NURS 3056 Final Info Test 2. Integumentary – Ch. 11,22,23 Complete Guide, Updated Spring 2021

NURS 3056 Final Info Test 2. Integumentary – Ch. 11,22,23 Anatomy review • Epidermis-5 layers o Passive circulation from dermis o Cell types in epidermis  Keratinocytes (90%) • Essential for the skin’s protective barrier function  Melanocytes (5%) • Protection against UV sunlight  Langerhans’ • Essential for skin immunity  Merkel cells • Touch receptors • Dermis o Highly vascular o Collagen  Critical in wound healing  Responsible for skin’s mechanical strength o Elastic fibers and reticular fibers • Subcutaneous Tissue o Connective tissue and fat cells o Function:  Insulation  Cushioning  Temp regulation  Energy storage • Glands o Sebaceous  Sebum 1) waterproofs 2) lubricates skin and 3) promotes absorption of fat-soluble substances o Apocrine sweat  Become active at puberty  Located in axillae, breast areola, umbilical and anogenital areas, external auditory canals, eyelids o Eccrine sweat  Widely distributed  Function: Cool body by evaporation, excrete waste products, moisturize surface cells • Hair and nails o Rooted in the dermis o Form from specialized keratin • Nails o Protection Functions of the Skin • Protection • Insulation • Sensation • Fluid balance • Temperature regulation • Vitamin production • Immune response function • Can act as a delivery system for drugs Primary vs. Secondary Lesions • Primary lesions o Develop on previously unaltered skin o Macule  Circumscribed, flat area with a change in skin color, <0.5cm diameter. If lesion is >0.5cm, it’s a patch  Ex. Freckles, petechiae, measles, flat mole (nevus), café-au-lait spots, vitiligo (complete depigmentation) o Papule  Elevated, solid lesion, <0.5cm diameter. If >0.5cm diameter it’s a nodule  Ex. Wart (verruca), elevated moles, lipoma, basal cell carcinoma o Vesicle  Circumscribed, superficial collection of serous fluid. <0.5cm diameter  Ex. Varicella (chickenpox), herpes zoster (shingles), second-degree burn o Plaque  Circumscribed, elevated, superficial, solid lesion. >0.5cm diameter  Ex. Psoriasis, seborrheic and actinic keratoses o Wheal  Firm, edematous, irregularly shaped area, diameter variable  Ex. Insect bite, urticaria o Pustule  Elevated, superficial lesion filled with purulent fluid  Ex. Acne, impetigo • Secondary skin lesions o Change with time o Occur because of secondary factors (scratching, infection, etc.) o Fissure  Linear crack or break from epidermis to dermis, dry or moist  Ex. Athletes foot, cracks at corner of the mouth o Scale  Excess, dead epidermal cells produced by abnormal keratinization and shedding  Ex. Flaking skin after drug reaction or sunburn o Scar  Abnormal formation of connective tissue that replaces normal skin  Ex. Surgical incision, healed wound o Ulcer  Loss of epidermis, extending into dermis, crater-like irregular shape  Ex. Pressure ulcer, chancre o Atrophy  Depression in skin resulting from thinning of the epidermis or dermis  Ex. Aged skin, striae o Excoriation  Area in which epidermis is missing, exposing the dermis  Ex. Abrasion, scratch Lesion distribution Term Description Annular Circular, begins in center and spreads to periphery (tinea corporis - ringworm) Asymmetric Unilateral distribution Confluent Merging together (urticaria - hives) Discrete Distinct individual lesions that remain separate (acne) Gyrate Twisted, coiled spiral, snakelike Grouped Clusters of lesions (multiple vesicles of contact dermatitis) Localized Limited areas of involvement that are clearly defined (confined to one area) Polycyclic Annular (circular) lesions grow together (psoriasis) Solitary Single lesion Symmetric Bilateral distribution Zosteriform Linear arrangement along a dermatome area (herpes zoster) Assessment • Subjective: health history, medications, surgery or other treatments, functional health patterns (ex: nutrition) • Objective – Physical Assessment - inspection and palpation o Nails  Color  Texture  Consistency  Thickness  Shape/angle of nail o Hair  Color  Texture  Distribution  Quantity o Skin  Color  Texture  Turgor  Temperature  Moisture  Lesions?  Vascular changes?  Skin changes can point to other disease processes that we will study throughout this year Effects of Drugs on Integumentary System • Drugs that cause photosensitivity (Table 23-2 for full list) o Examples of common offenders:  Antidepressants: amitriptyline, venlafaxine (Effexor)  Antidysrhythmics: amiodarone  Antihistamines: diphenhydramine (Benadryl), cetirizine (Zyrtec)  Antimicrobials: tetracycline, azithromycin (Zithromax), ciprofloxacin (Cipro)  Antifungals: griseofulvin, ketoconazole  Antipsychotics: haloperidol  Diuretics: furosemide (Lasix), hydrochlorothiazide  Hypoglycemics: glipizide, glyburide  NSAIDS: diclofenac (Voltaren), sulindac Categories Examples Antidepressants amitriptyline, doxepin, venlafaxine Antidysrhythmics quinidine, amiodarone (Cordarone) Antihistamines diphenhydramine, chlorpheniramine, clemastine, cetirizine (Zyrtec) Antimicrobials tetracycline, sulfamethoxazole, azithromycin (Zithromax), ciprofloxacin (Cipro) Antifungals griseofulvin, ketoconazole Antipsychotics chlorpromazine, haloperidol Chemotherapy methotrexate, dacarbazine (DTIC), 5-fluorouracil (5-FU) Diuretics furosemide (Lasix), hydrochlorothiazide