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					INTEGUMENTARY
    Disorders




   NUR 105 ADULT HEALTH




                    Williams 2004
         Legislative Day
Students with the Mayor Maddock




                        Williams 2004
     Legislative Day
Tuesday, January 31, 2006




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             Learning Outcomes

   Define key terms.
   Describe anatomy and physiology of the
    integumentary system.
   Identify structural changes of the integumentary
    system for elderly.
   Describe assessments of the integumentary system.
   Utilize the nursing process to care for clients with
    common alterations of the system.


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               INTEG- Anatomy

   Epidermis
   Dermis
   Subcutaneous
   Appendages
    –   Hair follicles, sweat and sebaceous glands,
        blood vessels



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       Functions of the Skin

 Protection
 Sensation
 Fluid Balance
 Temperature Regulation
 Vitamin Production (Vit. D)
 Immune Response Function
 Psychological


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              Integumentary
              Assessment -1

 HealthHistory
 General Examination and Clinical
  Manifestations
  –   General Appearance
  –   Vascularity and Hydration
  –   Nails and Hair
  –   Types of Lesions
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           INTEG-ASSESSMENT-2

   Chief complaint /Present history - (seven
    variables-PQRST)
   Past Health History - assess variables or
    factors may cause skin disorder.
   Physical Exam
    –   Inspection and Palpation
   Diagnostic Tests

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    INTEG-ASSESSMENT 3 – Health Hx

   Age, race, occupation
   Family Hx and Genetic Risk
   Personal HX – past medical, health
    practices, ADL
   Medication Hx
   Diet
   Socioeconomic
   Current Health Problems

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           INTEG-ASSESSMENT 4

   Chief complaints - redness, pain, dry,
    pruritus, lesions, open wound.
    –   Primary or secondary to skin disorders
   Physical Exam -
    –   Inspection - configuration, location, vesicles,
        color, lesions, scars, swelling, shape, contour.
    –   Palpation - temperature, texture, moisture,
        consistency, size, swelling, turgor edema, soft,
        smooth.
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Canker Sore




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Aging Spots




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Integ – Assessment of Elderly



   How do you assess skin turgor in a 79 year
    old female?




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INTEG-ASSESSMENT of ELDERLY

 –   Skin- aging spots

 –   Hair- color, texture, thickness

 –   Nail- Beau’s Nail

 –   Glands

 –   Subcutaneous

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                   Integumentary
                   Assessment 5
                    Diagnostic Tests
   Skin Biopsy (punch, shave, excisional)
   Culture and sensitivity (viral, bacteria, fungi)
   Immunofluorescence
   Allergy Tests
     –   Patch, intradermal, scratch
   Skin Scrapings
   Tzanck Smear
   Wood’s Light Examination
   Clinical Photographs
   Diascopy
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Wound Care for Skin
Conditions

 Wet Dressings
 Moisture-Retentive Dressings
  –   hydrophilic vs hydrophobic
 Occlusive  Dressings
 Autolytic Debridement
 Hyperbaric; Vacuum Irrigation

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INTEG-NURSING INTERVENTION

   Goal - Maintain skin
    integrity
    –   Clean, warm, dry,
        remove pressure;
    –   Skin care/good hygiene
    –   Turn and position
    –   Diet - well-balanced;
        avoid allergic foods;
        Protein and vitamins
    –   Rest, sleep


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        Medical Management

 Therapeutic baths and medications
  (balneotherapy)
 Pharmacologic Therapy
  –    lotions, powders, creams, gels, pastes,
      ointments, sprays and aerosols
  –   corticosteroids
  –   intralesional therapy
  –   systemic medications

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                INTEG-TREATMENT

            MEDICAL                       SURGICAL
   Diet                             Surgical excision of
   Medications                       precancerous and
    –   Corticosteroids               cancerous lesions.
    –   Antihistamines               Cryosurgery
    –   Antibiotics,antifungal,       Laser
        antiviral
                                     Electrodesication
    –   Scabicides and
        pediculicides
    –   Hormones
    –   Chemotherapeutics
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INTEGUMENTARY-TREATMENT

