Weber Ch 26 Integument

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Weber Ch 26 Integument
2011-09-19 10:54:51
Integumentary System

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  1. Components of the Integumentary System
    • Skin
    • Hair
    • Nails
    • Sweatglands
    • -eccrine
    • -apocrine
    • Sebaceous glands
  2. Functions of Skin
    • Protection from foreign substances & trauma
    • Retains body fluids & electrolytes
    • Primary contact with outside world; sensory input
    • Temperature regulation
    • Production of vitamin D.
    • Express emotions/blushing.
    • Excretion sweat, urea, and lactic acid.
    • Repair of surface wounds by cell replacement.
  3. 3 Layers of Skin
    • Epidermis-outermost layer.
    • ¨Stratified squamous epithelium
    • ¨Avascular
    • ¨Contains hair & nails
    • ¨Keratinization = Stratum germintavium
    • -Melaocytes

    • Dermis-middle layer.
    • Highly vascular connective tissue
    • Blood vessels dilate/constrict; response to external/internal stimuli – regulating temp/BP
    • Nourishes epidermis/supports outer layer
    • Sensory nerve fibers-touch, pain, temperature.
    • Stretch/contracts with body movement.
    • Variable thickness (1-4 mm).
    • Hypodermis layer/ Subcutaneous (inner layer)
    • Made up of loose connective tissue and subcutaneous fat.
    • Retains heat, cushions, & calorie storage
  4. Appendages
    • Hair:
    • ¨Epidermal cells (dermis) produce hair
    • ¨Papilla (base of hair follicle) provides nourishment for growth
    • ¨Melanocytes in hair shaft give color

    Nails: epidermal cells converted to keratin (protect fingertips; tissue under nail highly vascular with clue to O2 status

    • GLANDS
    • Eccrine Sweat Glands: Regulate body temperature.
    • Appocrine Sweat Gland: larger and deeper. Produce sweat in response to emotional stimuli.
    • Sebaceous Glands: Secretes sebum that lubricates skin and hair.
  5. Skin, Hair, Nails Risk Factors
    • Systemic disease - liver, kidney, autoimmue
    • Infections
    • Family history - dermatitis, exzema
    • Immobility
    • Excessive sun exposure
    • Chemical exposure
    • Allergen exposure
    • Medications
  6. Problem-Based History - Skin
    • Pruritus (most common) - itching (many causes - medications to bug bites, soap, etc)
    • Rash
    • Pain /discomfort
    • Lesions/changes in moles
    • Changes in skin color - vitiligo
    • Skin texture change
    • ¨Xerosis - excessive dry - thyroid disorders
    • ¨Seborrhea - excessive oily
    • Wounds - ask about what happened, how long they have been there
    • siver or white - been there a year or longer
    • Keliod formers - get overabundance of scar tissue
  7. Assessment - Hair & Nails
    Hair: experience change (dry, brittle, hair loss), when, contributing factors: hair products & diet change (low protein), distribution change on extremities (poor circulation)- skin discoroation will accompany?

    Nails: problems, chemical exposure, brittle, pitting, chew, infection, keeping clean, appear dirty?
  8. Health Promotion with Integumentary System
    • Screening is important to prevent problems with skin.
    • Skin cancer is the most important common cancer.
    • Older people tend to be diagnosed later with more deadly results.
    • One of the goals of Healthy People 2010 is to reduce number melanoma deaths and to increase the number of people who use protection.
  9. American Cancer Society Primary Prevention
    • Avoid sun exposure-especially between 10am-4pm
    • Avoid sunlamps and tanning booths.
    • Wear protective clothing and wide brimmed hats.
    • Wear sunglasses with 99%-100% UV protection.
    • Apply suncreen protection of 15 or higher every two hours while in the sun.
    • Apply suncreen even on overcast days
    • Screening-Cancer related skin checkup every 3 years for people 20-40.
    • Screening-Cancer related skin checkup every year for people over 40.
    • Monthly self-exam of skin starting at age 20
    • Use: ABCDEF mnemonic to help remember warning
    • signs of melanoma.
  10. Early Signs of Melanoma
    • A---- Asymmetry (not round or oval).
    • B---- Border (poorly defined or irregular border).
    • C---- Color (uneven, variegated).
    • D---- Diameter (usually > 6 mm).
    • E---- Elevation (recent change from flat to raised lesion).
    • F ----Feeling (sensation of itching, tingling, stinging
  11. Skin Cancer Warning Signs
    • A–Asymmetry (not round or oval)
    • B– Border poorly defined
    • C– Color uneven, variegated
    • D– Diameter > 6 mm
    • E– Elevation/raised
    • F– Feeling (itch, tingle, sting)
  12. Examining the Integumentary System
    • Inspect skin for general color & localized variations in skin color.
    • Palpate skin for texture, temperature, moisture, mobility, turgor & thickness.
    • Inspect facial & body hair for distribution, color, quantity & hygiene.
    • Inspect & palpate the nails for shape, contour, consistency, color, thickness & cleanliness.
  13. Examining Skin
    • General survey (color, pigmentation, vascularity, bruising, lesions, discolorations, odors)
    • ¨Systematic examination (head, neck, trunk, arms & legs)
    • ¨Adequate lighting
    • Inspect for color: uniformity (consistent over body
    • surface) except vascular areas
    • Inspect for localized variation in skin color
    • ¨Intentional: tattoos, coining or cupping patterns
    • ¨Normal localized variations
    • Moles, freckles, patches, striae
  14. Examination Techniques: Skin
    • Palpate for:
    • ¨Temperature and moisture
    • ¨Texture
    • ¨Mobility and turgor
    • ¨Thickness: varies with age/area

