Medsurg Integumentary Ana&Physio

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    THE INTEGUMENTARY SYSTEM

    FUNCTIONS OF THE SKIN:

    Protection of our internal organs against invasion by bacteria and otherforeign matter; protects from constant effects of trauma

    Thicker in our feet

    The skin will always adapt to its uses, more protection for those used often

    Sensation pain, light touch and pressure

    First line for stimulus

    Sensory receptors are mostly in our hands and foot

    F & E Balance has the capacity to absorb water; retains moisture

    in SQ; water evaporates thru skin insensible losses

    Even if you soak yourself in a tub you absorb water

    On the other hand, it is also lost thru perspiration

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    Temperature Regulation heat is dissipated thru skin by 3

    processes:

    Radiation transfer of heat to another object of lower temperature situated at adistance (ex. skin gets warm when sitting near a fireplace)

    Conduction transfer of heat to a cooler object in contact with it (ex. seat getswarm when one is sitting on it for a long time)

    Convection movement of warm molecules away from the body heat

    transferred by conduction to the air surrounding the body is removed by

    convection. (ex. heat dissipates from the body when you enter an air-conditioned room)

    Vitamin Production UV light from sun synthesize Vitamin D.

    LAYERS OF THE SKIN:

    EPIDERMIS outermost layer of skin; consists of ff. cells:

    Keratin dead cells, insoluble, fibrous portion that forms outer barrier of skin;

    principal hardening ingredients or hair and nails.

    Melanocytes (cell) produces the pigment melanin which colors skin and

    tissue

    Merkel receptor that transmit stimuli to the axon

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    Langerhans plays a role in the cutaneous immune system reaction (antibodies

    that pass through the skin brings them to the lymph system which activates T-Cells to kill the invaders)

    o Rete Ridges junction between dermis and epidermis; serves as another

    layer between the two (provides nutrients to the epidermis from the

    dermis)

    o Fingerprints produced by the interlocking between dermis and epidermis

    (produces ripples)

    DERMIS often referred to as true skin; second layer; makes up

    the largest portion of the skin; provides structure and strength; has 2 layers: made

    up of blood and lymph vessels; nerves; sweat and sebaceous glands; hair roots.

    Papillary lies beneath epidermis; composed of fibroblast cells that produces

    collagen (which is a component of connective tissue which makes our skinsupple)

    Reticular also produces collagen and elastic bundles

    SUBCUTANEOUS innermost layer; also known as

    hypodermis; primarily adipose tissues; fats are stored here

    Function: skin mobility, molds body contours, insulates the body

    SKIN GLANDS

    SEBACEOUS GLAND associated with hair follicles; ducts empty out

    sebum onto space between hair follicle and hair shaft

    SWEAT GLAND formed in most part of the body except glans penis,

    margin of lips, external ear and nail bed.

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    ECCRINE GLAND ducts open directly to skin; produces thin,

    watery sweat

    APOCRINE GLAND larger and their secretion contains part ofsecretory cells; the ducts open to hair follicles; found in axilla, anal, scrotum

    and labia majora; produces milky sweat

    SKIN

    APPENDAGES

    HAIR

    root formed in the dermis and shaftprojects beyond the skin

    Cycles of Hair Growth

    Anagen Phase growing phase everyday we grown 100,000/day)

    Telogen Phase resting phase or shedding phase and you could loose 50 to 100/

    day)

    Function:

    Provides protection

    Provides insulation

    Controlled by sex hormones: Androgens (beard, chest,back, legs); Testosterone (hirsutism in women)

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    NAILS

    Made of hard, transparent plate of keratin; grows from its root which lies under athin fold - cuticle:

    Function: to protect finger, toes and their highly developed sensory function

    Growth continues throughout life; fingernails grow faster than toenails

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    SKIN ASSESSMENT:

    COLOR:

    Pallor pale (anemia, shock, albinism (absence of melanin), vitiligo

    (destruction of melanocytes; patches of white

    Cyanosis bluish (unoxygenated states)

    Erythema red, pink (inc. blood flow, polycythemia vera RBC; carbon

    monoxide poisoning, venous stasis

    Jaundice yellowish (hepatic disorders)

    Brown Tan bronzed (Addisons disease low levels of cortisol will stimulate

    melanocytes to produce melanin)

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    PRIMARY SKIN LESIONS:

    Macule/Patch

    Flat, non-palpable

    Macule < 1 cm with circumscribed edges

    Patch: > 1 cm, may have irregular borders

    Ex: freckles, flat moles, petechia, vitiligo, ecchymosis

    Papule/Plaque

    Elevated, palpable solid mass with borders

    Papule: < 0.5 cm

    Plaque: > 0.5 cm

    Vesicle/Bulla

    Circumscribed, elevated, palpable mass containing serous fluid.

