Patho Part Two
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Geriatric considerations with skin
- Becomes thinner, dryer and more wrinkled
- DNA repair of damaged skin decreases
- epidermal cells contain less moisture and change shape
- dermis thins, producing translucent, paper-thin quality that is more susceptible to tearing
- dermis becomes more permeable and less able to clear substances
- loss of epidermal tete pegs which weakens the connection to the dermis
- loss of elastin-contributes to wrinkling
- loss of flexibility of collagen fibers
- barrier function of the stratum corneum is reduced increasing risk for injury and infection
- decreased number of langerhans cells reduces the skin's immune system
- wound healing decreases as a result of decreased blood flow and slower rate of basal cell turnover
- fewer melanocytes, pigmentation becomes irregular causing decreased protection from UV light which leads to gray hair
- atrophy of eccrine, apocrine and sebaceous glands
- pressure and touch receptors and free nerve endings decrease in number, causing reduced sensory perception
- Compromised temperature regulation-increased risk of heat stroke and hypothermia
- nail plate thins and nails are more brittle
- Pressure ulcers are ischemic ulcers resulting from unrelieved pressure, shearing forces, friction, and moisture. The term decubitus ulcer refers to ulcers or pressure sores that develop when an individual lies in the recumbent position for a long time. The risks for pressure ulcers are summarized in Risk Factors: Pressure Ulcer
- Pressure sores usually develop over bony prominences, such as the sacrum, heels, ischia, and greater trochanters. Continuous pressure on tissue between the bony prominence and a resistant outside surface distorts capillaries and occludes the blood supply. If the pressure is relieved within a few hours, a brief period of reactive hyperemia (redness) occurs and there may be no lasting tissue damage. If the pressure continues unrelieved, the endothelial cells lining the capillaries become disrupted with platelet aggregation, forming microthrombi that block blood flow and cause anoxic necrosis of surrounding tissues (Figure 39-3). Shearing and friction are mechanical forces moving parallel to the skin (dragging) and can extend to the bony skeleton, causing detachment and injury of tissues. Pressure ulcers are staged or graded and one classification scheme is as follows2:
- Stage 1—Nonblanchable erythema of intact skin, usually over bony prominence
- Stage 2—Partial-thickness skin loss (erosion or blister) involving epidermis or dermis
- Stage 3—Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to, but not through, underlying fascia
- Stage 4—Full-thickness tissue loss with exposure of muscle, bone, or supporting structures (tendons or joint capsules); can include undermining and tunneling
Describe a macule
- Flat, circumscribed area that is a change in color of skin; less than 1 cm. in diameter
- Ex: Freckles, flat moles, petechiae, measles and scarlet fever
describe a papule
- Elevated, firm, circumscribed area less than 1 cm in diameter
- Ex: wart, elevated moles, lichen planus
describe a patch
- Flat, non palpable, irregular-shaped macule more than i cm in diameter
- Ex: port wine stains, mongolian spots
describe a wheal
- elevated, irregular shaped area of cutaneous edema, solid, transient, variable diameter
- Ex: insect bites, urticaria, allergic reaction
describe a vesicle
- Elevated, circumscribed, superficial, not into dermis. Filled with serous fluid less than 1 cm in diameter
- Ex: Varicella (chickenpox) herpes zoster
describe a pustule
- Elevated superficial lesion, similar to a vesicle but filled with purulent fluid
- Ex: impetigo, acne
- Loss of epidermis; linear, hollowed out crusted area
- Ex: scratch, scabies
what is petechiae
- circumscribed area of blood loss less than 0.5 cm in diameter
- circumscribed area of blood greater than 0.5 cm in diameter
Progression of pressure ulcers
- A layer of dead tissue forms as an abrasion or blister when there is superficial damage or as a reddish blue discoloration when there is deeper tissue damage. Superficial sores are more common on the sacrum as a result of shearing or friction forces (forces parallel to the skin). Deep sores develop closer to the bone as a result of tissue distortion and vascular occlusion from pressure perpendicular to the tissue (over the heels, trochanter, and ischia).
Describe how one would prevent pressure ulcers?
Preventive techniques include frequent promotion of movement, pressure avoidance (type of positioning), pressure removal (positioning interval), pressure distribution (positioning aids), and elimination of excessive moisture and drainage. Adequate nutrition, oxygenation, and fluid balance must be maintained.
What is pruritus?
What are some inflammatory disorders?
The most common inflammatory disorders of the skin are eczema and dermatitis. Eczema and dermatitis are general terms that describe a particular type of inflammatory response in the skin and can be used interchangeably. Eczematous disorders are generally characterized by pruritus, lesions with indistinct borders, and epidermal changes.
Describe Stevens-Johnson syndrome
The most common forms of erythema multiforme are usually associated with severe drug reactions and include Stevens-Johnson syndrome (severe mucocutaneous bullous form involving 10% of body surface area) and toxic epidermal necrolysis (TEN) (severe mucocutaneous bullous form involving 30% of body surface area). An immune mechanism is probably related to drug reactions (see Chapter 40 for pediatric considerations)
Describe bacterial infections with staphylococcus aeureus?