    • Inspect/palpate for skin lesions/ observable change in
    • structure
    • ¨Location/distribution, color, size (cm), shape/border,
    • elevation (flat/raised), pattern, & characteristics (hard, soft, fluid, exudate)
    • Primary lesions: previously normal
    • Secondary lesions: change in primary
    • Vascular lesions: with bleeding, aging, circulatory problems (ecchymosis, telangiectasia, angioma)
  15. Terms Related to Color Variation
    • Cyanosis-bluish tone.
    • Eccymosis-bruise.
    • Jaundice-yellowish color.
    • Pallor-pale.
    • Petechiae-pinpoint purplish areas on skin
  16. Primary Skin Lesions
    • Macule-flat, circumscribed (round with definite borders), <1cm.
    • Ex. Freckles, nevi, petechiae, measles.

    Papule-elevated, firm, circumscribed, <1cm. Ex. Wart (verruca), skin tag, cherry angioma.

    Patch-flat, irregular shaped macule > 1cm. Ex. Vitiligo, port wine stains (birth marks), mongolian spots.

    Plaque-elevated firm, rough, flat surface >1cm. Ex. Psoriasis, exzema.

    Wheal-elevated irregular, solid, variable diameter. Ex. Insect bites, allergic reactions. TB test.

    Nodule-elevated, firm, circumscribed, deeper in the dermis than a papule 1-2 cm. Ex. Melanoma, neurofibroma, hemagioma.

    Tumor-elevated, solid. > 2cm. Ex. Neoplasms, hemangioma.

    Vesicle-elevaed circumscribed, superficial, fluid filled, <1 cm. Ex. Varicella, sherpers zoster, impetigo.

    Pustule-elevated, similar to vesicle but filled with purulent fluid. Ex.acne, herpes simplex.

    Bulla-vesicle > 1cm. Ex. Blister.

    • Cyst-elevated circumscribed, encapsulated in dermis, semisolid, filled with fluid.
    • Ex: cystic acne, sebaceous cyst.
  17. Secondary Skin Lesions
    Scale-flaky skin, irregular, thick or thin, dry or oily, size varies. Ex. Seborrheic dermatitis, drug reactions.

    Lichenification-rough, thick, epidermis. Comes from rubbing or irritation. (bra line)Ex: chronic dermatitis.

    • Keloid-irregular-shaped, elevated, grows larger
    • than the scar.

    • Scar-thin to thick fibrous tissue. Follows surgery
    • or injury.

    • Excoriation-loss of epidermis, hollow-out in appearance. also called denuded
    • Ex: abrasion, scratch, scabies.

    Fissure-linear, crack through epidermis to dermis. Moist or dry. Ex: Athelete’s foot, cracks at corner of mouth.

    Crust-dried drainage or blood, slightly elevated, size varies, may be red, back, tan. Ex: scab on abrasion, eczema.

    Erosion-loss of part of epidermis, depressed, moist. Ex: varicella, herpes simplex.

    • Ulcer-loss of epidermis and dermis, concave.
    • Ex: pressure ulcer, stasis ulcer

    • Atrophy-thinning of skin surface. Skin will
    • seem translucent. Ex: aged skin, striae.
  18. Vascular Skin Lesions
    • Petechiae-tiny flat, reddish purple, nonblanchable.
    • <0.5 cm.

    Purpura-flat, reddish >0.5 cm.

    Ecchymois-bruise, reddish purple.

