Presentation on theme: "Selected Integumentary System Diseases & Conditions"— Presentation transcript:
1Selected Integumentary System Diseases & Conditions The SKIN…Selected Integumentary System Diseases & ConditionsWound InfectionsWound Dehiscence & EviscerationPressure UlcersArterial and Venous UlcersSkin CancerSkin DiseasesLesions/WoundsRashesHerpes Zoster/ ShinglesPart I
2Trivia QuestionHow many square feet of skin does the average adult have?
3Trivia QuestionHow many square feet of skin does the average adult have?Answer: ~ square feet……5’x4’
4Integumentary Diseases Learning Outcomes:1. Use proper terminology to describe different skin lesions and problems2. Identify signs of wound infections3. Describe the ABCD(E) method of assessing skin cancer4. Identify clients at risk for pressure ulcer development5. Differentiate between the clinical manifestations for Stage I through Stage IV pressure ulcers, and their treatments.6. Identify appropriate treatment for prevention of pressure ulcers.7. Compare the clinical manifestations and modes of transmission for bacterial, viral, and fungal skin infections.8. Identify the difference between arterial ulcers and insufficiency versus venous stasis ulcers.
7“Beauty is Only Skin Deep…” RaisedpapuleplaquenodulecystcomedokeloidhornwhealDepressedatrophyerosionulcersinusstriaeburrowpoikoldermaFlat /MacularmaculepatcherythemaerythrodermaSurface ChangescalecrustexcoriationescharlichenificationexfoliationichthyosiformFluid FilledvesiclebullapustuleabscessfurunclePurpura / VascularpetechiaepurpuraecchymosistelangiectasiaConfigurationslineargroupedscatteredpolycyclicreticularserpinginoustargetoidwhorledarcuateannular“Beauty is Only Skin Deep…”
8“Beauty is Only Skin Deep…” “But UGLY goes down to the bone!” RaisedpapuleplaquenodulecystcomedokeloidhornwhealDepressedatrophyerosionulcersinusstriaeburrowpoikoldermaFlat /MacularmaculepatcherythemaerythrodermaSurface ChangescalecrustexcoriationescharlichenificationexfoliationichthyosiformFluid FilledvesiclebullapustuleabscessfurunclePurpura / VascularpetechiaepurpuraecchymosistelangiectasiaConfigurationslineargroupedscatteredpolycyclicreticularserpinginoustargetoidwhorledarcuateannular“Beauty is Only Skin Deep…”“But UGLY goes down to the bone!”
10Integumentary Diseases Review of anatomy & physiology
11Integumentary diseases Skin Function:Skin, hair, and nails are external structuresServe a variety of specialized functionsSebaceous and sweat glands cool and lubricate the body and get rid of wastesThe skin, hair, and nails have many vital functions, but the most important is protection.Once the skin has been pierced or damaged the body is much more susceptible to infection, even from organisms which would not normally be pathogenic, e.g., staphylococci.
13Integumentary diseases Wound Infections & RisksRisks for infection include any pathophysiological states which cause diminished circulation, poor immune response, or delayed repair of tissues These include:Radiation or traumaPoor circulationImmunosuppression, drug induced or disease inducedImpaired oxygenationNutritional deficienciesCoagulation disordersImmobilityDiabetes, lupus, and other immunodeficiencies
14Integumentary diseases Etiology: THINK – WHAT IS CAUSING THIS? And you might learn how to prevent itFor example – If the patient is immobile and starting to break down because they cannot move, how do we prevent the skin from breaking down?If the patient has an immunodeficiency, how do we prevent skin breakdown?If the patient has a nutritional deficiency, how do we promote wound healing?
15Diagnostic Procedures and Nursing Interventions Wound Culture and Sensitivity (swab cultures and/or wound biopsies):Definitively identify and quantify wound bacteria.Complete Blood Count (CBC) with Differential: Assess immune response.Blood Cultures: Rule out sepsis.Serum Albumin (normal > 3.5 g/dL) and Prealbumin (normal 17 to 40 mg/dL):Assess nutritional status (low levels indicate malnutrition).
16Therapeutic Procedures and Nursing Interventions Vacuum-assisted Wound Closure (Wound-Vac) – continuous low-level negative pressure is applied to a sponge-covered suction tube for several hours.Hyperbaric Oxygen Therapy (HBO / HBOT)– administration of high-pressurized 100% oxygen directly over the wound for 60 to 90 min.Surgical Debridement and / or Wound Grafting – surgical excision of nonviable tissue to promote wound healing and/or grafting of skin from donor sites to clean granulating or freshly excised wound bed.
