Integumentary Exam PDF

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Med Surg Exam 5 – Integumentary Chapter 24 - Assessment of the Skin, Hair, and Nails Anatomy of the Skin: Three skin layers: Epidermis- outermost layer, protects the skin (keratin), maintains homeostasis (water balance), temperature regulation by sweat glands, sensory functions, vitamin D synthesis. -Vit. D is activated in the epidermis by UV light, once activated it is distributed by the blood to the GI tract to promote uptake of dietary calcium. -Melanin also protects the skin from damage by UV light, which stimulates melanin production. Dermis – contains no skin cells, but some protective mast cells and macrophages (fight infection). Interwoven collagen and elastic fibers that give the skin flexibility and strength. Also has capillaries and lymph vessels for exchange of oxygen and heat. Rich in sensory nerves. Subcutaneous (fat) – helps absorb shock, insulate, and pads internal organs. Energy reserve, large pressure receptors. Anatomy of the Nail Figure 24-3 -Fingernail replacement requires 3-4 mo., toenail replacement requires up to 12. -Nail growth and appearance are often altered during systemic disease or serious illness. Age-Related Integumentary Changes: Thinning of skin Uneven pigmentation Wrinkling, skin folds, and decreased elasticity Dry skin Diminished hair Increased fragility and Increased potential for injury Reduced healing ability Chart 24-1 Age-Related Changes Benign integumentary changes in the older adult:

Cherry Angiomas

Seborrheic Keratoses

Diminished Hair (Especially on scalp and pubic area)

Wrinkles

Dyschromia

Neurodermatitis (chronic itching or scaling)

Xerosis (dry skin)

Telangiectasias (aka spider veins, widened venules [tiny blood vessels] cause threadlike red lines or patterns on the skin) Spider Angiomas (a type of telangiectasias (swollen blood vessels) found slightly beneath the skin surface). Xanthelasma (yellowish plaques on eye lid.)

Assessment: Noticing and Interpreting Demographic data Socioeconomic status Information about drug use (can cause rash and skin irritations) Allergies Nutrition status Family and genetic risk (more prone to cancers or skin variations) Current health problems Inspection Color, moisture level, edema, lesions, integrity Breaks in skin integrity (ulcers, wounds) Cleanliness Tattoos, piercings Lesions (primary, secondary) A—asymmetry of shape B—border irregularity C—color variation within one lesion D—diameter >6 mm E—evolving/changing features Palpation Confirms size and consistency of lesions Macular—flat rash Papular—raised rash Moisture level Turgor—amount of skin elasticity Table 24-2

Types of Lesions Primary Lesions: develop as a direct result of a disease process. Macules: freckles, flat moles, flat lesions less than 1 cm. Patches: vitiligo, macules larger than 1 cm. Plaques: psoriasis or seborrheic keratosis; elevated, plateaus-like patches more than 1cm. Papules: warts or moles; small, firm, elevated lesions less than 1 cm. Nodules: lipomas; elevated, marble-like lesions more than 1cm wide and deep. Cysts: nodules filled with either liquid or semisolid material. Vesicles: acute dermatitis; blisters filled with clear fluid, less than 1cm. Bullae: vesicles that are more than 1cm; second-degree burns. Pustules: acne, impetigo; vesicles filled with cloudy or purulent fluid. Erosions: varicella; wider than fissures but involve only the epidermis. Often associated with vesicles, bullae, pustules. Wheals: urtcaria and insect bites; elevated, irregularly shaped, transient areas of dermal edema.

Secondary Lesions: evolve from primary lesions or develop as a consequence of the patient’s activities. Scales: exfoliative dermatitis and psoriasis; visibly thickened stratum corneum, appear dry and whitish. Lichenifications: chronic dermatitis; palpably thickened areas of epidermis with accentuated skin markings. Caused by chronic rubbing and scratching. Ulcers: such as stage 3 pressure wounds; deep erosions that extend beneath the epidermis. Crusts and oozing: eczema, impetigo; dried serum or pus, beneath which liquid debris may accumulate. Frequently result from broken vesicles, bullae, pustules Fissures: athlete’s foot; linear cracks in epidermis that often extend into dermis. Atrophy: striae, thinning of skin surface, results in skin depression.

