Med Surg- Chapter 24: Assessment of the Integumentary system

Mole (nevus) manifestations related to skin abnormalities?

- Benign overgrowth of melanocytes - Defects of development; excess numbers and large, irregular moles; often familial

Vitiligo manifestations related to skin abnormalities?

- Complete absence of melanin (pigment) resulting in chalky-white patch - Autoimmune, familial, thyroid disease

Microscopic Tests of integumentary

- Culture - Immunofluorescence studies - Mineral oil slides - Potassium hydroxide (KOH)

Intertrigo manifestations related to skin abnormalities?

- Dermatitis of overlying surfaces of the skin - Moisture, irritation, obesity; may be complicated by Candida infection

Comedo (acne lesion) manifestations related to skin abnormalities?

- Enlarged hair follicle plugged with sebum, bacteria, and skin cells; can be open (blackhead) or closed (whitehead) - Heredity, certain drugs, hormonal changes with puberty and pregnancy - Cyanosis

Wood's lamp (blacklight)

- Examination of skin with long-wave UV light causes specific substances to fluoresce (e.g., Pseudomonas organisms, fungal infections, vitiligo) - Before: Teach patient the purpose of test and procedure. Tell patient it is not painful - During: Darken room

Diagnostics: Biopsy's

- Excisional - Incisional - Punch - Shave

Hematoma manifestations related to skin abnormalities?

- Extravasation of blood of enough size to cause visible swelling - Trauma, bleeding disorders

Tenting manifestations related to skin abnormalities?

- Failure of skin to return immediately to normal position after gentle pinching - Aging, dehydration, cachexia

Tzanck test (Wright's and Giemsa's stain)

- Fluid and cells from vesicles examined - Used to diagnose herpes infections. Specimen put on slide, stained, and examined microscopically. - Before: Teach patient the purpose of test - During: Use sterile technique for collecting fluid

Alopecia manifestations related to skin abnormalities?

- Hair loss (local or general) - Heredity, friction, rubbing, traction, trauma, stress, infection, inflammation, chemotherapy, pregnancy, emotional shock, tinea capitis, immunologic factors

Potassium hydroxide (KOH)?

- Hair, scales, or nails examined for superficial fungal infection. Put specimen on glass slide and add 10%-20% concentration of KOH - Before: Teach patient the purpose of test - During: Prepare slide

Keloid manifestations related to skin abnormalities?

- Hypertrophied scar beyond wound margins - Predisposition more common in dark-skinned persons

Varicosity manifestations related to skin abnormalities?

- Increased prominence of superficial veins - Interruption of venous return (e.g., from tumor, incompetent valves, inflammation), often found on lower legs with aging

Ecchymosis (bruising) manifestations related to skin abnormalities?

- Large, bruise-like lesion caused by collection of extravascular blood in dermis and subcutaneous tissue - Trauma, bleeding disorders

Hypopigmentation manifestations related to skin abnormalities?

- Loss of pigmentation resulting in lighter patches than the normal skin Chemical agents, nutrition, burns, inflammation, infection

Hirutism manifestations related to skin abnormalities?

- Male distribution of hair in women - Abnormality of ovaries or adrenal glands, decrease in estrogen level, familial trait

Petechiae manifestations related to skin abnormalities?

- Pinpoint, discrete deposits of blood <1-2 mm in the extravascular tissues and visible through the skin or mucous membrane inflammation, marked vasodilation, blood vessel trauma, blood dyscrasia that results in bleeding tendencies (e.g., thrombocytopenia)

Erythema manifestations related to skin abnormalities?

- Redness occurring in patches of variable size and shape - Heat, certain drugs, alcohol, UV rays, any problem that causes dilation of blood vessels in the skin

Cyst manifestations related to skin abnormalities?

- Sac containing fluid or semisolid material - Obstruction of a duct or gland, parasitic infection

Cyanosis manifestations related to skin abnormalities?

- Slightly bluish-gray or dark purple discoloration of the skin and mucous membranes caused by excess amounts of reduced hemoglobin in capillaries - Cardiorespiratory problems, vasoconstriction, asphyxiation, anemia, leukemia, and cancers

Immunofluorescence studies?

