Patho Test 3 - Chapter 46 - Alterations in the Integumentary System of the Adult and Child

Tinea Capitus

"Ringworm of the scalp" Propensity of organism at hair follicles with subsequent hair loss Common sources include cats and dogs Treatment: Oral Anti-fungal medication **Treat your pets if they have it too**

2nd Degree: Depth of Burn

***Deep***, partial thickness Skin function—absent Tactile and pain sensors—intact but diminished Blisters—possible blisters, tissue paper like skin that lifts off Wound after debridement—mottled, waxy, white, dry surface Healing—30 days or more on it's own

3rd Degree: Depth of Burn

***Full Thickness burn*** Formerly known as 3rd degree Skin function—absent Tactile and pain sensors—absent Blisters—rare, layers of skin lift off Wound after debridement—white, cherry red, black, dry, leathery Healing—cannot heal, requiring skin grafting

2nd Degree: Degree of Burn

***Superficial***, partial and Deep partial thickness Formerly known as 2nd degree Skin function—absent Tactile and pain sensors—intact Blisters—present within minutes, fluid filled Wound after debridement—red to pale ivory, moist Healing—21-28 days

1st Degree: Degree of Burn

***Superficial***—depth of epidermis only Skin function—intact Tactile and pain sensors—intact Blisters—only after ≈ 24 hours Wound after debridement—normal underneath, may be slightly red Healing—3-5 days

Pressure Ulcers: Stages

**KNOW THESE** Stage 1: Nonblanchable erythema of intact skin (the area of red skin should flash white when you push on it and back to red) Stage 2: Partial-thickness skin loss involving epidermis or dermis (doesn't flash white; there is open skin) Stage 3: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to, but not through underlying fascia (muscles are exposed; Stage 4: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (Stage 2) Partial-thickness - Epidermis & Dermis

Urticaria Dermatitis

AKA Hives System issue due to a reaction outside our body or we ingested something to set this reaction off Huge histamine response Type I hypersensitivity reaction Wheals and puritis (Circular & itching) Reaction to: Foods, medications, insect stings, viruses

Warning Signs of Melanoma

Asymmetry: Different halves are not the same Borders: Irregular, ill-formed Color: Not the same throughout the lesion Diameter: Larger than 6 mm Evolving/Enlargement/Elevation: Changes in size, shape, shades of color, symptoms (itching, tenderness), or surface (especially bleeding) Best defense - SPF use (at least 30SPF) & Early Detection!!!!!!! MELANOMA WARNING SIGNS: Melanoma experts advise looking for the ABCDE of melanoma: A. Asymmetry—the different halves of the skin lesion do not look the same B. Borders—irregular, shaggy, or ill-formed C. Color—not the same throughout the lesion D. Diameter—larger than 6 millimeters (1/4 of an inch, about the size of a pencil eraser) E. Elevation/Enlargement/Evolving—changes in size, shape, shades of color, symptoms (itching, tenderness), or surface (especially bleeding) Best defense is out of sun or SPF use and early detection Often goes to the brain and bone; mastisizes rapidly

Pustule vs. Vesicle

Both of them hold fluid. Pustule - holds puss Vesticles- clear fluid; seen with blisters

Braden Scale

Braden Scale (Skin Assessment; determines how likely your patient is to experience skin break down) If they are scoring 18 or below, then your patient is at risk for skin breakdown; you want a high number; the highest you can get is 23 (Per OHRH; but 24 according to this example) **KNOW: 18 or below = skin breakdown**

Pathophysiology of Major BurnsStage I

Burns associated with immediate major loss of fluid due to evaporation as well as shift of fluid and electrolytes into tissue Massive tissue edema - Loss of capillary function ("loss of capillary seal") - Albumin seeps out of intravasculature Hypovolemia - decrease ECF and IVF Hypotension - Low BP Burn shock—type of hypovolemic shock Also with extensive cellular response including release of inflammatory mediators (including histamine and prostaglandin) ↓ cardiac output with ↓ tissue perfusion to organs including liver, kidney, GI tract

Contact Dermatitis

Can be Type I IgE or Type IV cell-mediated hypersensitivity reaction Manifestations: Erythema, swelling, pruritus Vesicular lesions in a type IV reaction (vesicles are fluid filled spots) Most common - Poison ivy, oak, sumac

Pathophysiology of Burns (cont.)