Hair Assessment Inspect and palpate for cleanliness, distribution, quantity, quality. Dandruf—accumulation of patchy or diffuse white/gray scales on surface of scalp. -if severe dandruff is not handled, alopecia can occur. Hirsutism—excessive growth of body hair due to hormonal imbalance or side effect of drug therapy. Assessing the Hair Color, Texture, distribution, infestation Hirsutism Nail Assessment Dystrophy Color of nail plate Shape changes Thickness, consistency, lesions Paronychia (acute versus chronic) Acute: inflammation of the skin around the nail often occurs with a torn cuticle or an ingrown toenail. Chronic: common and is an inflammation that persists for months. Frequent exposure to water. Table 24-5 Table 24-6 Assessing the Nails Configuration, Color and Consistency Skin Assessment Techniques for Patients with Darker Skin Assess for: Pallor (mucous membranes) Cyanosis (lips, tongue, conjunctivae, palms, soles) Inflammation (excessive warmth, changes in skin consistency or texture) Jaundice (hard palate, conjunctivae, and sclera) Skin bleeding (darker than normal skin) Chart 24-3 Psychosocial Assessment Disturbed: Body image, Body language Social isolation Diagnostic Assessment Laboratory tests: Cultures: -Always wear gloves when examining skin that is not intact. Fungal: tongue blade to scrap scales, collect fingernail clippings and hair, piece of tissue. Bacterial: drainage from intact primary lesions (abscess, bullae, vesicles, pustules), cotton-tipped applicator, may need to unroof the intact lesion using sterile needle. If crust is present, the nurse can remove it with NS and swab the underlying lesion. Viral: cotton tipped applicator to obtain vesicle fluid. Must be placed on ice immediately. Tzanck smear. Skin biopsies: -Obtain informed consent. -instruct patient to keep dressing dry and in place for 8 hrs, clean site daily, use tap water or saline to remove dried blood or crusts, antibiotic ointment if prescribed, report any redness or excessive draining. Punch: cookie cutter, 2-6mm diameter. Cuts a small plug of tissue, may or may not need suturing. Shave: remove only the part of the skin that rises above the surrounding tissue. Indicated for superficial or raised lesions. Excisional: rarely used; for larger or deeper specimens, followed by suturing. Wood’s light examination: UV light used during physical examination. Infections may appear as blue-green or red. Easier to use in light-skinned patients.

Diascopy: painless technique to eliminate erythema caused by increased BF to skin, easing the inspection of skin lesions. Consists of a glass slide or lenses being pressed down over the area to be examined, blanching the skin to reveal lesion shape. Tzanck smear: smear is obtained from a viral lesion and examined for multinucleated giant cells. Patch Testing Question 1 The nurse explains to the patient that the surgeon will inject a local anesthetic and then use a small circular instrument to cut and remove a small plug of tissue. Which procedure has the nurse described? A. Unroofing B. Punch biopsy C. Shave biopsy D. Excisional biopsy Question 2 The nurse is assessing a patient’s skin. Which lesion finding requires further nursing intervention? A. Symmetry B. Consistent color C. Diameter of 8 mm D. Regular border