17Integumentary diseases Lesions & InfectionsSigns and symptoms of infection include:DrainageOdorAbscessFeverDiscolorationHeat / warmth at siteEdemaErythemaPoor healing
22Integumentary diseases Rashes – is it macular or papular?
23Integumentary diseases Rashes – is it macular or papular?This rash is actually vesicular, and is herpes zoster, or viral in origin
24Integumentary diseases Rashes – is it macular or papular?This rash is actually vesicular, and is herpes zoster, or viral in origin“chicken pox”
25Integumentary diseases Infected hair &/or nails also countThese are Beau’s lines
26Figure 25-3 Longitudinal ridging Figure 25-3 Longitudinal ridging. Parallel elevated nail ridges are a common aging change. This change does not indicate any deficiency.
27Figure 25-5 Pigmented bands occur as a normal finding in more than 90% of blacks.
28Figure 25-8 Psoriasis of the entire nail matrix causes grossly deformed nails.
29Figure 25-8 Psoriasis of the entire nail matrix causes grossly deformed nails.
30Figure 25-8 Psoriasis of the entire nail matrix causes grossly deformed nails.
31Figure 25-12 Acute paronychia Figure Acute paronychia. Erythema and purulent material occur at the proximal nailfold.
32Figure 25-12 Acute paronychia Figure Acute paronychia. Erythema and purulent material occur at the proximal nailfold.
33Figure 25-12 Acute paronychia Figure Acute paronychia. Erythema and purulent material occur at the proximal nailfold.
34Figure 25-14 Acute paronychia Figure Acute paronychia. Elevation of the lateral nailfold releases a large amount of purulent material. Pain is relieved immediately. Flush the cavity with normal saline.
35Figure Pseudomonas colonized the space between the nail and the nail plate after onycholysis occurred, imparting a green color to the nail plate.
36Figure 25-18 Herpes simplex of the finger (herpetic whitlow) Figure Herpes simplex of the finger (herpetic whitlow). Innoculation followed examination of a patient’s mouth.
37Figure 25-18 Herpes simplex of the finger (herpetic whitlow) Figure Herpes simplex of the finger (herpetic whitlow). Innoculation followed examination of a patient’s mouth.
38Figure 25-18 Herpes simplex of the finger (herpetic whitlow) Figure Herpes simplex of the finger (herpetic whitlow). Innoculation followed examination of a patient’s mouth.
39Figure 25-18 Herpes simplex of the finger (herpetic whitlow) Figure Herpes simplex of the finger (herpetic whitlow). Innoculation followed examination of a patient’s mouth.
40Figure 25-24 Distal subungual onychomycosis Figure Distal subungual onychomycosis. The infection has progressed proximally to form a linear channel. Channeling is a highly characteristic feature of a fungal infection.
41Figure 25-24 Distal subungual onychomycosis Figure Distal subungual onychomycosis. The infection has progressed proximally to form a linear channel. Channeling is a highly characteristic feature of a fungal infection.
42Figure 25-24 Distal subungual onychomycosis Figure Distal subungual onychomycosis. The infection has progressed proximally to form a linear channel. Channeling is a highly characteristic feature of a fungal infection.
43Figure 25-24 Distal subungual onychomycosis Figure Distal subungual onychomycosis. The infection has progressed proximally to form a linear channel. Channeling is a highly characteristic feature of a fungal infection.
44Figure 25-25 White superficial onychomycosis Figure White superficial onychomycosis. The surface is soft, dry, and powdery and can easily be scraped away. The nail plate is not thickened and does not separate from the nailbed.
45Figure 25-25 White superficial onychomycosis Figure White superficial onychomycosis. The surface is soft, dry, and powdery and can easily be scraped away. The nail plate is not thickened and does not separate from the nailbed.
46Figure Beau’s lines. A transverse depression of the nail plate that occurs several weeks after certain illnesses.
47Figure Beau’s lines. A transverse depression of the nail plate that occurs several weeks after certain illnesses.
48Figure Beau’s lines. A transverse depression of the nail plate that occurs several weeks after certain illnesses.
49Figure Beau’s lines. A transverse depression of the nail plate that occurs several weeks after certain illnesses.
50Figure 25-46 Spoon nails (koilonychia) Figure Spoon nails (koilonychia). Most cases are a variant of normal.
51Figure 25-48 Terry’s nails. The nail bed is white with only a narrow zone of pink at the distal end.
52Figure 25-53 Hutchinson’s sign Figure Hutchinson’s sign. Extension of pigmentation onto the nail folds is a classic sign of subungual melanoma.
