Objectives. The Integumentary System. Skin Overview. Anatomy. Epidermis. Dermis 3/7/2016

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1 Objectives The Integumentary System Janel Brown RN, BSN, CWON Wound/Ostomy RN North Kansas City Hospital Review anatomy and physiology of the skin Identify & Assess clinical manifestations of skin disorders Comprehend pressure ulcer formation and the complexity of care Describe a plan of care and nursing interventions for skin disorders/diseases Anatomy Physiology Function Skin Overview Anatomy Largest organ of the body Weighs 5-9 pounds, depth 0.5mm to 6mm Forms the major interface between internal organs and external environment Active role in the immune system protecting us from dx Three Layers: -Epidermis -Dermis -Hypodermis (subcutaneous) Basement Membrane Zone (separates Epidermis from dermis) Epidermis Outermost layer, less than 1mm thick Protective barrier between body and external environment Five layers (stratum layers) -Stratum: corneum (outermost layer), lucidum, granulosum, spinosum, germinativum Renews itself every 3-4 weeks, top layer (dead, flat skin cells) sheds every 2 weeks Contains openings for sweat glands and sebaceous glands Lacks blood supply Synthesis of Vitamin D with sunlight Dermis Thickest layer of skin Contains blood vessels and nerve fibers that supply the epidermis Major proteins: collagen (tensile strength) & elastin (elastic recoil) Gives skin flexibility and strength Noncellular connective tissue Fibroblast important in wound healing 1

2 Hypodermis-Subcutaneous Adipose layer (fat), innermost layer Contains blood vessels, lymphatics & nerves Attaches dermis to underlying structures Provides insulation, cushioning, a reserve of energy/calories, mobility of the skin over organs Distribution variable by age, sex, and anatomical area Skin Appendages Hair-follicles in dermal layer Nails Glands-dermis/epidermis -Sebaceous (oil): produce sebum, bacteriostatic fluid that lubricates the skin and minimizes water loss -Sweat (scent): body temperature regulation, body odor Physiology Primary Functions -Protection (trauma, infection), Excretion -Regulates body temperature -Immunity against microorganisms Secondary Functions - Sensation (pain, touch, temp, pressure) - Metabolism: Synthesis of Vit D - Body Image (appearance), social interaction Cells Keratinocytes-protective function of skin, account for 95% of epidermal cells Melanocytes-produce skin pigment, protect against Ultraviolet light Merkel cells-provide sensory information Langerhans-help activate immune system, macrophages responsible for detecting antigens that may adhere to the skin Skin Disorders Pressure Ulcers Infections Tumors Ulcers: Venous Stasis, Arterial ulcers, Diabetic foot Psoriasis Burns Macule Flat, change in color of skin, < 1 cm Ex: freckle, petechiae Patch Flat, nonpalpable, irregular, >1cm Ex: port-wine stain, vitiligo 2

3 Nodule Elevated, firm, 0.5 to 1-2cm Ex: lipoma Papule Elevated, firm, < 0.5cm Ex: wart, elevated mole Wheal Elevated, irregular, solid, transient Ex: insect bites, allergic reaction Plaque Elevated, firm, rough, >1cm Ex: psoriasis, actinic keratosis Tumor Elevated solid, >2cm Ex: neoplasms, benign tumors Vesicle Elevated, superficial, serous filled, <1cm Ex: varicella Pustule Elevated, purulent filled Ex: acne, impetigo Cyst Elevated, encapsulated, filled with fluid or semisolid material Ex: sebaceous cyst Bulla Vesicle >1cm Ex: blister, 2 nd degree burn Telangiectasia Fine, irregular red lines Ex: rosacea Scale Dry Flaky skin, irregular shape 3

4 Lichenification Rough, thickened epidermis Ex: chronic dermatitis, eczema Denuded/Excoriation Loss of epidermis Fissure Linear crack, moist or dry Ulcer Loss of epidermis Ex: pressure ulcer, DM ulcer Pressure Ulcers Definition: Localized injury to the skin and/or adjacent underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Cause: compression of soft tissue over a bony prominence over prolonged period of time Pathophysiology: vascular compromise, tissue anoxia, and cell death Pressure ulcers NPUAP (National Pressure Ulcer Advisory Panel) Stage I Stage II Stage III Stage IV Unstageable Suspected Deep Tissue Injury (DTI) Intact skin with nonblanchable erythema, tissue may be painful, firm, soft, warmer or cooler than adjacent tissue. May be difficult to detect in individuals with darker skin tones. Stage I Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serumfilled blister. Is NOT skin tears, tape burns, dermatitis, maceration or excoriation. Stage II 4

5 Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage III Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Stage IV Stage IV Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Unstageable Suspected Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. May further evolve. Pressure Ulcer-Prevention Remove the Pressure TURN, TURN, TURN q 2 hours Elevate Heels (heel lift boots) Keep skin clean and moisturized Use a draw sheet Provide adequate nutrition/hydration Evaluate bed surface or chair cushion Educate patient/caregiver 5