Cardiovascular Loss of fluid ↓ cardiac output, ↑ Hct, hypoproteinemia Renal damage to renal tubules r/t hypovolemia Cellular Hypermetabolic state (with ↑ SNS) Hypercoagulable state Changes in cell membrane K+ shifts ↓ extracellular Ca++ ***Low fluid = HIGH K***

Psoriasis

Chronic, relapsing, proliferative disorder ≈ 2.6 million Americans Average age of onset about 20-30 y/o genetic and/or immmunologic component Characterized by thickened dermis and epidermis with well-demarcated, thick, silvery, scaly plaque Can be mild, moderate or severe Can have remission and exacerbation Caused by increased epidermal cell turnover / cell regernation & cell replacement Normal epidermal cell turnover is every 27 days Psoriasis: cell turnover is roughly every 3-4 days, causing the buildup of cells Autoimmune / Chronic disorder Demarcated - easily see the outline of the border

Burns

Highest % of deaths 2ndary to burns are a result of home fires Burns may be thermal (e.g. flames, hot liquids, electrical) or nonthermal (e.g. acid or alkaline substances, radiation) Effect of burn depends on depth of injury and extent of total body surface involved (TBSA - Total Body Surface Area) Major Burns: - 25-40% TBSA in adults - 10% TBSA in children and elderly

Determining TBSA: The Rule of Nines

Examples: 9% - 1 Leg, only the front side 18% - 1 Leg, front and back side

Risk Factors for Pressure Ulcers

Immobilization Elderly patients Neurological disorders that impact mobility (stroke patients) Incontinence of bowel or urine (due to moisture on skin from BM or urine) Fractured femur Long surgeries or other procedures particularly if poor positioning or unrelieved pressure spots Debilitated state Obesity Hx of severe or chronic illness Shearing forces such as dragging to move up in bed (Patient who constantly needs to be moved up in bed) - Best treatment - turned the patient every 2 hours

Pathophysiology of Burns (cont.)

Immunologic: ↑ susceptibility to infection ↑ inflammatory cytokines Evaporative water loss Skin cannot regulate water loss Normal skin requires about 600-800 cc/day Burn wound may be as many 30 liters/ day

Skin Cancer

Increasing Incidence: ≈ 1 million new cases per year ≈ 90% are highly curable Risk Factors: Excessive exposure to UV light / sunburns Fair complexion Certain occupations including exposure to coal tar, creosote (particle found in chimnies) Warning Signs: Any unusual skin condition—particularly change in size or color of mole or other darkly pigmented area on skin

Pressure Ulcers

Ischemic (oxygen deprived) ulcers resulting from pressure or shearing forces that impede circulation to the skin and subcutaneous tissue (fatty tissue) If pressure relieved, mild hyperemia without damage If not relieved: breakdown of endothelial cells with formation of microthrombi and eventually anoxic necrosis of tissues Pressure Ulcers (Bed sores): elbows, spine, knees, heels of our feet, toes, coccyx, tail bone, Hyperemia - an excess of blood in the vessels supplying an organ or other part of the body.

Skin Cancer: Squamous Cell Carcinoma

Less common than basal, but grows rapidly. Risk factor: sun exposure Erythematous scaly patch with sharp margins Usually 1cm or more in size Develops central ulceration (in the middle of the ulcer)

Skin Cancer: Basal Cell Carcinoma

Major risk factor is sunlight exposure Usually in sun-exposed areas (e.g. ears, neck, face, hands) More common > 40yo Usually non-metastasizing Usually flesh or pink colored, smooth nodules that enlarge over time often with central depression; can appear shiny or waxy; can bleed easily may eventually ulcerate and develop crusting Can originate in hair follicles or sebaceous glands If untreated, can destroy surrounding tissues

Skin Cancer: Malignant Melanoma

Malignancy of melanocytes Common sites include skin, eyes, ears, neck, arms, legs, and trunk Usually brown or black in color may have erythema and tenderness May have ulceration and bleeding

Pressure Ulcers: Necrotic Tissue

Necrotic tissue (black tissue; deprived of oxygen due to tissue death) Necrotic tissue = inflammatory response: Pain and then possibly lack of sensation Hyperemia (increased blood flow to the area to carry oxygen to the tissue) Fever (due to infection) ↑ W.B.C. (lycocytosis due to infection) Can develop foul-smelling discharge If large, can develop extensive soft tissue infection, osteomyelitis (in bones), even septicemia (septic)