61Integumentary diseases Stage I ulcerDefined as non-blanching erythema of intact skin, discoloration of skins with warmth or hardness
62Integumentary diseases Stage II UlcerDefined – partial thickness skin loss involving epidermis and/or dermis layer; the ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.Coccyx
63Integumentary diseases Stage IIIDefined as a full thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to , but not through underlying fascia; the ulcer presents clinically as a deep crater with or without undermining or adjacent tissue.
64Integumentary diseases Stage IVDefined as full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle,bone, or supporting structuresBone visible under damage
65Integumentary diseases Venous Stasis Ulcers – no stagesCaused by poor circulation and poor venous return (PVD) Peripheral vascular disease
66Integumentary diseases Venous Stasis Ulcers – no stagesCaused by poor circulation and poor venous return (PVD) Peripheral vascular diseaseHarder to heal,May need a bypassto restore circulation,in addition todressings.etc.Edema and discolorationare primary symptoms priorto skin breakdown.
67Integumentary diseases Treatments of ulcers#1 = prevention and turning, ROMDressings and packings, from simple to complex colloids
68Integumentary diseases Drug therapyDebridementDiet therapy with vitamins and supplementswound – vacuum (Wound Vac)Hyperbaric oxygenation (HBO)Surgical repair
69Integumentary diseases Documentation of ulcersIt is necessary to identify any skin damage or breakdown on admission, as if these are missed, the hospital or facility can be liableIf it was not documented, it was not done
70Integumentary diseases Documentation of ulcersDocumentation should include a photograph, measuring the ulcer or wound with a sterile paper tape or circle; the depth, the width, the breadth and the total area involved, and any breaking of the skin, any color and any drainage (including color and odor). Then “stage” it.
71Integumentary diseases The ABCDE’s of Skin Cancer:AsymmetryBorder IrregularityColor - changesDiameter – increasing(Elevation--variable)
80Integumentary diseases Psoriasis – can erode and disfigure fingers and toes that are affected
81Integumentary diseases Psoriasis TreatmentsSteroidsTopical zinc ointmentsTopical steroidsTar and oil preparationsUltraviolet light therapy – sunlight often helps
82Integumentary diseases Psoriasis Treatments‘Older’ drugs include methotrexate & cyclosporine to suppress the immune system, but this requires monitoring of liver enzymes.New treatments include monoclonal antibodies (A form of chemotherapy—the ‘-mabs’ i.e. efalizumab (Raptiva) for severe forms
83Integumentary diseases Lesions – see handouts of definitions and terms, be able to use these.A rash is a rash is a rash….or is it?Common causes of rashes includeAllergic dermatitis, usually localized to the areas of contact, hivesDrug reactions, usually all over the bodyBacterial infectionsViral infections
84Integumentary diseases What kind of rash is this? If you can’t tell, describe it. Describe the area as well.
85Integumentary diseases ‘Ringworm’ – tinea capitus – a fungal infection
86Integumentary diseases Etiology: Systemic or local?
91the Integumentary System Terminology AppendixTerminologyAssociated Withthe Integumentary System
92The “ABCDE’s of Skin Cancer” AsymmetryBorderIrregularityColorDiameter:¼ inch<or> 6 mmElevation
93angiomaAngiomas : benign tumors that are made up of small blood vessels or lymph vessels.Cherry angiomasSpider angiomas
94asymmetric asymmetric 1. Pertaining to an individual lesion: Unequal shape from side to side.2. Pertaining to a body distribution: Unequal distribution of lesions on both sides of body.
95Beau’s linesBeau's lines Transverse depressions or grooves in the nail plate typically occurring at corresponding positions within each nail plate.Often a sign of a prior severe illness such as malnutrition, a systemic disease, or trauma.
96carcinomaCarcinoma refers to an invasive malignant tumor consisting of transformed epithelial cells.Alternatively, it refers to a malignant tumor composed of transformed cells of unknown histogenesis, but which possess specific molecular or histological characteristics that are associated with epithelial cells, such as the production of cytokeratins or intercellular bridges.Carcinoma in situ (CIS) refers to a small, localized focus of carcinoma that has not yet invadedBasal Cell Carcinoma
97dermatitis Contact dermatitis~ Atopic dermatitis~ Contact dermatitis is an inflammation of the skin caused by direct contact with an irritating substance. Symptoms: Itching (pruritus) of the skin in exposed areas ; Skin redness or inflammation in the exposed area.Treatment: remove irritating exposure; topical corticosteroids.Atopic dermatitis~atopic dermatitis is a very common, often chronic (long-lasting) skin disease that affects a large percentage of the world's population.It is also called eczema, dermatitis, or atopy. Most commonly, it may be thought of as a type of skin allergy or sensitivity.The atopic dermatitis triad includes asthma, allergies (hay fever), and eczema. There is a known hereditary component of the disease, and it is seen more in some families. The hallmarks of the disease include skin rashes and itching.