6 Treatment-Dressing Options Infections Moist Wound Healing -Too dry---wet it -Too wet---dry it -Moist---Maintain it Dressings/tx: -Hydrocolloid -Wound Gels -Foam -Gauze/ABD pads -Calcium Alginates -Wet/dry, Wound VAC -Transparent film -Collagenase, Iodosorb, silver Bacterial Viral Fungal Cellulitis: Diffuse, acute infection of skin or SQ tissue Pathophysiology: Group A Beta-hemolytic strep or Staph Aureus, Non group A Strep, Pseudomonas, H Influenza type B Clinical Manifestations: erythema, edema, leukocytosis, pain/tenderness, odor, excess drainage Bacterial Herpes simplex: cold sores, fever blisters, genital lesions Herpes Zoster: shingles - vesicobullous eruption -unilateral - pain, burning - pruritis - erythematous, plaques, vesicles then crusting Viral Fungal Infections Interventions/Treatment Bacterial Cultures Antibiotic therapy Antimicrobial dressings, ointment, gels (silver, iodine) Fungal Antifungals Viral Cool, moist compresses Analgesics Drying agents Moisture barrier creams/ointments Topical antimicrobials Antivirals: Acyclovir 6

7 Tumors Basal Cell Carcinoma Squamous Cell Carcinoma Malignant Melanoma Basal Cell Carcinoma Invasive epidermal tumor, well defined borders Low rate of metastasis Chronic exposure to sun causes cellular changes Most common form, frequently seen on head/neck Growth rate is slow Basal Cell Carcinoma Flesh-colored pink nodule, well defined border Overtime, central depression that progresses to an ulcer Squamous Cell Carcinoma Malignant tumor of epidermal layer Prolong exposure to UV light, tanning beds Head, neck, hands, scalp, arms, back, shoulders, rim of ears, lower lip Fast growing Can spread to lymph nodes Risk: Pre-malignant lesions (actinic keratosis) Squamous Cell Carcinoma Single superficial lesion Sore that will not heal Develops a crust, occasionally bleeds Malignant Melanoma Highly metastatic Risk Factors: -genetic predisposition -exposure to UV light -fair skin, light skin, freckles -moles -weakened immune system 7

8 Malignant Melanoma Burns Severity: Depth of burn Percent of tissue involvement Part of body burned Cause Age Types: Thermal Radiation Chemical Electrical Rule of Nines: Entire head 9%, Entire trunk front 18%, Entire trunk back: 18%, Each arm 9%, Each Leg 18% Burns Superficial 1 st degree: Extend to epidermis, never blister, painful, heal 3-4 days, no scar Superficial partial thickness: Blister with weeping, extend into upper dermis, painful Deep partial thickness: Involve epidermis and deeper part of dermis, Red/white patches, waxy, usually dry, may have scarring Full Thickness: Destruction of dermis & epidermis, healing only at skin margins with graft, painless, waxy/white gray color, may appear leathery brown Fourth degree: Full thickness, muscle/fascia, or bone damage, requires skin grafting and flaps Nursing Assessment Nursing History Physical Assessment Diagnostic Studies Nursing History Past/present history -Xerosis (dry skin) -Pruritis (itching) -Rash -Erythema -Edema -, wounds, ulcers -Ecchymosis Nursing History Family History: skin cancer, chronic skin infections/conditions Social History: occupation, sun exposure, foreign travel, smoking, nutrition, use of sunscreen, hobbies, use of tanning bed 8

9 Inspection Color Moisture Edema Intactness Personal Hygiene Hair Nails Physical Assessment Nursing Assessment Palpation - (firm, boggy, fluctuant) -Excess moisture (maceration, edema) -Temperature (cold, warm, hot) -Texture (frail, thickness) -Turgor (elastic, tenting) -Non blanchable erythema (Stage I ulcers) Diagnostic Studies Documentation Cultures: swab, tissue, fluid Skin Biopsy: punch, shave, needle, surgical excision Wood s light examination: UV light illuminates skin infections, sun damage Skin testing: patch, scratch testing Location: Anatomically correct Describe: surface, color, drainage, surrounding skin, measurement (cm, length x width x depth) Do Not diagnose Stage: ONLY pressure ulcers Sample questions: While caring for a patient admitted with an allergic reaction, you assess an irregular, solid, elevated, erythematous lesion and document this as a: Patch Macule Scale Wheal 9

10 You are assessing a patient with a history of Diabetes II who is bed bound and note a 3x3cm serous fluid filled blister on his left heel. You document this as: B: A Diabetic foot ulcer A: A Stage III pressure ulcer C: A Stage II pressure ulcer D: An Unstagable pressure ulcer Which is true regarding Langerhans cells?: A: Regulate body temperature B: Help activate the immune system C: Produce skin pigment D: Provide sensory information While caring for a 30 y/o male who works in construction, you assess a round, well defined, pearly pink nodule with a central clearing on his left ear. You suspect: Squamous Cell Carcinoma Malignant Melanoma Basal Cell Carcinoma Seborrheic Keratosis, a benign lesion References Blankenship, J. (2009). The Integumentary System. In Craven, H. (Eds), Core Curriculum for Medical-Surgical Nursing (4 th ed., pp ). Pitman, NJ: Jannetti. National Pressure Ulcer Advisory Panel. (2007). Stages. [On-line]. Available: Porth, C. M. (2007). Integumentary Function: Essentials of Pathophysiology Concepts of Altered Health States (2 nd ed., pp ). Philadelphia: Lippincott Williams & Wilkins. Wound, Ostomy and Continence Nurses Society. (2011). Stages. [On-line]. Available: Wound, Ostomy and Continence Nurses Society (WOCN). (2010). Guideline for Prevention and Management of Pressure Ulcers. Mt. Laurel, NJ: Author. 10