    Angioma-benign tumor, consisting of small mass of small blood vessels. Ex. Cherry or strawberry angioma.
  19. Examination Procedures: Hair
    • Inspect hair; head, face, body
    • ¨Shiny, soft
    • Inspect and palpate
    • ¨Scalp(nits/lice)
    • ¨Quantity (alopecia v. hirsutism)
    • ¨Distribution esp. lower extremities
    • ¨Texture (fine/vellus v. coarse/terminal)
    • -hypothyroid - course dry hair
    • -hyperthyroid - fine thin hair
    • ¨Color

    • Inspect:
    • ¨Shape
    • ¨Angle
    • ¨Contour
    • ¨Consistency
    • ¨Color
    • ¨Thickness
    • ¨Cleanliness

    • Palpate:
    • ¨Nail base
    • ¨Capillary refill < 2 sec.
  20. Abnormal Nail Findings
    • Abnormal nail findings:
    • ¨Clubbing > 180 degrees
    • - - long term oxygen deficit
    • ¨Hypertrophy
    • ¨Thinning/brittleness
    • ¨Koilonychia (spoon nail) - iron deficinecy
    • ¨Inflammation
    • ¨Pitting
    • ¨Leukonychia
    • ¨Beau’s lines - horizontal - due to chronic illness
    • - vertical - dosent really mean anything
  21. Age related changes
    • drier skin
    • from decreased perspiration & decreased sebaceous/sweat gland activity
    • Appearance: thin, parchment skin due to decreased dermal vascularity
    • ¨Folding/wrinkled appearance: loss of dermal elasticity, collagen, mass
    • ¨Sharp/angular appearance over joints/bones, deepening of hollows: decreased cutaneous & SQ tissue

    ¨Nails get thicker, brittle, hard, yellow; ridges & split

    • nExamination: extra care to correlate
    • history with lesions (normal aging vs. cancer or systemic illness)

    • ¨↑
    • pigmentation due to sun exposure

    • ¨Isolated
    • areas of hypopigmentation

    • ¨↑ sun
    • exposure - ruddy,
    • thickened skin

    • ¨Solar lentigo
    • (liver spots)

    • ¨Seborrheic keratoses
    • (wart-like lesions on trunk)

    • ¨Acrochordons (skin
    • tags)

    • ¨Sebaceous
    • hyperplasia (yellow, flat papules)

    • ¨Tenting
    • due to loss of adipose tissue & elasticity
  22. Age Related Changes: Examination
    • Examination: extra care to correlate history with lesions (normal aging vs. cancer or systemic illness)
    • ¨↑ pigmentation due to sun exposure
    • ¨Isolated areas of hypopigmentation
    • ¨↑ sun exposure - ruddy, thickened skin
    • ¨Solar lentigo (liver spots)
    • ¨Seborrheic keratoses (wart-like lesions on trunk)
    • ¨Acrochordons (skin tags)
    • ¨Sebaceous hyperplasia (yellow, flat papules)
    • ¨Tenting due to loss of adipose tissue & elasticity
    • - - test skin turger over scapula or other firmer skin site
  23. Age Related Variation
    • ¨Decreased melanin causes graying
    • ¨Thinning of scalp, axillary & pubic hair
    • ¨Follicles change size; terminal hair to vellus (fine) hair (age-associated baldness, symmetrical)
    • ¨Men with (coarse) hair in nares, ears, & eyebrows
    • ¨Females develop facial hair (increased androgen> estrogen ratio)
    • ¨Loss of hair from trunk, extremities, axillary,
    • pubic area in both sexes
  24. Integumentary Nursing Diagnoses
    • Risk for hypothermia RT thinning skin.
    • Risk for infection RT scratching at rash.
    • Altered nutrition, less than body requires RT malnutrition.
    • Impaired skin integrity RT leg ulcers.
    • Disturbed body image RT scarring.
    • Risk for injury RT sun exposure.
  25. Hair Problems
    Pediculosis (Lice) – parasites lay eggs/ nits that attach to hair shafts with underlying skin red & excoriated

    Alopecia Areata– chronic autoimmune inflammatory disease with loss of hair in round patches while eyebrows & eyelashes remain

    Hirsutism – increase growth in facial hair in women associated with menopause, endocrine disorders, or steroids
  26. Nail Problems
    Onychomycosis – fungal infection of nail plate due to tinea unguium affecting 18% population; nail plate turns yellow/white and separates from bed

    • Paronychia – acute or chronic infection of cuticle usually due to staph, strep, or candida & associated with moisture; rapid onset painful inflammation at base of nail with possible abscess
    • - - frequest in nail biters