   MEDICATIONS                 Photochemotherapy
   Local anesthetics,          Radiation
   Antiseptics                 Dressings
   Keratolytics                 –   dry, sterile; wet to dry;
                                     packings, cleaning, applying
   Antiseborrheic agents            ointments or lotions.
   emollients, ointments,      Therapeutic Baths-
    powders, and lotions.        –   cornstarach, oatmeal



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      Nursing Management

 Maintain   skin integrity
 Relieve discomfort and promote
  restful sleep
 Promote self acceptance
 Increase knowledge of skin care and
  self care
 Avoid complications


                              Williams 2004
          INTEG-Common Disorders
   Dryness                           Cutaneous Anthrax
   Pruritus/Sunburn/ Urticaria       Dermatitis
   Trauma
                                        – contact dermatitis
   Pressure /Stasis Ulcers
                                        – primary dermatitis
   Parasitic/Infestations
     –   Pediculosis                  Inflammation
     –   Scabies                        – Psoriasis - chronic
     –   Dermatophytoses (tinea)      Infections
         fungus
                                        – Impetigo, furuncles,
   Seborrheic Dermatitis                   carbuncles
   Other Skin Disorders –
    Acne, Frostbite, Leprosy          Cancer- Benign and
                                       Malignant


                                                     Williams 2004
         INTEG-Common Disorders

   Dryness – common in elderly; emollient, lotion, and hydration

   Pruritus- primary or secondary; treat cause; colloidal and tar
    baths; trim fingernails, wear mittens at night; cool sleeping
    environment; anti-histamine and anti-inflammatory


   Urticaria- (hives); antihistamine

   Sunburn – redness and painful; antibiotics for blisters, topical
    corticosteriods, cooling, soothing lotions for dryness.


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                  Pruritus
 May be first indication of systemic internal
  disease
 Scratching causes inflamed cells to release
  histamine creating a vicious itch-scratch
  cycle
 Medical management based upon cause-
  allergic or infectious
 Nursing management reinforces teaching
  and self care

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     INTEG- Pharmacology Review

   Anti-Histamine Classification
    –   Two types
            Histamine H1 receptor antagonist –respiratory and
             allergic responses
            Histamine H2 receptor antagonist – GI tract; antiemetics
    –   Description
            First generation – Sedating
            Second generation – Nonsedating
    –   Major action
            Sedation, antiemetics, anticholinergic, GI or antipruritus

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               INTEG – Pharmacology
                  Antihistamines

   Sedating                            Nonsedating
    –   Dimetane                          –   Optimine
    –   Chlor Trimeton                    –   Allegra*
    –   Tavist                            –   Claritin*
    –   PBZ, Palemine                     –   Zyrtec*
    –   Phenergan*
    –   Periactin

    Common adverse effects:               Common adverse effects:
      drowsiness and dry                    drowsiness and
      mouth                                 headache
                     ‘S’ in Sedating, ‘S’ in Safety
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      INTEG – Nursing Responsibilities
       Sedating        Non-sedating

   Force fluids 2000-3000ml                Force Fluids
   Avoid CNS depressants and               Take with food or milk
    alcohol                                 Chew gum, suck hard candy
   Avoid OTC allergy and cold with         Avoid alcohol and CNS depressants
    alcohol                                 Avoid driving or performing tasks require
                                             mental alert
   Take with food or milk                  Discontinue meds at least 4 days before
   Chew gum or suck hard candy for          skin testing
    dry mouth                               Monitor for possibility of sedation
   Avoid driving or operating
    equipment
   Avoid prolonged exposure to
    sunlight
   Phenergan – IV, IM, not SQ
   Phenergain – respiratory
    depression
   Discontinued 4 days before allergy
    testing
   Phenergan – given deep IM
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                  INTEG - Trauma