Chapter 25 - Care of Patients with Skin Problems Tissue Integrity Concept Exemplar: Pressure Injuries: Loss of tissue integrity caused when skin and underlying soft tissue are compressed between a bony prominence and external surface for extended period of time. Mechanical forces create ulcers: Pressure Friction: when surfaces rub the skin and irritate or tear fragile epithelial tissue (pulling pt across sheets) Shear: when skin doesn’t move but underlying tissues do; often seen when a patient slides down while sitting in a wheelchair or in a semi-sitting position in a bed. Health Promotion and Maintenance -Recognize risk, begin interventions early (ROTATE Q2, elevate heels, use cushions) -Identify high-risk patients early (nutritional deficiency, immobile, elderly) -Implement aggressive intervention of prevention with pressure relief or reduction devices -Pressure mapping Identifying High Risk: The Braden Scale (KNOW THIS) Sensation is critical to prevention of Pressure Ulcers Stage 1 Pressure Injury Skin intact Area usually over bony prominence, red and does not blanch with external pressure Observable pressure-related alterations of intact skin Stage 2 Pressure Injury Skin not intact Partial-thickness skin loss of epidermis or dermis Ulcer is superficial, may appear as abrasion, blister, or shallow crater Bruising not present Stage 3 Pressure Injury Full-thickness skin loss. Subcutaneous tissue and underlying fascia may be damaged or necrotic. Damage extends down to but not through the Bone, tendon, and muscle but they are NOT exposed. May have undermining and tunneling Stage 4 Pressure Injury Full-thickness skin loss with exposed or palpable muscle, tendon, or bone. Undermining and tunneling common with sinus tracts possible. Slough and eschar often present Unstageable: Skin loss is full thickness, and the base is completely covered with slough or eschar, obscuring the true depth of wound.

Assessment: Noticing -Identify cause of tissue integrity loss, factors that may impair healing -Inspect entire body Assess wounds for: Location Size Color Extent of tissue involvement & surrounding tissue Cell types in wound base and margins Exudate

Foreign bodies Documentation -Location and size of wound— deepest length, width, depth -If present, location and length of each tunnel -Serial photographs (if permitted by facility policy, and informed consent) Laboratory and Diagnostic Assessment -Exposed chronic wounds are always colonized with microorganisms, but not always infected. -Swab cultures are helping in identifying bacteria on surface -Infection is diagnosed based on clinical indicators, systemic signs. -presence of purulent exudate alone does not indicate an infection because pus forms whenever necrotic tissue liquefies and separates. -Arterial blood flow studies -Prealbumin, albumin, total protein Analysis: Interpreting -Compromised tissue integrity due to vascular insufficiency and trauma -Potential for wound deterioration due to insufficient wound management

Nonsurgical management Dressings- Table 25-2, Chart 25-3 Mechanical, topical, or natural chemical debridement: Mechanical: mechanical entrapment and detachment of dead tissue Topical: topical enzyme preparations to loosen necrotic tissue Natural: promoting self-digestion of dead tissues by naturally occurring bacterial enzymes (autolysis). Physical therapy Drug therapy Nutrition therapy Technology-based therapies: Electrical stimulation: increase blood vessel growth and promote granulation with low-voltage current. Negative Pressure Wound Therapy: removes infection materials or fluids and enhances granulation. CONTRAINDICATED in patients on anticoagulants or reduced tissue health (chemo, radiation pt’s), or any exposed vessels, organs, or nerves in wound area. Hyperbaric Oxygen Therapy Surgical management – more extensive, try to save for last Preventing Infection and Wound Deterioration Monitor ulcer’s appearance (progress) Maintain safe environment to prevent wound infection Chart 25-4 Care Coordination and Transition Management Home care management Self-management education Health care resources Minor Skin Irritations Pruritis- itching **nursing priority is to focus on increasing pt comfort and preventing skin injury from scratching. Xerosis- dry skin -worsens pruritis. Chart 25-6 Urticaria- hives of white or red edematous papules or plaques usually caused by exposure to allergens and release of histamines.

