Professional Documents
Culture Documents
INTEGUMENTARY DISORDERS
Structures & Functions of Skin & Appendages
Epi de rmi s
Stratum Corneu m (outer layer of dead keratinized cells) flat scale like
cells called squamous cells
Stratum Germinativum (basal cell layer)– cells migrate from basal layer
upward to corneum and sheds
Dermi s
Sub cut an eou s Tis su e (f at) - below the dermis an is not part of the
skin.
Sebaceous glands – secret sebum which is emptied into the hair follicles
- prevents skin from drying
Eccrine Gland s- widely distributed over the body, except in a few areas,
such as the lips.
- These glands function to cool the body by evaporation, to
excrete waste products, and moisturize surface cells
A. Protection
B. Homeo stasis
C. Thermoregulation
Adult – male baldness, facial hair on women, sebaceous cysts, skin tags
A. H istory
B. Ph ysical Exam
Good lighting (natural lighting), privacy, moderate room temp, expose section
at a time, pt comfortable
Syst ematic – proceed head-to-toe; compare symmetrical parts; perform
general inspection then lesion specific exam
Inspect general color & pigmentation, vascularity or bruising, presence of
lesions or discoloration
Vascularity ( angioma, petechiae, purpura)
Lesion – color, size, distribution, location, shape recorded; also configuration
(pattern) and distribution (arrangement); note odor
Refer to Table 22-7 & 22-8, pg. 483
Tattoos, needle-track marks
Annular - ring-shaped
Gy rate - Ring-Spiral-shaped
Iris lesion s - Concentric rings or “bull’s eyes”
Linear - In a line
Num mular, discoid - Coinlike
Pol ymorphous - Occurring in several forms
Punctuate - Marked by points or dots
Serpig inou s - Snakelike
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Sk in As se ssm ent
1. Pallor
2. Jaundice
3. Temperature
4. Texture
5. Turgor
6. Edema
7. Tenderness
Ab no rmaliti es
Alopecia - loss of hair
Come do - black heads and white heads
Cyanosis - bluish-grey or dark or dark purple discoloration of the skin
Ecch ymo sis - bruise like lesions caused by collection of blood in dermis
Keloid - hypertrophied scar beyond margin of incision or trauma
Mole (nevus) - Benign overgrowth of melanocytes
Petechiae - pinpoint, discrete deposits of blood
Varicosit y - Increased prominence of superficial veins
Vitil igo - cyst depigmentation- congenital or acquired loss of melanin resulting
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As se ss me nt of D ark Ski n C ol or
Refer to table 22-6, pg. 483
Cyano sis – Shen or gray color most easily seen in the conjunctiva of the eye,
mucous membranes and nail beds
Jaundice - Yellowish-green color most obviously seen in sclera of eye (do not
confuse w/ yellow pigmentation, which may be evident in dark-
skinned patients) Palms of hands, and soles of feet
Pallor – Underlying red tone in brown or black skin is absent. Lighted skinned
AA may have yellowish brown skin dark skinned AA may appear
ashen or gray
Typ es of Le sio ns
Primary – lesions that develop on previously unaltered skin
Nodule – raised, firm, palpable, solid lesion extending deeper into dermis
and larger and deeper than papule – greater than .5 cm in diameter;
Ex: lipomas, erythema nodosum
Plaque – raised but flat topped, firm, rough, superficial papule greater
than 1 cm in diameter; formed from merging papules or nodules; larger
than papule but not deeper;
Ex: psoriasis, seborrheic and active keratoses
Tumor – larger than nodule, elevated firm lesion that may or may not be
easily demarcated; greater than 2 cm in diameter; may or may not vary
from skin color; can be benign or malignant;
Ex: neoplasm
Typ es of Le sio ns
Sec on dar y – lesions that change with time or because of a factor such as
scratching or infection
Diagnostic Tests
Refer to Table 22-10, pg. 485
Mineral Oil Slides – To check for infestations, scrapings are placed on slide
with mineral oil
Punch Biopsy – circular instrument cuts down into epidermis, dermis, and
Su n Ex po sur e
Wear broad spectrum sunscreen with a sun protection factor (SPF) of 15 or
higher
Protection – wear large-brimmed hat, UV-blocking sunglasses, long sleeved
Tr eatme nt
Cryosurger y – Liquid nitrogen applied to growth with spray device or
cotton-tipped applicator to freeze them; crusted & fall off; minimal side
effect – redness, swelling, dark skinned individual may be loss of pigment
Curettage & Desicccation – lesions suspected to be early cancer –
biopsy specimen taken by shaving of top of lesion with a scalpel or
scraping of with curette, then curette used to remove base of lesion;
bleeding stopped with electrocautery needle; wound care afterward
Topical
5- fluo rouracil (5- FU) - creates a therapeutic inflammatory
response that causes erythema, vesicles, erosion, ulcerations,
necrosis and finally epithelialization; Pin meds and topical
corticosteroids may be used to enable to withstand process.
* Teach client it w ill get wo rse before it gets
bett er & avoid sun du ring t x
Imiquimod cream
Gel with hyaluronic acid & anti-inflammatory drug diclofenac
Chemical Peeling
Laser Surgery
Photodynamic Therapy (PDT)
Slow growing
Rarely metastasizes, but can invade and destroy local tissue; invade
bone and brain
Treatm ent
- Multiple treatment modalities are used depending on the tumor location and
histologic type, history of recurrence, and partient characteristics
- Electrodessication, curettage, excision, cryosurgery, radiation therapy, Mohs’
micrographic surgery, topical chemo, and intralesional alph-interferon.
