevated, solid, palpable, more than 0.5 cm. Wheal – firm, edematous Pustule – elevated, superficial, filled with purulent fluid Nodule – elevated , solid, extends into dermis, circumscribed border, 0.5 – 2 cm Tumor – elevated, solid, extends into dermis, irregular border, greater than 2 cm


Secondary Skin Lesions: Secondary Skin Lesions Fissure – linear cracks Scale - excess shedding of dead keratinized tissue Scar – abnormal formation of connective tissue Ulcer – irregular, crater-like loss of epidermis & dermis Atrophy – depression in skin from thinning of the epidermis or dermis Excoriation – area where epidermis is missing, exposing dermis


Nursing Diagnoses: Nursing Diagnoses Impaired skin integrity Situational low self esteem Ineffective health maintenance Altered body image Social interaction, impaired


Common Benign Conditions: Common Benign Conditions Pruritis Psoriasis Acne


Pruritis: Pruritis Itching If a chronic problem… C/S of scrapings Fungal studies Cutaneous patch testing Pharmacology Antihistamines, Tranquilizers, and Antibiotics


Pruritis: Pruritis Nursing Intervention Therapeutic baths Aveno, colloid , alpha-keri Administer creams, pastes, or ointments Comfortable, cool room temperature Monitor skin for infection


Psoriasis: Psoriasis Chronic, noninfectious skin condition characterized by raised, reddened, round circumscribed plaques covered by silvery white scales. Size varies. Cause unknown; some evidence supports autoimmune. Stress, sunlight, hormonal fluctuations, and some medications can induce.


Psoriasis: Psoriasis Pharmacology Corticosteriods Tar preparations-suppress miotic activity Amevive (alefacept) injection- suppress rapid turnover of epidermal cells Antimetabolites (Methotrexate) Treatments Sunlight Ultraviolet Light Therapy-decreases the growth rate of epidermal cells


ACNE: ACNE Acne vulgaris effects 85%^ of the population. The peak incidence is age 17 to 18 years of age. Family history, premenstrual flares, and sometimes stress can cause a flare up. Cosmetics containing lanolin, petrolatum, vegetable oils, lauryl alcohol, butylsterate, and oleic acid can increase comedome production. Exposure to oils in cooking grease can be a precursor in adolescents.    


Acne: Acne Acne is a disease that involves the sebacceous glands & hair follicles of the face, neck, chest, and upper back.. Characterized by comedones & inflammatory lesions   Adequate rest, moderate exercise, a well-balanced diet, reduction of emotional stress, and elimination of any foci of infections are all part of general health promotion.       


Acne: Acne Retin-A is the only drug that disrupts the abnormal follicular keratinization that produces microcomedones. It is available in cream, gel, or liquid. A pea-sized dot of medication is used. It should not be applied until 30 minutes after washing face to prevent burning.    Topical benzyl peroxide is antibacterial and can be used to treat mild cases. The medication can have a bleaching effect on sheets and clothes. Other antibacterials used topically are Clindamycin, Erythromycin and Metronidazole. When combined with benzyl peroxide, glycolic acid or Retin-A penetration improves    


Acne: Acne  Accutane is a potent and effective oral agent. It decreases sebum production. This medication needs to be managed by a dermatologist. Adolescents with multiple, active, deep dermal or subcutaneous cyctic and nodular acne lesions are treated for 20 weeks. Side effects include dry skin, dry mucous membranes, nasal irritation, dry eyes decreased night vision, photosensitivity, arthralgia, headaches, mood changes, depression, and suicidal ideation. The most significant is tetragenic effects. It is contraindicated in pregnancy. If the young women are sexually active, they must be on some kind of contraceptive. Tetracycline longterm


Acne: Acne Gentle cleansing with a mild cleanser once or twice daily is needed. Antibacterial soaps are not effective and may cause drying.     Nursing care is focused on supportive and educating the child and parent. Teenagers need to understand that it takes 4 to 6 weeks to see improvement.  


Infections of the Skin: Infections of the Skin Bacterial, Viral & Fungal


Bacterial Infections: Bacterial Infections Impetigo- Staphylococcus. Reddish macule, vesicle, then erupts. Dries to a honey-colored crusts. Topical, oral, or IV antibiotics.Contagious. Seen in toddler and preschool. Folliculitis- Staph aurous. Pimple- infection of hair follicle. On legs of women or bearded faces of men. Contagious. Never pop or squeeze.