    Vesicle: < 0.5 cm (ex. Herpes simplex, chicken pox, secondary burn blister

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    Bulla: > 0.5 cm. (contact dermatitis; large bun blisters)

    Pustule

    Pus-filled vesicle or bulla

    Ex: acne, impetigo, furuncles, carbuncles

    Wheal

    Elevated mass with transcalent borders; often irregular size and color vary Ex: urticaria, hives, insect bites

    Nodule/Tumor

    Elevated, palpable, solid mass; extends deeper into the dermis

    Nodule: 0.5 to 2 cm circumscribed. (ex: lipoma, poorly absorbed injection)

    babies after injection apply hot compress

    Tumor: >1 to 2 cm; does not always have sharp borders (ex. larger lipoma

    and carcinoma)

    SECONDARY SKIN LESIONS:

    Erosion

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    Ulcer skin loss is past epidermis (bed sores)

    Fissure linear crack in skin (chapped lips)

    Scales desquamated dead skin (dry skin during cold or after beach or

    swimming in pool)

    Crust residue of serum, blood, pus on skin surface

    Scar Cicatrix; healed wound or healed surgery incision Keloid hypertrophied scar tissue

    Lichenification thickening and roughing of skin

    VASCULAR SKIN LESIONS:

    Petechiae: red, pinpoint macule associated with bleeding (ex. Denguehemorrhagic stage)

    Ecchymosis associated with trauma and bleeding

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    Cherry angioma red/purple, papular and round; N-age-related skin

    alteration; no clinical significance

    Spider angioma red, arteriole (S/SX: liver cirrhosis) lesions associatedwith liver disese. Vitamin B. Deficiencies

    Telangiectasia venous star; varicosities

    COMMON NAIL DISORDERS

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    ALOPECIA/BALDNESS

    LABORATORY/DIAGNOSTIC EXAMINATIONS

    SKIN BIOPSY

    Tissue of skin removed for exam

    Either by scalpel excision or skin punch instrument

    Dermal punch: an electrical punch that can penetrate skin to a

    certain depth

    Mgt: Clean area with antiseptic solution; local anesthesia applied;specimen examined by histologist.

    PATCH TESTING

    Identifies substances to which the patient is sensitive to

    Patch left 24 to 48 hours

    20 minutes after, it is removed a reading is made

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    Reading

    Weak (+): redness, fine bumps, itching

    Moderate (+): fine blisters, papules, severe itching

    Strong (+): blisters, pain, ulceration

    SKIN SCRAPINGS

    Samples are scraped from a suspected fungal lesion with a scalpel

    blade which is moistened with oil

    Sample are transferred to the slide to be examined

    TZANCK SMEAR

    Examine cells of blistering conditions (herpes zoster, varicella,

    herpes simplex)

    Secretions are transferred to a glass slide and stained and examined

    IMMUNOFLUORESCENCE

    Identify site of an immune reaction Combines antigen or antibody with a fluorochrome dye

    Antigen/antibody can be made fluorescent by attachment to dye

    Detects auto-antibodies directed against portion of the skin

    WOOD LIGHTS EXAMINATION

    Uses a special lamp which produces long warm UV rays which results in darkpurple fluorescence

    Differentiates epidermal from dermal lesions; hyperpigmentation/hypopigmentation

    from normal skin

    Color of light best seen in darkened room

    Light not harmful to skin and eyes

    Lesions with melanin disappears with light

    Lesions without melanin increased in whiteness with light

    CLINICAL PHOTOGRAPHS

    Photographs are taken to record extent and progression of skindisorder

    Before and after photos

    GOALS OF CARE FOR INTEGUMENTARY SYSTEM

    1. Protecting the skin (bathing, using mild soap, drying thoroughly, changingdressings)

    2. Preventing secondary infections (adhere to standard precautions, handwashing &

    gloving, proper disposal of contaminated dressings; keep nails short & avoidscratching)

    3. Reversing inflammatory Process (local or topical medications)

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    INTERVENTIONS:

    1. WOUND CARE

    Wound a disruption in the continuity and regulatory processes of tissue cells

    Wound Healing the restoration of the skin continuity; may or may not restore

    normal cellular function

    I. PHYSIOLOGY OF WOUND HEALING

    A. Inflammatory Phase (lasts 1-5days) vascular & cellular response

    B. Proliferative Phase (lasts 2-20 days) granulation periodC. Maturation Phase (21 days to months & even years) collagen production & scar

    formation

    II. TYPES OF WOUND HEALING

    A. First-Intention Healing (Primary Union)

    Wounds are made aseptic with a minimum of tissue damage & tissue reaction;

    wound edges are properly approximated with sutures

    Granulation tissue is not visible and scar formation is typically minimal

    B. Second-Intention Healing (Granulation)

    Wounds are left open to heal spontaneously or surgically closed at a later date

    Examples: burn, traumatic injuries, ulcers, suppurative infected wounds

    Produces a deeper, wider scar

    III. DEGREE OF CONTAMINATION

    A. CLEAN: an aseptically made wound, as in surgery, that does not enter thealimentary, respiratory, or genito-urinary tracts