Most bacterial infections of the skin are caused by local invasion of pathogens. Coagulase-positive Staphylococcus aureus and, less often, β-hemolytic streptococci are the common causative microorganisms. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) also is a cause of serious skin infection, particularly skin abcesses.
What is cellulitis?
An infection of the dermis and subcutaneous tissue usually caused by staphylococcus aureus
- AKA verrucae
- are benign lesions of the skin caused by the many different types of HPV
Describe tinea infections
- Are classified according to their location the body.
- Fungal infection
What is candidiasis?
Caused by the yeastlike fungus Candida albicans and normally can be found on mucous membranes, on the skin, in the gastrointestinal tract, and in the vagina. C. albicans can, under certain circumstances, change from a commensal (normal) microorganism to a pathogen, particularly in the critically ill and those who are immunosuppressed
WHat is a nevi?
- Singular: nevus
- AKA birthmarks
- Benign pigmented or non pigmented lesions
Important trends for skin cancer
- • More than 1 million new cases of skin cancer are diagnosed each year with the majority being the highly curable basal (90%) or squamous cell cancers.
- • Malignant melanoma is the most serious form of skin cancer; it is not as common with an estimated 68,130 new cases per year.
- • Total estimated deaths from skin cancer in 2010 were 11,790: 8700 from malignant melanoma, 3090 from other nonepithelial skin cancers.
- Risk Factors
- • Excessive exposure to ultraviolet radiation from the sun or tanning salons
- • Fair complexion
- • Occupational exposure to coal tar, pitch, creosote, arsenic compounds, and radium
- • In people of color, skin cancer is less common, is diagnosed at a more advanced stage, and has higher morbidity and mortality than in people with light-colored skin.
- Warning Signs
- • Any unusual skin condition, especially a change in the size or color of a mole or other darkly pigmented growth or spot
- Prevention and Early Detection
- • Avoid the sun when ultraviolet light is strongest (e.g., 10 am to 3 pm), seek shade, use sunscreen preparations, especially those containing ingredients such as PABA (para-aminobenzoic acid), and wear protective clothing.
- • Basal and squamous cell skin cancers often form a pale, waxlike pearly nodule or a red, scaly, sharply outlined patch.
- • Melanomas usually have dark brown or black pigmentation; they start as small mole-like growths that increase in size, change color, become ulcerated, and bleed easily from slight injury.
- • Options for treatment include surgery, electrodesiccation (tissue destruction by heat), radiation therapy, or cryosurgery (tissue destruction by freezing).
- • Malignant melanomas require wide and often deep excisions and removal of nearby lymph nodes; selective lymphadenectomy or immunotherapy can be used; vaccines and gene therapy are in development.
- • For basal cell and squamous cell cancers, cure is virtually ensured with early detection and treatment; malignant melanoma, however, metastasizes quickly and accounts for a lower 5-year survival rate.
Which is more deadly?
- The brown one!! Melanoma
- The red ball one is squamous cell carcinoma
Rules for checkin melanoma-ABCDE
- Border irregularity
- Color variation
- Diameter larger than 6 mm
How does staging work with melanoma?
Determined by lesion thickness (presence of tumor), lymph node involvement, and presence of metastasis (TNM staging)
What is the treatment of melanoma
Treatment of melanoma with no evidence of metastatic disease involves surgical excision of the primary lesion site and involved regional lymph nodes. Radiation therapy, chemotherapy, and biologic response modifiers may be prescribed. Lesions of the extremities have the best surgical prognosis. Immunotherapy is advancing and vaccines, gene therapy, and biomarkers are under investigation. Less than 10% of individuals with regional metastasis are alive after 5 years. Early detection is critical to decreasing mortality from metastatic disease.
Describe first-degree burns
- Superficial burns
- involve only the epidermis. The skin maintains water vapor and bacterial barrier functions. There is local pain and erythema, and usually no blisters (e.g., sunburn). An extensive first-degree burn may cause systemic responses, such as chills, headache, localized edema, and nausea or vomiting. No treatment is required unless the person is elderly or an infant, in which case severe nausea and vomiting may lead to inadequate fluid intake and dehydration. Fluid therapy may be required in these cases. First-degree burns heal in 3 to 5 days without scarring.
Describe second-degree burns
Second-degree burns include superficial and deep partial-thickness burns. Superficial partial-thickness burns involve thin-walled, fluid-filled blisters that develop within just a few minutes after injury. Tactile and pain sensors remain intact throughout the healing process, and wound care can cause extreme pain. Wounds heal in 3 to 4 weeks with adequate nutrition and no wound complications. Scar formation is unusual and is genetically determined.
Describe third degree burns
- Involves destruction of the entire epidermis, dermis and often underlying subcutaneous tissue.
- The wound has a dry, leathery appearance from
What can happen to your body after a burn? Stupid question
Diminished range of motion
What is total body surface area (TBSA)
The extent of total body surface area (TBSA) burned is estimated using either the “rule of nines” (Figure 39-30) or the modified Lund and Browder chart.81 The severity of burn injury also considers many factors, including age, medical history, extent and depth of injury, and body area involved. The American College of Surgeons has defined criteria to assist healthcare professionals in identifying who should be referred to a specialized burn center
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