dermatologic problems/ integumentary system. physical examination obtain history obtain history...

Dermatologic Problems/ Dermatologic Problems/ Integumentary SystemIntegumentary System

Physical ExaminationPhysical Examination

Obtain historyObtain history WHATS UPWHATS UP

InspectionInspection Palpation Palpation Gloves are worn during examination Gloves are worn during examination


Observe for:Observe for: ColorColor TemperatureTemperature MoistureMoisture DrynessDryness


Skin texture (rough-smooth) Skin texture (rough-smooth) LesionsLesions VascularityVascularity MobilityMobility Texture of hair and nailsTexture of hair and nails Skin turgorSkin turgor

Physical ExaminationPhysical Examination ColorColor

Varies from person to personVaries from person to person Ivory-deep brownIvory-deep brown Pigmentations r/t Pigmentations r/t

Sun exposure Sun exposure FeversFevers

Sunburn, inflammation-Sunburn, inflammation- Pink or Pink or Reddish hueReddish hue

PallorPallor Decreased skin tonesDecreased skin tones

Physical ExaminationPhysical Examination ColorColor

Vascularity Vascularity Observed in Observed in

ConjunctivaeConjunctivae Mucous membranesMucous membranes

Bluish hueBluish hue Cyanosis = cellular hypoxiaCyanosis = cellular hypoxia

JaundiceJaundice Yellow pigmentYellow pigment

sclerasclera mucous membranemucous membrane


ColorColor Dark skinned personsDark skinned persons

Have reddish base and undertonesHave reddish base and undertones Buccal mucosa, tongue, lips,nails normally Buccal mucosa, tongue, lips,nails normally

appear pinkappear pink Cyanosis-skin assumes grayish castCyanosis-skin assumes grayish cast

Age related changesAge related changes


Types of dressingsTypes of dressings Wet-dry dressingsWet-dry dressings Moisture-retentive dressingsMoisture-retentive dressings

Already impregnated with moistureAlready impregnated with moisture Occlusive dressingsOcclusive dressings

Cover woundCover wound


Topical medicationsTopical medications Lotions, suspensionsLotions, suspensions Clear solutions, liniment,Clear solutions, liniment, Powders, creams, Powders, creams, Gels, pastes, Gels, pastes, Ointments, sprays, Ointments, sprays, Corticosteroids etc.Corticosteroids etc.

WoundsWounds

Abrasion – skin is rubbed or Abrasion – skin is rubbed or scraped offscraped off

Lacerations – torn, ragged, Lacerations – torn, ragged, irregular edges made by blunt irregular edges made by blunt objectsobjects

Avulsions – the tearing away of Avulsions – the tearing away of tissue from a body parttissue from a body part

Incisions – cuts made by sharp Incisions – cuts made by sharp cutting instrumentscutting instruments

Punctures – caused by objects Punctures – caused by objects that penetrate tissue while that penetrate tissue while leaving a small surface opening leaving a small surface opening

Amputations – traumatic is the Amputations – traumatic is the nonsurgical removal of a limb nonsurgical removal of a limb from the bodyfrom the body

Wound Healing Wound Healing

11stst intention intention

22ndnd intention intention

33rdrd intention intention

Diagnostic Tests/TreatmentsDiagnostic Tests/Treatments

CulturesCultures Skin biopsySkin biopsy Wood’s light examinationWood’s light examination Skin testing (allergies) Skin testing (allergies) Open wet dressing/other dressingsOpen wet dressing/other dressings Therapeutic bathsTherapeutic baths Topical medsTopical meds

Herpes Zoster {Shingles}Herpes Zoster {Shingles}

Acute inflammatory and infectious Acute inflammatory and infectious disorderdisorder

Painful vesicular eruption Painful vesicular eruption Bright red edematous plaques along Bright red edematous plaques along

the nerve from one or more posterior the nerve from one or more posterior gangliaganglia

Herpes Zoster {Shingles} Herpes Zoster {Shingles} cont’dcont’d

Eruption follows the course of the Eruption follows the course of the nervenerve

Almost always unilateralAlmost always unilateral


CauseCause Varicella-zoster virus (like chicken-pox)Varicella-zoster virus (like chicken-pox) Incubation period 7-21 daysIncubation period 7-21 days Vesicles appear in 3-4 daysVesicles appear in 3-4 days