Hypoglycemics tolbutamide, glipizide (Glucotrol), glyburide Nonsteroidal antiinflammatory drugs diclofenac (Voltaren), piroxicam (Feldene), sulindac Diagnostic tools • Inspection and history • Dermatoscopy • Biopsy • Potassium hydroxide (KOH) • Tzanck test • Stains and cultures • Curretage • Mineral oil slides • Wood’s lamp • Patch testing Study Description and Purpose Nursing Responsibility Biopsy Punch Special punch biopsy instrument of appropriate size used. Instrument rotated to appropriate level to include dermis and some fat. Suturing may or may not be done. Provides full-thickness skin for diagnostic purposes Before: Verify that consent form is signed (if needed). During: Assist with site preparation, anesthesia, procedure, and hemostasis. Properly identify specimen. After: Apply dressing, give postprocedure instructions to patient. Excisional Used when good cosmetic results and/or entire lesion removal desired. Skin closed with subcutaneous and skin sutures Same as above Incisional Wedge-shaped incision made in lesion too large for excisional biopsy. Useful when larger specimen than shave or punch biopsy is needed Same as above Shave Single-edged razor blade used to shave off superficial lesions or small sample of a large lesion. Provides thin specimen for diagnostic purposes Same as above Microscopic Tests Potassium hydroxide (KOH) Hair, scales, or nails examined for superficial fungal infection. Specimen put on glass slide and 10%-20% concentration of KOH added Before: Instruct patient regarding purpose of test. During: Prepare slide. Tzanck test (Wright's and Giemsa's stain) Fluid and cells from vesicles examined. Used to diagnose herpes infections. Specimen put on slide, stained, and examined microscopically Before: Inform patient of purpose of test. During: Use sterile technique for collection of fluid. Culture Test identifies fungal, bacterial, and viral organisms. For fungi, scraping or swab of skin performed. For bacteria, material obtained from intact pustules, bullae, or abscesses. For viruses, vesicle or bulla and exudate taken from base of lesion Before: Instruct patient regarding purpose and procedure. During: Properly identify specimen. Follow instructions for storing specimen if not immediately sent to laboratory. Mineral oil slides To check for infestations, scrapings are placed on slide with mineral oil and viewed microscopically. Before: Instruct patient about purpose of test. During: Prepare slide. Immunofluorescent studies Some skin diseases have specific, abnormal antibody proteins that can be identified by fluorescent studies. Both skin tissue and serum can be examined. Before: Inform patient about purpose of test. During: Assist in obtaining specimen. For punch biopsy, place specimen in special fixative (e.g., Michel's) and not formalin. Miscellaneous Wood's lamp (black light) Examination of skin with long-wave ultraviolet light causes specific substances to fluoresce (e.g., Pseudomonas fungal, infections, vitiligo). Before: Explain purpose of examination. Inform patient it is not painful. During: Darken room. Patch test (Fig. 22-10) Used to assess for allergic dermatitis and photoallergic reactions. Application of allergens to the patient's skin (usually on the back) for 48 hr. Test sites examined 48 hr later for a reaction, characterized by the presence of erythema, papules, vesicles, or all of these. Additional readings beyond 48 hr may be done. Before: Explain purpose and procedure to patient. After: Instruct patient that patches are left in place for 48 hr, during which time it is important not to wash the area or play vigorous sport because if the adhesive tapes peel off the process will have to be repeated. The patches should not be exposed to sunlight or other sources of ultraviolet (UV) light. Skin care • Environmental Hazards o Sun exposure  Ultraviolet (UV) rays • UVA—tanning • UVB—sunburn  Sun protection • Protective clothing • Sunscreen • Risk factors o Fair skin o Blonde or red hair, blue eyes o Outdoor sunbathing o Living near the equator or high altitudes o History of skin cancer Nonmelanoma skin cancers • Actinic keratosis o Premalignant skin lesions • Basal cell carcinoma o Most common type of skin cancer o Least deadly Inflammatory response • Clinical Manifestations o Local response to inflammation  Redness  Heat  Pain  Swelling  Loss of function o Systemic response to inflammation  Increased WBC count with a shift to the left  Malaise  Nausea and anorexia  Increased pulse and respiratory rate  Fever  Beneficial aspects of fever include: • Increased killing of microorganisms • Increased phagocytosis • Increased proliferation of T cells • Types of inflammation o Acute  Healing occurs in 2 to 3 weeks, usually leaving no residual damage  Neutrophils are predominant cell type at site of inflammation o Subacute  Has same features as acute inflammation but persists longer o Chronic  May last for years  Injurious agent persists or repeats injury to site  Predominant cell types involved are lymphocytes and macrophages  May result from changes in immune system (e.g., autoimmune disease) Nursing and interprofessional management • Nursing Implementation o Health Promotion  Prevention of injury  Adequate nutrition  Early recognition of inflammation  Immediate treatment ....Continues