    B. CLEAN-CONTAMINATED: as aseptically made wound that enters the

    respiratory, alimentary, or GU tracts; wounds have a slightly higher probability of

    wound infection than do clean woundsC. CONTAMINATED: wounds exposed to excessive amounts of bacteria; wounds

    may be open or accidentally made or the result of surgical operations in which

    there are major breaks in aseptic techniques or gross spillage from GI tractD. INFECTED: a wound that retains devitalized tissue or involves existing infection

    or perforated viscera; such wounds are left open to drain

    IV. DRESSINGS

    Principles:

    a. Dressing change depends on patient, wound & dressing assessment not onstandardized routines; but traditionally 3-4x/day

    b. Natural wound healing process should not be disrupted; chronic wounds covered

    for 48-72 hours; acute wounds covered for 24hours; unless wound is with heavydischarges

    Purposes:

    a. Protect the wound from mechanical injury

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    b. Splint or immobilize the wound

    c. Absorb drainage

    d. Prevent contamination from bodily discharges (feces, urine)e. Promote hemostasis, as in pressure dressings

    f. Debride the wound by combining capillary action & the entwining of necrotic

    tissue within its mesh

    g. Inhibit or kill microorganisms by using dressings with antiseptic or antimicrobialproperties

    h. Provide physiologic environment conducive to healingi. Provide mental & physical comfort for the patient

    TYPES OF DRESSINGS:

    A. WET DRESSINGS

    Wet compress is applied to skin

    Indicated for acute weeping, inflammatory lesions (vesicles, bullae, pustules,

    ulcers)

    Could be sterile or clean technique depending on the disorder

    Purposes:

    a. Reduce inflammation by producing constriction of blood vessel

    b. Clean exudates, crusts, & scalesc. Maintain drainage of infected areas

    d. Promote healing by facilitating free movement of epidermal cells across

    involved skin so new granulation could form

    Wet-to-Dry Dressing:

    Particularly useful for untidy or infected wounds that must be debrided & closedby secondary intention

    Gauze saturated with sterile saline or antimicrobial solution is packed into the

    wound

    The wet dressing is then covered by dry dressing

    As drying occurs, wound debris & necrotic tissue are absorbed into gauze

    dressing

    The dressing is changed when it becomes dry

    Wet-to-Wet Dressing:

    Used on clean open wounds or on granulating surfaces; sterile saline or anantimicrobial agent may be used to saturate the gauze

    Provide a more physiologic environment (warmth & moisture) which can enhancethe local healing processes as well as assure patient of greater patient comfort;

    thick exudates is more easily removed

    Disadvantage surrounding tissues can become macerated, the risk of infection

    may rise, and bed linens become damp

    B. MOISTURE-RETENTIVE DRESSINGS

    Performs same function as wet dressing

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    More efficient in removing exudates because of moisture-vapor transmission rate

    Has reservoir that can hold excessive exudates

    Already impregnated with saline solution, zinc-saline solution, hydrogel,

    antimicrobial agents

    Advantages: reduced pain, fewer infections, less scar tissue, gentle debridement,

    frequency of dressing change

    Forms: Hydrogels, Hydrocolloids, Foams, Ca. Alginates

    C. DRY-TO-DRY DRESSINGS

    Used primarily for wounds closing by primary intention

    Offers good wound protection, absorption of drainage, & provides pressure (if

    needed) for hemostasis

    Disadvantage they adhere to the wound surface when drainage dries; removal can

    cause pain & disruption of granulation tissue

    D. OCCLUSIVE DRESSINGS

    Commercially produced or from sterile or clean gauze squares or wrap Purpose: cover topical meds applied to dermatosis

    Kept airtight by using plastic film (thin & readily adapts to size, body shape & skin

    surface)

    Should be used no more than 12 hours each day

    WOUND DRAINAGE

    Placed on wounds only when abnormal fluid collections are present or expected

    Collection of body fluids in wounds can be harmful: provides media for bacterial

    growth, pressure in wound site interfering with blood flow to the area, causespressure on the adjacent area, causes local irritation & necrosis due to fluids such as

    pus

    Commonly made of soft rubber or plastic & placed within wounds typicallyattached to portable suction with a collection bottle

    Drains within wounds are removed when the amount of drainage over a period of

    days

    2. THERAPEUTIC BATH

    BALNEOTHERAPY bath or soaks; useful when large areas of skin are affected

    Purposes:

    a. Removes crusts, scales & old medications

    b. Relieve inflammation & itching that accompany acute dermatoses

    Principles: water temperature must be comfortable to the patient; should not exceed20-30 minutes to avoid skin maceration

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    Bath Solutions:

    a. Water same effect as wet dressing; fill the tub half-fullb. Saline for widely disseminated lesions; keep water at comfortable temperature

    c. Colloidal (Aveeno, Oatmeal) antipruritic, soothing; dont allow water to cool

    excessivelyd. Sodium Bicarbonate (Baking Soda) cooling; use bath mat; causes tub to be

    slipperye. Starch soothing; same mgt as baking soda

    f. Medicated Tars (Balnetar, Doak Oil, Lavatar) for psoriasis, chronic eczema;apply emollient cream to damp skin after bath

    g. Bath Oils antipruritic & emollient action

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