Common Inflammations: Contact Dermatitis Chart 25-7 Atopic Dermatitis More extensive Psoriasis Psoriasis vulgaris: most common type, thick, reddened papules or plaques covered by a silvery white scales. Exfoliative psoriasis: explosively eruptive and inflammatory form with generalized erythema and scaling byt no obvious lesions. Palmoplantar pustulosis: forms pustules on the palms of hands and soles of feet with reddened hyperkeratotic plaques. Skin Infections Chart 25-9*** Bacterial Folliculitis: superficial infection involving only the upper part of the hair follicle and is often caused by staphylococcus. The rash is raised an red and usually shoes small pustules. Furuncles (boils): infection is much eeper in the follicle, the raised bump is inflamed and may have a pustular “head”. Cellulitis: often occurs as a general infection with either staph or strept and involves deeper connective tissues. Methicillin-resistant Staphylococcus aureus (MRSA) Chart 25-10 Contact precautions Cutaneous anthrax: raised vesicle, the center becomes hemorrhagic and sinks inward, starting an area of necrosis and ulceration. The surrounding tissue swells and can become very edematous. Two distinct features: painless and eschar. Viral Herpes simplex virus (HSV) Herpes Simplex 1: mouth sores Herpes Simplex II (Chronic herpes simplex): genitalia Herpes Zoster (Shingles) • Take antiviral therapy at onset • Keep lesions covered with wet dressing; or isolate until the fluid-filled blisters have crusted over and are dry. • HAND HYGIENE • Educate on pain as long-term complication (postherpetic neuralgia) • Caused by Varicella Zoster Virus • Precursor is Chickenpox virus as child • Painful vesicular lesions • CONTAGIOUS to people who haven’t had chickenpox or are not vaccinated. Fungal Fungal Dermatoses (Dermatophyte): looks different depending on location and species of organism. Tinea Corporis (ringworm, whole body) Tinea Pedis (foot) Tinea Cruris (jock itch, groin) Tinea Capitis (head) Tinea ungums

Candida Albicans (yeast infection) -moist, red, irritated appearance with burning and itching. Keep skinfolds clean and dry. Interventions for Skin Infections -Avoidance of offending organism -Practice of good hygiene Handwashing Do not share personal items -Vaccination (e.g., Zostavax) especially shingles.

Parasitic Disorders Pediculosis: lice infestation. Accompanied by itching, excoriation from scratching. Scabies: contagious skin infection caused by mite infestation. Transmitted by close contact or contaminated bedding. Accompanied by curved or linear ridges in the skin (burrowing mites), with intense itching. Can cause a hypersensitivity reaction with excoriated erythematous papules, pustules, and crusted lesions. Bedbugs: does not live on humans but survives on human blood. Itchy, the bite resembles a mosquito bite but is surrounded by a wheal.

TRAUMA: Phases of Wound Healing: First intention—edges brought together with skin lined up in correct anatomical position Second intention—requires gradual filling in of dead space with connective tissue Third intention—delayed closure; high risk for infection with resulting scar

Mechanisms of Wound Healing: Partial-thickness wounds Damage to epidermis, upper layers of dermis Heal by re-epithelialization within 5 to 7 days Full-thickness wounds Damage extends into lower layers of dermis and subcutaneous tissue Must be filled with granulation tissue to heal (scar tissue) Contraction develops in healing process Pg. 472 Wound Healing

Describing and measuring acute open wounds or Lesions -Describe the wound bed, edges and margins -Open area only -Length x Width x Depth -Point of the greatest length by the point of greatest width by the point of greatest depth (in centimeters). -Surrounding skin Assess for color, suppleness and moisture, irritation and scaling. Re-epithelialization

Skin Cancer Etiology and Genetic Risk Chronic wounds that remain open for long periods of time Genetic predisposition Excessive exposure to UV light Presence of one or more precursor lesions that resemble unusual moles Assessment Family history of skin cancer Past surgery for removal of skin growths Recent changes in moles, birthmark, wart, scar Demographic information Occupational and recreational activities (sun exposure) Table 25-5 Management of Skin Cancer Surgical Cryosurgery- cell destruction by the local application of liquid nitrogen (isolated lesions) Curettage and electrodesiccation- Removal of cancerous cells with the use of curette or scrape away, followed by electric probe to destroy remaining tumor tissue Excision- Total surgical removal of small lesions Mohs’ surgery- Specialized form of excision for basal and squamous cell carcinomas- sectioned horizontally in layers Wide excision-Deep skin resection often unvolving removal of full-thickness skin in the area of the lesions Nonsurgical Drug therapy Biotherapy- targeted therapy Radiation therapy Prevention: Chart 25-11

Toxic Epidermal Necrolysis (TEN) Stevens–Johnson Syndrome (SJS) 

Life threatening cutaneous reactions to medications. Characterized by diffuse erythema and blister formation, often involving the mucous membranes. SJS can turn into TEN....