Occur posteriorlyOccur posteriorly Progress anteriorly & peripherallyProgress anteriorly & peripherally Along dermatomeAlong dermatome

Duration 10 days to 5 weeksDuration 10 days to 5 weeks


Occurs most frequently in Occurs most frequently in ElderlyElderly Immunosuppressed Immunosuppressed Malignancy or injury to spinal or cranial Malignancy or injury to spinal or cranial

nervenerve


ComplicationsComplications Facial and acoustic nerve involvementFacial and acoustic nerve involvement

Hearing lossHearing loss TinnitusTinnitus Facial paralysisFacial paralysis VertigoVertigo painfulpainful


ComplicationsComplications Full thickness skin necrosis and scarringFull thickness skin necrosis and scarring Systematic infection from scratching, Systematic infection from scratching,

causing virus to enter blood streamcausing virus to enter blood stream


Medical treatmentMedical treatment Control outbreak Control outbreak Reduce pain and discomfortReduce pain and discomfort Prevent complicationsPrevent complications

Acyclovir (Zovirax) IV, PO, topicallyAcyclovir (Zovirax) IV, PO, topically CorticosteroidsCorticosteroids AntihistaminesAntihistamines AntibioticsAntibiotics


Nursing CareNursing Care Cool compresses two-three times per Cool compresses two-three times per

dayday Help cleanse and dry lesions Help cleanse and dry lesions Measures to decrease itchingMeasures to decrease itching Medication Medication

Parasitic Skin Infections Parasitic Skin Infections (PSI)(PSI)

Higher risk situations? Higher risk situations? Poor hygienePoor hygiene Living in close quartersLiving in close quarters

Pediculosis- Lice (PSI)Pediculosis- Lice (PSI)

Infestation by human liceInfestation by human lice Pediculosis capitis-headPediculosis capitis-head Pediculosis corporis-bodyPediculosis corporis-body Pediculosis pubis- pubic or crabPediculosis pubis- pubic or crab

Pediculosis (PSI) Pediculosis (PSI)

ParasiteParasite Approximately 2-4 mmApproximately 2-4 mm Female lays eggs-hundreds-nitsFemale lays eggs-hundreds-nits Deposit on hair shaft baseDeposit on hair shaft base


SymptomsSymptoms PruritusPruritus ExcoriationExcoriation

Vectors of other diseasesVectors of other diseases TyphusTyphus Recurrent feverRecurrent fever

Pediculosis Capitis (PSI)Pediculosis Capitis (PSI)

More common in womenMore common in women Sides and back of scalpSides and back of scalp Assess for Assess for

Visible white flecks (nits)Visible white flecks (nits) Matting and crusting of scalpMatting and crusting of scalp Foul odorFoul odor

Pediculosis Capitis (PSI)Pediculosis Capitis (PSI)

TreatmentTreatment PediculicidesPediculicides Hand pick or comb nits outHand pick or comb nits out Launder bed linens & vacuumLaunder bed linens & vacuum Seal items in plastic bags for 14 daysSeal items in plastic bags for 14 days Repeat above in 10-14 daysRepeat above in 10-14 days

Pediculosis Corporis (PSI)Pediculosis Corporis (PSI)

Lice live and lay eggs in clothingLice live and lay eggs in clothing ItchingItching Assess forAssess for

Excoriation onExcoriation on TrunksTrunks AbdomenAbdomen ExtremitiesExtremities

Pediculosis Pubis (PSI)Pediculosis Pubis (PSI)

Intense pruritisIntense pruritis Vulvar regionVulvar region Peri-rectal Peri-rectal More compactMore compact Crab-like appearanceCrab-like appearance

Pediculosis Pubis (PSI) Pediculosis Pubis (PSI)

Contracted fromContracted from Infested bed linensInfested bed linens Sexual intercourseSexual intercourse