- Some skin diseases have specific, abnormal antibody proteins that we can identify with fluorescence studies - Can examine both skin tissue and serum - Before: Teach patient the purpose of test - During: Help obtain specimen. For punch biopsy, place specimen in special fixative (e.g., Michel's) and not formalin

Punch biopsy?

- Special punch biopsy instrument of appropriate size used. Instrument rotated to appropriate level to include dermis and some fat. Suturing depends on size and site - Provides full-thickness skin for diagnostic purposes

Culture test?

- Test identifies fungal, bacterial, and viral organisms - For fungi, scraping or swab of skin performed - For bacteria, material obtained from intact pustules, bullae, or abscesses - For viruses, vesicle or bulla and exudate taken from base of lesion - Before: Teach patient the purpose of test - During: Properly identify specimen. Follow instructions for storing specimen if not immediately sent to laboratory

Lichenification manifestations related to skin abnormalities?

- Thickening of the skin with accentuated normal skin markings - Repeated scratching, rubbing, and irritation usually because of itching or neurosis

Mineral oil slides?

- To check for infestations, place scrapings on slide with mineral oil and view microscopically - Before: Teach patient the purpose of test - During: Prepare slide

Angioma manifestations related to skin abnormalities?

- Tumor consisting of blood or lymph vessels - Normal increase in incidence with aging, liver disease, pregnancy, varicose veins

Patch test

- Used to assess for allergic dermatitis and photoallergic reactions - Application of allergens to the patient's skin (usually on the back) for 48 hr - Test sites examined 48 hr later for a reaction, characterized by the presence of erythema, papules, and/or vesicles - May do additional readings beyond 48 hr - Before: Teach patient the purpose of test and procedure - After: Tell patient to leave patches in place for 48 hr. During this time, it is important not to wash the area or play vigorous sports because if the adhesive tape peels off, the process will need to be repeated. Do not expose the patches to sunlight or other sources of UV light

Excisional biopsy?

- Used when good cosmetic results and/or entire lesion removal desired. Skin closed with subcutaneous and skin sutures - Before: Verify that consent form is signed (if needed) - During: Help with site preparation, anesthesia, procedure, and hemostasis. Properly identify specimen - After: Apply dressing, give post procedure instructions to patient

Telangiectasia manifestations related to skin abnormalities?

- Visibly dilated, superficial, small blood vessels, often found on face and thighs - Aging, acne, sun exposure, alcohol, liver failure, corticosteroids, radiation, certain systemic diseases, skin tumors

Jaundice manifestations related to skin abnormalities?

- Yellow (in white patients) or yellowish-brown (in dark-skinned patients) discoloration of the skin, best seen in the sclera, due to increased bilirubin in the blood - Liver disease, red blood cell hemolysis, pancreatic cancer, common bile duct obstruction

Carotenemia manifestations related to skin abnormalities?

- Yellow discoloration of skin, no yellowing of sclerae, most noticeable on palms and soles - Vegetables containing carotene (e.g., carrots, squash), hypothyroidism

Gastrointestinal disease's with skin manifestations?

-Cystic fibrosis -Deficiency of essential fatty acids -Inflammatory bowel disease -Liver and biliary tract obstruction -Malabsorption disease

What systemic diseased are associated with skin?

-Diabetes -Thyroid disease -Cardiovascular disease -Immune disorders

Vitamin B1 (thiamine) deficiency manifestations?

-Edema -Redness of soles of feet

Liver and biliary tract obstruction related to skin manifestations?

-Jaundice -Changes in nail's and hair -Spider angiomas -Telagiectasia

Important health information related to past health history?

-Jaundice (liver disease) -Delayed wound healing (diabetes) -Cyanosis (respiratory/cardiovascular) -Pallor (anemia)

Metabolic disease's with skin manifestations?

-Nicotionic deficiency -Vitamin B1 (thiamine) -Vitamin B2 (riboflavin) -Vitamin C deficiency

Anemia manifestation related to skin?