98café’ au lait patch café au lait patch A well circumscribed macule or patch varying from pale brown in lighter skin to dark brown in darker skin patients.The macule or patch may have a serrated or irregular margin.
99Clubbingclubbing(Hippocratic fingers, watch-glass nails, drumstick fingers) Transverse and longitudinal over-curvature of the nail plate. The distal digit may have associated enlargement. Lovibond's angle is greater than 180 degrees.Typically associated with chronic hypoxia, e.g in those with congenital heart disease, or COPD..
100DermaldermalRelating to the layer of skin below the epidermis, but above the panniculus, consisting of papillary and reticular layers and containing blood and lymphatic vessels.
101eczemaeczema :a general term for many types of skin inflammation, also known as dermatitis.The most common form of eczema is atopic dermatitis (some people use these two terms interchangeably).
102edemaEdema is swelling that is caused by fluid trapped in your body’s tissues.Edema happens most often in the feet, ankles, and legs.Other parts of the body, such as the face and hands, can also be affected
103ecchymosisecchymosis Extravasation of blood into the skin or mucous membranes forming large macules or patches; flat color changes over time may go from blue-black, to brown-yellow, or green.
104excoriationexcoriation A focal erosion usually due to scratching.
105erythemaerythemaLocalized, blanchable redness of the skin or mucous membranes.
106escharescharAn adherent, thick, dry black crust.
107folliculitisFolliculitis is inflammation of one or more hair follicles.It can occur anywhere on the skin.Common symptoms include a rash, itching, and pimples or pustules near a hair follicle in the neck, groin , or other areas...“Hot Tub Folliculitis”:
108furunclefuruncle A follicle-centered nodule caused by a suppurative infection characterized by pain, redness,and potentially visible pus. Usually greater than 1 cm in diameter.
109hematomahematoma A collection of extravasated blood that is relatively or completely confined within a space. The blood is usually clotted (or partly clotted), and depending on time may manifest various degrees of organization and color.
110hirsutismhirsutismUnwanted, excess hair growth; generally in women.
111Hyperbaric oxygen (HBO) Hyperbaric oxygen therapy (HBO) involves the breathing of pure oxygen while in a sealed chamber that has been pressurized at 1 1/2 to 3 times normal atmospheric pressure.used in conventional treatment for decompression sickness (the bends); severe carbon monoxide poisoning; certain kinds of wounds, injuries, and skin infections; delayed radiation injury; and certain bone or brain infections.
112keloidkeloid A firm, usually elevated, proliferation of scar tissue exceeding the area of the preceding skin injury or wound.
113lichenificationlichenification Thickened skin with accentuated markings usually due to repeated rubbing and scratching of skin.
114maceration maceration Softened or broken down skin resulting from prolonged exposure to wetness causing whitening and thickening of the keratin sometimes with redness, oozing, and/or scaling.
115maculeA flat, generally less than .5 cm area of skin or mucous membrane with different color from surrounding tissue. Macules may have non-palpable, fine scale.
116melanomaMelanoma is a malignant tumor that originates in melanocytes, the cells which produce the pigment melanin that colors our skin, hair, and eyes.The majority of melanomas are black or brown. However, some melanomas are skin-colored, pink, red, purple, blue or white.Melanoma is the most serious form of skin cancer.
117nevus Nevus (singular); nevi (plural) 1. Any birthmark. 2. A benign pigmented spot on the skin such as a mole (a cluster of melanocytes and supportive tissue that appears as a tan, brown, or flesh-colored spot on the skin).3. A benign blood vessel tumor on the skin such as a vascular nevus, a local collection of capillaries of the skin (a strawberry birthmark, stork mark, or port wine stain).From the Latin naevus meaning a body mole, especially a birthmark. The plural of nevus is nevi.
118nodulenodule A dermal or subcutaneous firm, well-defined lesion usually greater than .5 cm in diameter.
119papulepapule A discrete, solid, elevated body usually less than .5 cm in diameter. Papules are further classified by shape, size, color, and surface change.
120paronychiaParonychia: Inflammation of the folds of tissue surrounding the nail due to infection.The infection may be bacterial (most commonly, staph or strep species) or fungal.The term "paronychia" is compounded from "para-", next to + the Greek "onyx", nail = next to the nail. Paronychia is synonymous with perionychia.