May also infestMay also infest AxillaAxilla EyelashesEyelashes ChestChest


TreatmentTreatment Chemical killingChemical killing Clean linens with hot water and soapClean linens with hot water and soap Dry-cleanDry-clean Fine-tooth combFine-tooth comb Treat social contactsTreat social contacts

Scabies Scabies (PSI)(PSI)

Contagious skin diseaseContagious skin disease Mite infestationMite infestation Transmitted byTransmitted by

Close-prolonged contact withClose-prolonged contact with Infested companionInfested companion Infested beddingInfested bedding

Scabies Scabies (PSI)(PSI)

Characterized byCharacterized by Epidermal curved or linear ridgesEpidermal curved or linear ridges Follicular papulesFollicular papules Pruritus PalmsPruritus Palms

More intense and unbearable at nightMore intense and unbearable at night White visible epidermal ridges byWhite visible epidermal ridges by

Mite burrowing into outer layers of skinMite burrowing into outer layers of skin

Scabies Scabies (PSI) (PSI)

Hypersensitivity reactionHypersensitivity reaction Excoriated erythematous papulesExcoriated erythematous papules Pustules, crusted lesionsPustules, crusted lesions

Elbows Elbows Axillary foldsAxillary folds Lower abdomenLower abdomen Buttocks, thighsButtocks, thighs Between fingersBetween fingers GenitaliaGenitalia

Scabies Scabies (PSI) (PSI)

TreatmentTreatment

Topical sulfur preparationsTopical sulfur preparations One-two applications dailyOne-two applications daily Launder personal itemsLaunder personal items No disinfectantNo disinfectant

Ringworm Ringworm (PSI)(PSI) Ringworm - an infection caused Ringworm - an infection caused

by a fungusby a fungus Jock itch – form of ringworm on Jock itch – form of ringworm on

groin area groin area Athlete’s foot – fungal infection Athlete’s foot – fungal infection

of foot (feet) of foot (feet) FungusFungus

live and spread on the top layer live and spread on the top layer of the skin and on the hair of the skin and on the hair

grow best in warm, moist areas, grow best in warm, moist areas, contagious via skin-to-skin contagious via skin-to-skin

contact with a person or animal contact with a person or animal that has it or when you share that has it or when you share things like towels, clothing, or things like towels, clothing, or sports gear.sports gear.

You can also get ringworm by You can also get ringworm by touching an infected dog or cat, touching an infected dog or cat, although this form of ringworm although this form of ringworm is not common.is not common.

PsoriasisPsoriasis

Lifelong disorderLifelong disorder ExacerbationsExacerbations RemissionsRemissions Cannot be curedCannot be cured

PsoriasisPsoriasis

PathophysiologyPathophysiology Scaling disorderScaling disorder Underlying dermal inflammationUnderlying dermal inflammation Abnormality in proliferation of epidermal Abnormality in proliferation of epidermal

cells in outer skin layerscells in outer skin layers Normal – 28 days to shed cellsNormal – 28 days to shed cells Psoriasis Cells shed every 4-5 daysPsoriasis Cells shed every 4-5 days

PsoriasisPsoriasis

Cause-unknownCause-unknown Genetic predispositionGenetic predisposition Environmental factorsEnvironmental factors May appear after skin traumaMay appear after skin trauma SunburnSunburn SurgerySurgery

PsoriasisPsoriasis

Improves in warmer climatesImproves in warmer climates Aggravated byAggravated by

InfectionsInfections Streptococcal throat infectionStreptococcal throat infection Candida infectionsCandida infections

Hormonal changesHormonal changes Psychological stressPsychological stress

PsoriasisPsoriasis

AssessmentAssessment HistoryHistory Family historyFamily history Age at onsetAge at onset Disease progressionDisease progression Pattern of recurrencesPattern of recurrences Gradual or suddenGradual or sudden

Psoriasis Vulgaris Psoriasis Vulgaris {Ordinary/Common}{Ordinary/Common}

Most commonMost common Thick erythematous papules or Thick erythematous papules or

plaquesplaques Surrounded by silvery white scalesSurrounded by silvery white scales

Psoriasis Vulgaris Psoriasis Vulgaris {Ordinary/Common}{Ordinary/Common}

Common sitesCommon sites ScalpScalp ElbowsElbows TrunkTrunk KneesKnees SacrumSacrum Extensor surfaces of limbsExtensor surfaces of limbs