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Squam ou s C el l Ca rc in oma
- Second most common skin cancer among fair-skinned persons (rarely found in
dark-skinned persons)
- Malignant tumor of epidermal keratinocytes found in areas of sun exposure –
long term exposure; outer layer of skin (the epithelium)
SSX
- Early- firm nodules with indistinct border w/ scaling and ulceration;
opaque
- Late- Covering of lesion with scale or horn form keratinization; most
common on sun exposed areas such as face and hands
Treatm ent
- Surgical removal, cryosurgery, radiation, chemo, Mohs’ procedure or
microscopically controlled excision, electrodessication, and curettage; untreated
lesion possible metastasizes to regional lymph nodes; high cure rate with early
detection and Tx
Mali gn ant Me la no ma
A symmetry – one side does not look like the other side
C olor – more than one color present- streaks of tan, brown, black, red, blue,
white
D iameter – larger than size of a pencil eraser (6 mm) or has changed shape
Treatmen t
Intial treatment is surgery.
Pru ritus
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Itching
Caused by any physical or chemical stimulus to the skin – drugs, insects, dry
skin
Itch-scratch cycle must be broken (protective barrier) to prevent excoriation
Keep fingernails short
Mitten or gloves especially at bedtime
Heat or rubbing (causes vasodilation) avoided
Dryness of skin lowers the itch threshold & increases itch sensation
Emollients – moisten and lubricate skin – apply to moist skin
Pat dry & not totally dry
Medication Vehicles
Powders
Lotions
Creams
Ointments
Emollients
Paste s – mixtures of powders & ointments used to protect the skin; applied
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skin and spread evenly in a downward motion small amount on affected area;
ensure even distribution
Contac t Dermatitis
Treatment
1.
2.
3.
4. Unna’ s Boot – a fixed protective dressing; stimulates granulation tissue and
epithelial growth. Protects and enhances venous circulation like TED hose.
Dressing soaked with zinc oxide, glycerin and gelatin – after application it
hardens into a cast-like substance. Start at top of foot and work up to just
below knee. Remove weekly to assess and reapply. Must teach pt and family to
watch for pain, drainage, fever, warmth, swelling (all could mean infection); they
should return ASAP with these findings and not wait until next appointment
5. Skin g rafts may be nece ssary
In te rt ri go
Patho – surfaces rubbing against each other - skin breakdown, large areas,
under breast, pendulous abdomen, rolls of skin tissue; moisture, obesity, Monilia
infection (yeast)
SSx – Dermatitis of overlying surfaces of skin
Treatment –
Psoriasis
Patho – Inflammatory disorder- certain immune cells become overactive and
release proteins called cytokines which cause proliferation of keratinocytes
(skin cells) and the growth of small blood vessels that supply blood and nutrients
to the affected area; skin cells grow much faster than they should
SSx –
Treatment
Ce llu litis
Patho – infection in skin; inflammation of subcutaneous tissue; not clearly
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Er ysip el as
Patho – Superficial cellulitis involving the dermis; group A β-hemolytic strip
SSx – Red, hot sharply demarcated plaque, indurated & painful, fever,
Leukoctyosis WBC
Treatm ent – Same as cellulites – PCN
Vir al I nf ec tio ns of Sk in
along nerve root in body from chicken pox years ago. Occurs in
immunocompromised pt – chronically ill, transplant, older adults
SS x –
Rx TCAs and opioids – stay well hydrated, select high-fiber foods; use fiber
laxative or stool softener to avoid constipation; carefully assess for suicidal
ideation & promptly refer for tx if needed
Sh ingle s itself no t contagious – close exposure can pass varicella virus to
others, causing initial episode of chickenpox; pts with open lesions educate to
reduce exposing others (unvaccinated, immunocompromised or pregnant
individuals who never had chickenpox
Profound itching – discouraged scratching; measures to protect skin and
reduce risk from bacterial infection important
Soothing oatmeal baths, painted-on topical lotions (calamine or Benadryl;
application of washcloths with cool water; Domeboro astringent and gel from
aloe vera plant relieve itching & pain
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Fun ga l Sk in In fe cti on s
Tinea C ruris – jock itch, well defined border in groin area; itchy, painful,
red, raw
Tinea P edis – athlete's foot; interdigital scaling, and maceration, erythema
Sc abie s
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Patho – infestation of skin with itch mite Sarcoptes scabie, penetrates stratum
corneum; deposits eggs, allergic reaction resulting from presence of eggs, feces,
mite parts; transmission by direct physical contact
SS x
Treatmen t
Nu rs in g Ma na gem en t
Baths (ba ln eoth er apy) – used when large body area need to be Tx;
sedative antipruritic effects; tub full enough to cover effected area; soak
15-20 mins 4 x’s/day; stress importance that skin should not be rubbed
dry with a towel but gently patted to prevent irritation and inflammation; oils
make tub slippery, safety
Nu rs in g Ca re Pl an ( Ch ro ni c S ki n l esio ns )