121petechiaepetechiaeTiny, 1-2 mm non- blanchable purpuric macules resulting from tiny hemorrhages.
122plaqueplaque A discrete, solid, elevated body usually broader than it is thick measuring more than .5 cm in diameter. Plaques may be further classified by shape, size, color, and surface change.
123Pressure ulcer…an area of skin that breaks down when you stay in one position for too long without shifting your weight.Pressure ulcers are categorized by severity, from Stage I (earliest signs) to Stage IV (worst):Stage I: A reddened area on the skin that, when pressed, is "nonblanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop.Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.Stage III: The skin breakdown now looks like a crater where there is damage to the tissue below the skin.Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.
124pruritisPruritus is an itch or a sensation that makes a person want to scratch. Pruritus can cause discomfort and be frustrating. If it is severe, it can lead to sleeplessness, anxiety, and depression.The exact cause of an itch is unknown.It is a complex process involving nerves that respond to certain chemicals like histamine that are released in the skin, and the processing of nerve signals in the brain.Pruritus can be a part of skin diseases, internal disorders, or due to faulty processing of the itch sensation within the nervous system.
125psoriasisA common skin condition that causes skin redness & irritation. Most persons with psoriasis have thick, red skin with flaky, silver-whit patches called scales.There are five main types of psoriasis.Erythrodermic -- The skin redness is very intense and covers a large area.Guttate -- Small, pink-red spots appear on the skin.Inverse -- Skin redness and irritation occurs in the armpits, groin, and in between overlapping skin.Plaque -- Thick, red patches of skin are covered by flaky, silver-white scales. This is the most common type of psoriasis.Pustular -- White blisters are surrounded by red, irritated skin.
126purpurapurpura Hemorrhage into skin or mucous membranes which varies in size and ranges in color related to duration. Types of purpura include palpable purpura, ecchymosis, and petechiae.
127pustulepustule A circumscribed elevation that contains pus. Pustules are usually less than .5 cm in diameter.
128splinter hemorrhages splinter hemorrhages Dark-red, sometimes black thin longitudinal lines appearing to be within the nail plate or nail bed. The shape of the hemorrhages is due to the longitudinal orientation of nail bed capillaries.Splinter hemorrhages are caused by injury to the nail or by certain drugs and diseases. However, trauma is the most common cause. Splinter hemorrhages resolve spontaneously
129symmetricsymmetric 1. Pertaining to an individual lesion: Equal shape from side to side. 2. Pertaining to a body distribution: Equal distribution of lesions on both sides of body.
130striaestriae A flat or atrophic, usually linear, area of skin that may vary in color from pink to red that eventually becomes hypopigmented.
131telangiectasiatelangiectasia Visible, persistent, dilation of small, superficial cutaneous blood vessels.
132ulcerulcer A circumscribed loss of the epidermis and at least upper dermis. Ulcers are further classified by their depth, border, shape, edge, and tissue at its base.
133Vacuum assisted closure (Wound VAC) Under negative pressure, V.A.C. Therapy with proprietary V.A.C. GranuFoam Dressings applies mechanical forces to the wound to create an environment that promotes wound healing. These forces are known as macrostrain and microstrain.Macrostrain:Draws wound edges togetherProvides direct and complete wound bed contactEvenly distributes negative pressureRemoves exudate and infectious materialsMicrostrainReduces edemaPromotes perfusionPromotes granulation tissue formation by facilitating cell migration and proliferation
134vesiclevesicle A fluid filled cavity or elevation less than .5 cm in diameter. Fluid may be clear, serous, hemorrhagic or pus- filled.
135turgor Skin turgor test a fold of skin is picked up and then quickly let go. The amount that it will stretch is an indication of its extensibility.The speed with which it returns to a normal position is determined by the degree of hydration of the skin and subcutaneous tissue and the amount of fat in the subcutaneous tissue, e.g. in an animal that is 10 to 12% dehydrated the skin fold will not disappear until 20 to 45 seconds have elapsed.The best place to assess skin turgor on a patient who has been laying in the bed for prolonged amounts of time is: forehead or sternum.
136urticaria urticaria (“hives”) An edematous, transitory papule or plaque having a ring of erythema known as a flare and surrounded often by a narrow peripheral zone of pallor or vasoconstriction.Also known as a wheal.
137whealWhealAn edematous, transitory papule or plaque having a ring of erythema known as a flare and surrounded often by a narrow peripheral zone of pallor or vasoconstriction.Also known as urticaria.