NURSING CARE OF CLIENTS WITH INTEGUMENTARY PROBLEMS

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NURSING CARE OF CLIENTS WITH INTEGUMENTARY
PROBLEMS

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The Skin

• Epidermis-
• Epithelial cells
• Melanocytes- provides difference in skin color
• Keratinocytes-fibrous, water-repellent protein
  that gives the epidermis its tough, protective
  quality
• Dermis-
• Second, deeper layer
• Blood cells, nerve fibers, and lymphatic vesicles
• Hair follicles, sebaceous glands, and sweat
  glands

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The Skin

• Subcutaneous tissue
• Below the dermis not part of the skin
• Attaches skin to muscle bone
• Stores fat
• Regulates temperature
• Provides shock absorption

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The Skin

• Sebaceous glands
• Contain sebum to soften and lubricate the skin
  and hair
• Secretion stimulated by sex hormones
• Sweat glands
• Eccrine glands-forehead, palms, and soles
• Apocrine sweat glands- axillary, anal, and
  genital
• Ceruminous glands-external ear canal for cerumen

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The Skin

• Nails-
• Nail bed
• Color ranges from pink to yellow or brown
  depending on skin color
• Pigmented bands in nail bed normal for dark
  skinned people
• Protects ends of fingers and toes

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The Skin

• Hair
• Grows over most of body except lips, palms
  soles
• Color is inherited depends on amount of melanin
• Protects and warms the head

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Functions of the Skin

• Protect underlying tissue
• Barrier against pathogens excessive water loss
• Controls heat regulation
• Provides sensory perception (pain, heat, cold,
  touch, pressure vibration
• Mirrors emotion, e.g. anger or embarrassment

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Assessment

• Past medical history involving skin (jaundice,
  delayed wound healing, pallor, bruising)
• Skin reactions to foods, insect bites,
  medications
• Exposure to ultraviolet light (sun, radiation,
  tanning beds)
• Use of sunscreen
• Changes in skin, hair or nails
• Family history of skin diseases (alopecia,
  psoriases, cancer)
• Tobacco use

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The Skin

• Health Assessment
• Describe itching?
• When did you see a change in the mole?
• Any new hair products or skin products?
• Allergies? Any new medications
• How do you care for your skin?
• Intake in the last 24 hours
• Is your scalp oily or dry? Do you perspire
  heavily?
• Describe your activities in the past 24 hours?
• How much sleep do you get?
• Any changes in your hair or nails
• Any recent hair loss?
• Nails changed shape or color?

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The Skin

• Health Assessment
• Color
• Lesions
• Pearly-edged nodules with a central ulcer are
  seen in basal cell carcinoma
• Dark, asymmetric, multicolored patches with
  irregular edges appear in malignant melanoma
• Circular lesions can be ringworm
• Urticaria-hives
• Psoriasis-scaly red patches
• Temperature

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The Skin

• Health Assessment
• Moisture
• Tugor
• tenting
• Edema
• Hair
• Hirsutism increased hair growth on face or
  trunk
• Alopecia absence of hair
• Scalp lesions
• Ring worm Tinea capitius
• Furnicles- red swollen hair follicles
• Lice- Pediculosis

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The Skin

• Health Assessment
• Nails
• Curvature
• Color
• Thickness
• Pseudomonas and Candida infections can cause the
  nail to separate and to be darker or red
• Normal Older Adult Variations of the skin
• Dry, itchy, decreased melanocytes, liver spots
  decrease in Subcutaneous fat, increased
  wrinkling, sagging, bruising, hair loss in outer
  third of eyebrows, thick, ridged nails

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Common Assessment Abnormalities

• Alopecia- absence of hair
• Comedo blackheads whiteheads
• Cyst fluid filled sac d/t obstructed duct or
  gland
• Ecchymosis bruise
• Erythema redness occurring in patches
• Hematoma extravasion of blood causing swelling
  d/t trauma

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Common Assessment Abnormalities

• Hirsutism male distribution of hair in women
• Keloid hypertrophied scar beyond margin of
  trauma
• Mole benign overgrowth of melanocytes
• Petechiae pinpoint deposits of blood under the
  skin
• Telangiectasia dilated, superficial small blood
  vessels found on face thighs

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Primary Skin Lesions

• Macule flat, nonpalpable, less than 1 cm
• Papule elevated, solid, palapable, less than
  0.5 cm
• Vesicle circular, superficial collection of
  serous fluid, less than 1 cm.
• Plaque elevated, solid, palpable, more than 0.5
  cm.
• Wheal firm, edematous
• Pustule elevated, superficial, filled with
  purulent fluid
• Nodule elevated , solid, extends into dermis,
  circumscribed border, 0.5 2 cm
• Tumor elevated, solid, extends into dermis,
  irregular border, greater than 2 cm