Skin CancersSkin Cancers

Overexposure to sunlightOverexposure to sunlight Common skin cancersCommon skin cancers

Squamous cell carcinomaSquamous cell carcinoma Basal cell carcinomaBasal cell carcinoma MelanomaMelanoma

Actinic KeratosisActinic Keratosis

Pre-malignant lesionsPre-malignant lesions Cells of epidermisCells of epidermis Chronically sun-damaged skinChronically sun-damaged skin Can lead to squamous cell carcinomaCan lead to squamous cell carcinoma

Squamous Cell CarcinomaSquamous Cell Carcinoma

Malignant neoplasms of epidermisMalignant neoplasms of epidermis Invade locallyInvade locally Potentially metasticPotentially metastic EarEar LipLip External genitaliaExternal genitalia CauseCause

Repeated irritation or injuryRepeated irritation or injury

Basal Cell CarcinomaBasal Cell Carcinoma

Basal cell layer of epidermisBasal cell layer of epidermis Lesions go unnoticedLesions go unnoticed Metastasis rareMetastasis rare Underlying tissue destruction Underlying tissue destruction

progresses to underlying vital progresses to underlying vital structurestructure

MelanomasMelanomas

Pigmented malignant lesionsPigmented malignant lesions Originate in melanin-producing cells Originate in melanin-producing cells

of epidermisof epidermis

MelanomasMelanomas

Risk factorsRisk factors Genetic predispositionGenetic predisposition Excessive exposure to UV lightExcessive exposure to UV light

Precursor lesions resembling unusual Precursor lesions resembling unusual molesmoles

Highly metastaticHighly metastatic Survival depends on early diagnosis Survival depends on early diagnosis

and treatmentand treatment


Incidence/PrevalenceIncidence/Prevalence Light skinned personsLight skinned persons Outside workOutside work Higher altitudesHigher altitudes Chemical carcinogensChemical carcinogens

Type IType I - Often burns, rarely tans. Tends to have freckles, red or fair - Often burns, rarely tans. Tends to have freckles, red or fair hair, and blue or green eyes.hair, and blue or green eyes.

Type IIType II - Usually burns, sometimes tans. Tends to have light hair, - Usually burns, sometimes tans. Tends to have light hair, and blue or brown eyes.and blue or brown eyes.

Type IIIType III - Sometimes burns, usually tans. Tends to have brown hair - Sometimes burns, usually tans. Tends to have brown hair and eyes.and eyes.

Type IVType IV - Rarely burns, often tans. Tends to have dark brown eyes - Rarely burns, often tans. Tends to have dark brown eyes and hair.and hair.

Type VType V - Naturally black-brown skin. Often has dark brown eyes - Naturally black-brown skin. Often has dark brown eyes and hair.and hair.

Type VIType VI - Naturally black-brown skin. Usually has black-brown eyes - Naturally black-brown skin. Usually has black-brown eyes and hair.and hair.


PreventionPrevention Avoid exposure to sunlightAvoid exposure to sunlight Use of sunscreen SPF30 or greaterUse of sunscreen SPF30 or greater


AssessmentAssessment AgeAge RaceRace Family historyFamily history Removal of skin growthsRemoval of skin growths


AssessmentAssessment Change in Change in

Size, Color, SensationSize, Color, Sensation Of anyOf any

Mole, Birthmark, Wart, ScarMole, Birthmark, Wart, Scar

Hair-bearing areas of bodyHair-bearing areas of body


Interventions: Radiation therapyInterventions: Radiation therapy ElderlyElderly Large, deeply invasive basal cell tumorsLarge, deeply invasive basal cell tumors Poor risk for surgeryPoor risk for surgery Malignant melanoma resistantMalignant melanoma resistant May be used in combination with May be used in combination with

systemic chemotherapysystemic chemotherapy


Interventions: SurgeryInterventions: Surgery CryosurgeryCryosurgery

Local application of liquid nitrogenLocal application of liquid nitrogen Cell deathCell death Tissue destructionTissue destruction Hemorrhagic blister formation x 1-2 daysHemorrhagic blister formation x 1-2 days