Herpes Simplex Virus - Type 1

Oral Herpes Inflamed, painful vesicles Usually located around mouth, lips, and nose Tingling sensation prior to eruption AKA Cold Sore No cure; we try to prevent eruption;

Herpes Zoster ("Shingles")

Outbreak of blisters or vesicles on the skin associated with severe pain—usually one side of body or face Incidence ≈ 20% population Risk factors: People over 50 y/o Anyone who has had chickenpox More common in people with weakened immune system Caused by varicella-zoster virus Pain is similar to a buring / knife like pain; occurs due to extreme stress (most of the time) Biggest difference between this and chicken pox: It occurs unilaterally (meaning only on one side of the body) No Cure for this; virus is usually asleep in the nerve root area waithing to flair up Vaccine: Zostavax (doesn't cure Shingles, but it tries to make sure the virus stay's asleep"

Fungal Skin Infection: Candidiasis

Risk factors: Moist environment Pregnancy Antibiotic therapy Diabetes Immunosuppressed Obese Patients Yeast-like infection: In mouth called "thrush" Dense white plaques in mouth Also can be in groin, buttocks

Sites of Psoriasis

Scalp Ears Elbows Umbilicus (belly button) Genitalia Butt Crack Knees

3 Stages of Major Burn Physiology

Stage I: Hypovolemic Shock, also known as "Burn Shock" - Emergent Care - First Aid to stop the burn - Types of Burns: thermal, chemical, electrical radiation Stage II: Fluid Resuscitation (need to replace fluid rapidly) Stage III: Wound Care (Need to prevent infection) 2 Priorities of taking care of a burn wound victim: Fluid Replacement (stage 2) and Infection prevention (stage 3) Examples: Stage I: (meth lab that blew up, firefigher that was stuck in a building)

Pathophysiology of Major Burns (Con't)

Stage II - Fluid Resuscitation Maintain stable fluid volume Diminishing inflammatory response can then lead to hypervolemia Stage III - Wound Care

Healing Decubitus Ulcer

This stage 4 has a "tunnel" spot that goes in deep; usually requires a wound vac with suction to help it heal and close faster

Fungal Skin Infection: Tinea

Tinea - THINK FUNGAL IS CONTAGIOUS!!!! Tinea capitus—fungal infection of the scalp Tinea corporis—superficial fungal infection of the body (ring worm) Tinea pedis—superficial fungal infection of the foot ("athlete's foot") Takes forever to treat; approximately 6 weeks

Atopic Dermatitis or Atopic Eczema

Type I Hypersensitivity reaction Can be triggered by allergens, stress, heat and sweating Characterized by: Severe pruritis (itching) Eczematous appearance - Skin patchy on top of erythema, swelling Frequent exacerbations Skin dry and easily irritated Inflammatory condition of the skin Hallmark Sign: Redness rash that feels like sandpaper Common in children; generally resolves itself with children as they age and they have less outbreaks as they age as well

Decubitus Ulcer

Ulcer on the butt Stage 2 ulcer (left butt cheak) Stage 3 Ulcer (right butt cheak)

Macule

less than a centimeter in width/diameter ; sun spots

Contact Dermatitis (Con't): Diaper Dermatitis

most common skin disorder of infancy and early childhood Can affect lower abdomen, genitalia, buttocks and upper thigh Generally r/t prolonged contact with urine and feces May be secondarily infected with Candida albicans Vary from mild erythema to erythematous papular lesions

Papule

solid bump; usually small, less than a centimeter in diameter / width; raised spots on your skin. feels like bumps; 2nd pic: Papular rash

Rash

temporary eruptions of the skin generally associated with childhood diseases Example: heat, diaper irritation, drug-induced reactions May range in size from fraction of mm to many centimeters May be blanched (white) or erythematous (red) Scratching can lead to lichenfication or excoriation (irritation; red Petechiae)

Lesions

traumatic or pathologic loss of normal tissue continuity, structure or function (sometimes referred to as rashes) May range in size from fraction of mm to many centimeters May be blanched (white) or erythematous (red) Scratching can lead to lichenfication or excoriation (irritation; red Petechiae)

Skin Cancer: Malignant Melanoma

≈ 4% of skin cancers More likely to metastasize than other skin cancers Risk Factors: Fair complexion, particularly blond or red hair Excessive childhood sun with blistering sunburn ↑ number of moles + family history of melanoma Presence of changing mole on the skin Hx of 3 or more years of an outdoor job as teenager