-Pallor -Hyperpigmentation -Pale mucous membranes -Hair loss -Nail dystrophy

Vitamin C deficiency manifestations?

-Petechiae -Purpura -Bleeding gums

Vitamin B2 (riboflavin) deficiency manifestations?

-Red fissures at corner of mouth -Glossitis

Nicotionic deficiency manifestations?

-Redness of exposed areas of skin, hand, neck, or foot -Infected dermatitis

Important health history related to skin?

-alopecia -psoriasis

Structures of the Integ system include?

1)Epidermis 2)Dermis 3)SubQ tissue

How much water do we loose a day through insensibleness?

600-900 ml/day

Cystic fibrosis related to skin manifestations?

Abnormal sweat gland function

What is the main function of skin?

Acts as a barrier against invasion of bacteria and viruses, and prevents excess water loss

Where is the most reliable area to asses for erythema, cyanosis, pallor, and jaundice?

Areas of least pigmentation such as sclera, conjunctive, nail beds, lips and buccal mucosa

What is the most common diagnostic test used to evaluate skin lesions?

Biopsy

When does localized skin temperature increase?

Burns, and local infection

How does skin regulate heat?

By responding to changes in internal/ external temperature with vasoconstriction and vasodilation

What is the epidermis?

Connective tissue below the epidermis that is very vascular

What is the function of sweat (eccrine) gland?

Cool the body by evaporation, excrete waste products, and moisturize surface cells

Elimination pattern rated to skin?

Dehydration, edema, and pruritus can indicated fluid balance

What type of cell is langerhan's cell?

Dendritic/immunocompetent cells that recognize antigens

Where does endogenous synthesis of vitamin D occur?

Epidermis

Immune disease's with skin manifestations?

HIV infection

What does skin appendages include?

Hair, nails and glands (sebaceous & Apocrine glands)

What stimulates sweat (eccrine) secretion?

Heat, certain mental stimuli, and hot/spicy foods

Important health information related to medications?

Hormones, corticosteroids, and antimetabolics have side effects that may manifest in the skin

What is the function of subq tissue?

Insulates body and provides protection from trauma

Why is endogenous synthesis of vitamin D important?

It is critical to calcium and phosphorus balance in the epidermis

What is pruritus?

Itching of the skin

HIV infection related to skin manifestations?

Kaposi sarcoma, eosinophilic folliculitis

What type of cell depletion happens in psoriasis?

Langerhan cells

Secondary skin lesion related to ulcer?

Loss of epidermis and dermis, crater like irregular shaped Heals with scarring

What specialized cells is the epidermis protect the body from external stimuli?

Mast cells & Macrophages

What is the dermis?

Most butter layer of skin, that is relatively thin

Inflammatory bowel disease related to skin manifestations?

Mouth ulcers, erythema nodosum

What type of skin lesion is psoriasis?

Plaque on skin described as circumscribed, elevated superficial solid lesion

What does the subcutaneous layer do?

Provides insulation, cushioning, temperature regulation, and energy storage

What do skin appendages do?

Receive nutrients, electrolytes, and fluids from the dermis

Why is diet history important in skin assessment?

Reveals adequacy of nutrients essential to healthy skin and wound healing such as vitamin A, B, C, E

Deficiency of essential fatty acids related to skin manifestations?

Scaly skin

What is the function of sebaceous (apocrine) gland?

Secret sebum which waterproof's and lubricates skin, and promotes absorption of fat soluble substances

When does decreased body temperature occur?

Shock/circulatory problems, chilling, or infection

Shave biopsy?

Single-edged razor blade used to shave off superficial lesions or small sample of a large lesion. Provides thin specimen for diagnostic purposes

What happens as a result of increased blood flow to the dermis?

Skin temperature increases

What type of diseases affect skin appendages?

Systemic diseases

What happens when langerhan's cells are depleted?

The skin cannot initiate an immune response

Incisional biopsy?

Wedge-shaped incision made in lesion too large for excisional biopsy. Useful when specimen needed is larger than shave or punch biopsy