Bacterial Infections: Bacterial Infections Furnucle- Boil. Larger lesion with more redness and edema . Painful. Moist compress Systemic antibiotics. Contagious. Never pop or squeeze Carbuncle- Multiple boils. Wide spread inflammation. Moist compress. Systemic antibiotics. Never pop or squeeze. Treatment: good hand washing, antibiotics, good hygiene, warm compresses


Bacterial Infections: Bacterial Infections Cellulitis – inflammation of subcutaneous tissue following break in skin -Caused by staph of strep. Treat with anitbiotics Erysipelas – involved the dermis – Caused by strep. Treatment is IV antibiotics (PCN usually) to prevent septicemia


Viral Infections: Viral Infections Warts – caused by HPV Common wart – fingers Planter warts – soles of feet Flat wart – forehead Condylomata acuminata – venereal warts Treatment Salicylic acid, Cyrotherapy, Liquid Nitrogen


Viral – Herpes Simplex: Viral – Herpes Simplex Vesicle type lesion Type 1 – above the waist – cold sores Type 11 – below the waist – STD, Genital herpes Signs/Symptoms – burning, tingling Diagnosed with Tzanck smear – identifies herpes but doesn’t differentiate between simplex & zoster Treatment – Zovirax (Acyclovir), moist compresses & white petrolatum


Viral – Herpes Zoster: Viral – Herpes Zoster AKA Shingles Caused by varicella zoster which also causes chickenpox Painful Treatment – Acyclovir & Narcotics Isolate from people who have not had chickenpox


Fungal Infections: Fungal Infections Candidiasis – caused by Candida albicans Occurs with immunosuppression & following antibiotics Found in mouth, vagina & skin (yeast infection) Treatment –Antifungal such as Mycostatin, Diflucan Treat sexual partner


Fungal Infections – the “tineas”: Fungal Infections – the “tineas” Tinea pedis – athlete’s foot Tinea capitis – scalp ringworm Tinea corporis – body ringworm Tinea cruris – groin – jock itch Treatment – antifungal cream or solution, Griseofulvin, Diflucan Contagious


Common Allergic Conditions: Common Allergic Conditions Contact dermatitis - Hypersensitivity response/ chemical irritation, i.e Latex glove allergy Urticaria – allergic phenomena causing hives Treatment – remove the irritant & give antihistamines


Atopic Dermatitis: Atopic Dermatitis Inflammatory skin disorder also called eczema Cause unknown, thought to be related to IgE, T lymphocytes, monocytes, and other inflammatory cells. Adult have lichenification, erythema, scaling, itching, and scratching. Familial history, foods, cold weather, stress can be the cause Treat with antipruritic, oral antihistamines, and oral and or topical corticosteriod.


Skin Cancers: Skin Cancers Non-Melanoma’s Basal cell carcinoma Squamous cell carcinoma Melanoma


Basal Cell Carcinoma: Basal Cell Carcinoma Most common malignant tumor in U.S. Originates from basal layer of epidermis Risk factors: UV exposure & severe sunburn in childhood or adolescence Usually found on head or neck, especially the nose Dome-shaped, flat, slightly red papule or macule, translucent, indistinct border, hard scale


Squamous Cell Carcinoma: Squamous Cell Carcinoma Malignant tumor of keratinocytes of skin & mucosal surfaces Actinic keratosis is precursor Second most common skin cancer in U.S. Can be aggressive & metastasize Found on head & neck (lips & mouth of smokers) Begins as firm, dull red keratosis & progresses to nodule which ulcerates & attaches to underlying tissue


Actinic Keratosis: Actinic Keratosis


Basal & Squamous Cell Carcinomas: Basal & Squamous Cell Carcinomas


Malignant Melanoma: Malignant Melanoma 55,100 new cases of invasive melanoma in U.S. per year (1 or 57 males & 1 of 75 females) Arises from melanocytes. 1/3 occurs in existing moles Most often found on chest & trunk on males & lower legs of females. Can form in eyes, mouth, vagina, & other internal organs.


Signs & Symptoms of Melanoma: Signs & Symptoms of Melanoma Asymmetry of mole- ½ doesn’t match the other Border irregularity - edges are ragged or notched Color – differing shades of tan, brown, black with sometimes patches of red, blue or white. Diameter – mole is wider than 6 mm (1/4 inch) Any change of a spot or bleeding from lesion


Moles: Moles GOOD BAD


Melanoma: Melanoma


Risk factors: Risk factors Congenital moles, large or numerous moles Fair skin that freckles, red or blond hair Family history of melanoma Immune Suppression Excessive exposure to UV radiation & sunburn Age & gender


Treatment of Melanoma: Treatment of Melanoma Biopsy of skin & underlying tissue if necessary Wide, local incision to remove all of lesion Wedge resection of earlobe Amputation of fingers or toes Wide resection of sole of foot Thickness of lesion & ulceration are strongest prognostic features


Prognosis : Prognosis Patients treated early with removal of total lesion have 100% cure rate. Patients who have metastasis to the lymph nodes have 50% survival rate after 5 years following treatment. Patients who have systemic metastasis can live 6-9 months after treatment


Nursing Intervention: Nursing Intervention Teaching prevention Teaching ABCD’s Support patient receiving chemotherapy Routine post-op care Support the patient & family emotionally to decrease fear, and low self-esteem if body image is altered.