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Secondary Skin Lesions

• Fissure linear cracks
• Scale - excess shedding of dead keratinized
  tissue
• Scar abnormal formation of connective tissue
• Ulcer irregular, crater-like loss of epidermis
  dermis
• Atrophy depression in skin from thinning of the
  epidermis or dermis
• Excoriation area where epidermis is missing,
  exposing dermis

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Nursing Diagnoses

• Impaired skin integrity
• Situational low self esteem
• Ineffective health maintenance
• Altered body image
• Social interaction, impaired

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Common Benign Conditions

• Pruritis
• Psoriasis
• Acne

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Pruritis

• Itching
• If a chronic problem
• C/S of scrapings
• Fungal studies
• Cutaneous patch testing
• Pharmacology
• Antihistamines, Tranquilizers, and Antibiotics

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Pruritis

• Nursing Intervention
• Therapeutic baths
• Aveno, colloid , alpha-keri
• Administer creams, pastes, or ointments
• Comfortable, cool room temperature
• Monitor skin for infection

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Psoriasis

• Chronic, noninfectious skin condition
  characterized by raised, reddened, round
  circumscribed plaques covered by silvery white
  scales. Size varies.
• Cause unknown some evidence supports autoimmune.
• Stress, sunlight, hormonal fluctuations, and some
  medications can induce.

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Psoriasis

• Pharmacology
• Corticosteriods
• Tar preparations-suppress miotic activity
• Amevive (alefacept) injection- suppress rapid
  turnover of epidermal cells
• Antimetabolites (Methotrexate)
• Treatments
• Sunlight
• Ultraviolet Light Therapy-decreases the growth
  rate of epidermal cells

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ACNE

• Acne vulgaris effects 85 of the population. The
  peak incidence is age 17 to 18 years of age.
  Family history, premenstrual flares, and
  sometimes stress can cause a flare up.
• Cosmetics containing lanolin, petrolatum,
  vegetable oils, lauryl alcohol, butylsterate, and
  oleic acid can increase comedome production.
  Exposure to oils in cooking grease can be a
  precursor in adolescents.
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Acne

• Acne is a disease that involves the sebacceous
  glands hair follicles of the face, neck, chest,
  and upper back..
• Characterized by comedones inflammatory
  lesions  
• Adequate rest, moderate exercise, a well-balanced
  diet, reduction of emotional stress, and
  elimination of any foci of infections are all
  part of general health promotion.
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Acne

• Retin-A is the only drug that disrupts the
  abnormal follicular keratinization that produces
  microcomedones. It is available in cream, gel, or
  liquid. A pea-sized dot of medication is used. It
  should not be applied until 30 minutes after
  washing face to prevent burning.
•  
•  Topical benzyl peroxide is antibacterial and can
  be used to treat mild cases. The medication can
  have a bleaching effect on sheets and clothes.
• Other antibacterials used topically are
  Clindamycin, Erythromycin and Metronidazole.
  When combined with benzyl peroxide, glycolic acid
  or Retin-A penetration improves
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Acne

•  Accutane is a potent and effective oral agent.
  It decreases sebum production. This medication
  needs to be managed by a dermatologist.
  Adolescents with multiple, active, deep dermal or
  subcutaneous cyctic and nodular acne lesions are
  treated for 20 weeks.
• Side effects include dry skin, dry mucous
  membranes, nasal irritation, dry eyes decreased
  night vision, photosensitivity, arthralgia,
  headaches, mood changes, depression, and suicidal
  ideation. The most significant is tetragenic
  effects. It is contraindicated in pregnancy. If
  the young women are sexually active, they must
  be on some kind of contraceptive.
• Tetracycline longterm

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Acne

• Gentle cleansing with a mild cleanser once or
  twice daily is needed. Antibacterial soaps are
  not effective and may cause drying.
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• Nursing care is focused on supportive and
  educating the child and parent. Teenagers need to
  understand that it takes 4 to 6 weeks to see
  improvement.
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Infections of the Skin

• Bacterial, Viral Fungal

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Bacterial Infections

• Impetigo- Staphylococcus. Reddish macule,
  vesicle, then erupts. Dries to a honey-colored
  crusts. Topical, oral, or IV antibiotics.Contagiou
  s. Seen in toddler and preschool.
• Folliculitis-
• Staph aurous. Pimple- infection of hair
  follicle. On legs of women or bearded faces of
  men. Contagious. Never pop or squeeze.

