Weber Ch 26 Integument

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cswett
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102768
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Weber Ch 26 Integument
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2011-09-19 10:54:51
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Integumentary System
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Integumentary
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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
    Recommendations
    • 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

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