Nursing CareNursing Care Clean site with hydrogen peroxideClean site with hydrogen peroxide Topical antibiotic may be orderedTopical antibiotic may be ordered


Interventions: Plastic or Interventions: Plastic or reconstructive surgeryreconstructive surgery Wound flapsWound flaps Pressure woundsPressure wounds

Skin Flap vs. Skin GraftSkin Flap vs. Skin Graft

Skin FlapSkin Flap Segment of tissue Segment of tissue

attached on one attached on one end while other end end while other end is moved to new is moved to new sitesite

Nursing CareNursing Care Assess for infectionAssess for infection Assess circulation Assess circulation

of tissueof tissue

Skin GraftSkin Graft Section of skin Section of skin

detached & detached & transferredtransferred

Nursing Care Nursing Care Keep affected part Keep affected part

immobilizedimmobilized Inspect dressingInspect dressing After 2-3 weeks, After 2-3 weeks,

massage with oilmassage with oil No heating pads No heating pads

or sun exposureor sun exposure

Pressure UlcersPressure Ulcers

EtiologyEtiology


EtiologyEtiology ImmobilityImmobility Impaired sensory perception or Impaired sensory perception or

cognitioncognition Decreased tissue perfusionDecreased tissue perfusion Decreased nutritional statusDecreased nutritional status Friction and shearFriction and shear Increased moistureIncreased moisture


StagesStages


StagesStages Stage IStage I

Non-blanchable erythemaNon-blanchable erythema Tissue swellingTissue swelling C/O discomfortC/O discomfort

Stage IIStage II Break in skinBreak in skin EpidermisEpidermis DermisDermis NecrosisNecrosis


StagesStages Stage IIIStage III

Subcutaneous tissueSubcutaneous tissue Deep craterDeep crater

With underminingWith undermining Without underminingWithout undermining

Stage IVStage IV Underlying structuresUnderlying structures May have large undermined areaMay have large undermined area


Nursing CareNursing Care Relieve pressureRelieve pressure Proper positioningProper positioning Improve mobilityImprove mobility Improve sensory perceptionImprove sensory perception Improve tissue perfusionImprove tissue perfusion Improve nutritional statusImprove nutritional status Reduce friction and shearReduce friction and shear Minimize moistureMinimize moisture

BurnsBurns

11stst degree – partial- degree – partial-thickness thickness (superficial)(superficial)

22ndnd degree – partial- degree – partial-thickness (deep)thickness (deep)

33rdrd degree – full- degree – full-thicknessthickness

Chemical burnsChemical burns

Electrical burnsElectrical burns

Thermal burnsThermal burns

SunburnSunburn

BurnsBurns

Extent of burn injuryExtent of burn injury Rule of nines Rule of nines

Stages of careStages of care I – EmergentI – Emergent II – AcuteII – Acute III - RehabilitationIII - Rehabilitation

BurnsBurns

TestsTests Wound culturesWound cultures CBC, BUN, glucose, electrolytes, urine CBC, BUN, glucose, electrolytes, urine

studiesstudies InterventionsInterventions

IV fluid replacementIV fluid replacement Antibiotic/antimicrobial agentsAntibiotic/antimicrobial agents Analgesics Analgesics

BurnsBurns

TreatmentTreatment Debridement & cleaningDebridement & cleaning

Mechanical, chemical, surgicalMechanical, chemical, surgical EscharotomyEscharotomy

DressingDressing Open, closed, biological, syntheticOpen, closed, biological, synthetic

Skin graftsSkin grafts Autograft Autograft

Split-thicknessSplit-thickness Full-thickness Full-thickness

Burn CareBurn Care

Impaired gas exchangeImpaired gas exchange Impaired skin integrityImpaired skin integrity Deficient fluid volumeDeficient fluid volume PainPain Ineffective peripheral tissue Ineffective peripheral tissue

perfusionperfusion Risk for sepsisRisk for sepsis

QUESTIONS?QUESTIONS?

dermatologic problems/ integumentary system. physical examination obtain history obtain history...

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