   Phases of wound healing
    –   First, second, third intentions


   Partial-Thickness and Full – Thickness
    Wounds

   Decubitus Ulcers – pressure, friction, shear
    forces

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     INTEG – Pressure Ulcers



   Who is at risk for pressure ulcers?
Altered mental status, impaired sensory,
 immobile, malnourished or poor intake of
         nutrients, incontinence



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Stages of Pressure Ulcers
   Stages 1, 2 3, and 4




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INTEG – Treatment of Pressure Ulcers

   Pressure-relief or pressure-reduction devices
   Positioning and skin care
   Assessments to treatment( stage, location, drainage)
   Swab wound cultures; CBC, Electrolytes, Urinalysis
   Wound Care – hydrophobic/hydrophilic-dressings
   Physical Therapy – whirlpool and debridment
   Pharmacology – topical, systemic antibiotics
   Diet – Proteins, vitamins, minerals, and hydration

                                           Williams 2004
           INTEG – Pressure Ulcers

   New Technologies                Complications
    –   Electrical Stimulation       –   Infection (purulent
                                         drainage)
    –   Vacuum-Assisted              –   Bleeding
        Wound Closure                –   Dehiscence
                                     –   Eviseration
    –   Hyperbaric Oxygen
        Therapy                     Surgical – Post op Graft
                                     Sites
                                     –   Pressure dressings


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         Integumentary – Infections

   Bacterial
    –   Impetigo, folliculitis, furuncle, carbuncle, cellulitis
   Viral
    –   Herpes simplex virus, Herpes zoster, warts
   Fungal
    –   Candidiasis
   Infestations – Tinea’s, pediculosis, scabies




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            Bacterial Infections:
                Pyodermas
   Impetigo- superficial infection of skin caused by
    staphylococci, streptococci, and multiple bacteria
   Folliculitis- infection of bacterial or fungal origin
    arising within the hair follicle
   Furuncles- acute inflammation spreading to
    surrounding dermis
    Carbuncles- abscess of skin and subcutaneous
    tissue
   Cellulitis – cell/tissues by Staphyloccus or
    Streptococcus

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         Viral Skin Infections

 Herpes   Zoster- infection caused by
  varicella-zoster virus
 Herpes Simplex- (HSV-1, HSV-2)
  –   Type 1 typically occurs on mouth
  –   Type 2 typically occurs on genitals



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    Fungal (Mycotic) Infections

 Tinea Corporis- Ringworm of the Body
 Tinea Capitis- Ringworm of the Scalp
 Tinea Cruris- Ringworm of the Groin
 Tinea Pedis- Athlete’s Foot
 Tinea Unguium- Onychomycosis




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INTEG – Treatment of Infections

   Antibiotics, antiviral, antifungal
    –   Topical antiviral (Zovirax or Denavir)
    –   Topical antifungal (Nizoral)


   Standard Precautions
   Burow’s solution
   Open wound, dressing care
   Pharmacology

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      INTEG – Cutaneous Anthrax

   Bacillus anthracis
   Skin or Systemic
   Vesicle lesion, raised; hemorrhagic center forms to
    necrosis, eschar
   Painless, swelling, pruritus; systemic in enlarged
    lymph nodes (fever and chills)
   Appearance and Culture
   Oral antibiotics for 60 days (Cipro, Doryx,
    Vibramycin)


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            INTEG – Cutaneous Anthrax
                    Antibiotics

   Fluoroquinolone                         Tetracyclines
     –   Cipro, Levaquin                      –   Achromycin, Vibramycin,
     –   Monitor Theophylline and                 Declomycin
         warfarin                             –   Most common adverse effects
     –   Avoid milk products, antacids            are nausea, cramping and
     –   Avoid overexposure to sun                distention, vomiting, diarrhea,
                                                  and superinfections
                                              –   Caution for photosensitivity
                                              –   Antacid doses at least three
                                                  hours after med.
                                              –   Check CBC, urinalysis, and
                                                  liver and kidney function tests
                                              –   Diary and iron avoided with
                                                  med