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Bacterial Infections

• Furnucle-
• Boil. Larger lesion with more redness and edema
  . Painful. Moist compress
• Systemic antibiotics. Contagious. Never pop or
  squeeze
• Carbuncle-
• Multiple boils. Wide spread inflammation. Moist
  compress. Systemic antibiotics. Never pop or
  squeeze.
• Treatment good hand washing, antibiotics, good
  hygiene, warm compresses

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Bacterial Infections

• Cellulitis inflammation of subcutaneous tissue
  following break in skin -Caused by staph of
  strep. Treat with anitbiotics
• Erysipelas involved the dermis Caused by
  strep. Treatment is IV antibiotics (PCN usually)
  to prevent septicemia

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Viral Infections

• Warts caused by HPV
• Common wart fingers
• Planter warts soles of feet
• Flat wart forehead
• Condylomata acuminata venereal warts
• Treatment
• Salicylic acid, Cyrotherapy, Liquid Nitrogen

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Viral Herpes Simplex

• Vesicle type lesion
• Type 1 above the waist cold sores
• Type 11 below the waist STD, Genital herpes
• Signs/Symptoms burning, tingling
• Diagnosed with Tzanck smear identifies herpes
  but doesnt differentiate between simplex
  zoster
• Treatment Zovirax (Acyclovir), moist compresses
  white petrolatum

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Viral Herpes Zoster

• AKA Shingles
• Caused by varicella zoster which also causes
  chickenpox
• Painful
• Treatment Acyclovir Narcotics
• Isolate from people who have not had chickenpox

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Fungal Infections

• Candidiasis caused by Candida albicans
• Occurs with immunosuppression following
  antibiotics
• Found in mouth, vagina skin (yeast infection)
• Treatment Antifungal such as Mycostatin,
  Diflucan
• Treat sexual partner

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Fungal Infections the tineas

• Tinea pedis athletes foot
• Tinea capitis scalp ringworm
• Tinea corporis body ringworm
• Tinea cruris groin jock itch
• Treatment antifungal cream or solution,
  Griseofulvin, Diflucan
• Contagious

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Common Allergic Conditions

• Contact dermatitis - Hypersensitivity response/
  chemical irritation, i.e Latex glove allergy
• Urticaria allergic phenomena causing hives
• Treatment remove the irritant give
  antihistamines

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Atopic Dermatitis

• Inflammatory skin disorder also called eczema
• Cause unknown, thought to be related to IgE, T
  lymphocytes, monocytes, and other inflammatory
  cells.
• Adult have lichenification, erythema, scaling,
  itching, and scratching.
• Familial history, foods, cold weather, stress can
  be the cause
• Treat with antipruritic, oral antihistamines, and
  oral and or topical corticosteriod.

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Skin Cancers

• Non-Melanomas
• Basal cell carcinoma
• Squamous cell carcinoma
• Melanoma

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Basal Cell Carcinoma

• Most common malignant tumor in U.S.
• Originates from basal layer of epidermis
• Risk factors UV exposure severe sunburn in
  childhood or adolescence
• Usually found on head or neck, especially the
  nose
• Dome-shaped, flat, slightly red papule or macule,
  translucent, indistinct border, hard scale

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Squamous Cell Carcinoma

• Malignant tumor of keratinocytes of skin
  mucosal surfaces
• Actinic keratosis is precursor
• Second most common skin cancer in U.S.
• Can be aggressive metastasize
• Found on head neck (lips mouth of smokers)
• Begins as firm, dull red keratosis progresses
  to nodule which ulcerates attaches to
  underlying tissue

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Actinic Keratosis
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Basal Squamous Cell Carcinomas
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Malignant Melanoma

• 55,100 new cases of invasive melanoma in U.S. per
  year (1 or 57 males 1 of 75 females)
• Arises from melanocytes. 1/3 occurs in existing
  moles
• Most often found on chest trunk on males
  lower legs of females. Can form in eyes, mouth,
  vagina, other internal organs.

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Signs Symptoms of Melanoma

• Asymmetry of mole- ½ doesnt match the other
• Border irregularity - edges are ragged or notched
• Color differing shades of tan, brown, black
  with sometimes patches of red, blue or white.
• Diameter mole is wider than 6 mm (1/4 inch)
• Any change of a spot or bleeding from lesion

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Moles
GOOD
BAD
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Melanoma
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Risk factors

• Congenital moles, large or numerous moles
• Fair skin that freckles, red or blond hair
• Family history of melanoma
• Immune Suppression
• Excessive exposure to UV radiation sunburn
• Age gender

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Treatment of Melanoma

• Biopsy of skin underlying tissue if necessary
• Wide, local incision to remove all of lesion
• Wedge resection of earlobe
• Amputation of fingers or toes
• Wide resection of sole of foot
• Thickness of lesion ulceration are strongest
  prognostic features

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Prognosis

• Patients treated early with removal of total
  lesion have 100 cure rate.
• Patients who have metastasis to the lymph nodes
  have 50 survival rate after 5 years following
  treatment.
• Patients who have systemic metastasis can live
  6-9 months after treatment

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Nursing Intervention

• Teaching prevention
• Teaching ABCDs
• Support patient receiving chemotherapy
• Routine post-op care
• Support the patient family emotionally to
  decrease fear, and low self-esteem if body image
  is altered.