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Parasitic Skin Infestations

 Pediculosis-   infestation of lice
  –   Pediculosis Capitis- head lice
  –   Pediculosis Corporis and Pubis-
      infestation of body and pubic region
         infestation by itch mite
 Scabies-
 Sarcoptes scabiei


                                       Williams 2004
          INTEG – Parasitic Disorders
                  Treatment

   Pruritus – antipruritis measures
    –   colloidal and tar baths; cool sleeping
        environment; anti-histamine and anti-inflammatory
    –   Sedative anti-histamine best given at bedtime
   Clean clothing and bed linen, personal items
   Bio-well, Kwell, Ovide, Prioderm



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                Dermatitis

 Contact Dermatitis- Inflammatory reaction of
  skin to physical, chemical, or biological
  agents
 Noninfectious Inflammatory Dermatoses
   – Psoriasis
   – Exfoliative Dermatitis




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Chronic Skin Disorders

             Eczema

             Psoriasis

     Seborrheic Dermatitis




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INTEG – Treatment of Dermatitis

                     Steroids – topical or systemic

                 Oil-based or water-soluble creams

                             Antihistamines

           Compresses and Baths (colloidal, tar extracts)

   Tar, Ultraviolet light, Methotrexate, Cyclosporine, and Imuran



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Dermatitis




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          INTEG – Benign Tumors

   Cysts – hard, but moveable growth; excision
   Seborrheic Keratoses – elderly; called aging spots;
    excision for cosmetic purposes
   Keloids – growth from scar; dark skin people
   Nevus – mole
   Warts- papillomavirus-elevated flesh color or reddish
    brown
   Hemangiomas – blood vessel tumor; elderly; red to
    purple; pink to bluish


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           Integumentary - Cancers

   Actinic Keratosis (Premalignant)
   Squamous Cell Carcinoma
   Basal Cell Carcinoma
    –   Nodular or superficial; suspicious lesions are >2 cm
    –   Treatment – removal
   Melanoma
   Kaposi’s sarcoma (associated with HIV/AIDS)



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         Malignant Tumors : Skin Cancer




   Basal Cell and Squamous Cell Carcinoma
      – BCC is most common with small waxy nodule
      – Nodular or superficial; suspicious lesions are >2
         cm
      – Treatment – removal
      – SCC is malignant proliferation arising from
         epidermis
   Malignant Melanoma- cancerous neoplasm is most
    lethal


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Skin Cancer Squamous




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Skin Cancer - Melanoma




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Kaposi Sarcoma




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INTEG – Treatment of Cancers

   Medical                              Surgical
    –   Pharmacology                      –   Cryosurgery
            Topical corticosteriod
            Topical and systemic
             chemotherapy
                                          –   Curettage and
            Interferon
                                              Electrodesiccation

    –   Radiation                         –   Excision

    –   Immunotherapy

                                                         Williams 2004
 Dermatologic and Plastic Reconstructive
                Surgery


 Wound   Coverage: Grafts and
  Flaps
 Chemical Face Peeling
 Dermabrasion
 Facial Reconstructive Surgery
 Face Lift
 Laser treatment of cutaneous
  lesions
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                    INTEG-Study Key

   For each disorder, know the:
    –   Etiology or pathophysiology
    –   Signs and symptoms
    –   Diagnostic tests
    –   Treatment
            medical/surgical
            complications
    –   Nursing interventions
            Health Promotion; Client Teaching; Psychosocial; Safey;
             Infection Control Issues


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         Legislative Day 2006
Shelton Nursing Students with Rep. Allen




                               Williams 2004
Legislative Day 2006 in Montgomery
     Glorymar and Ms. Griffin




                          Williams 2004
                  INTEG - Summary

   Most skin disorders are treatable, not fatal.

   Most skin disorders are uncomfortable with pain, swelling,
    pruritus.

   Most skin disorders require physiological and psychological
    care; lesions alter body image

   Most skin disorders are treated with medical intervention; few
    disorders require surgery for cosmetic purposes, or promote
    healing, or to remove cancer cells.


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