Med surg integumentary
squamous cell carcinoma
Type of skin cancer more serious than basal cell carcinoma; often characterized by scaly red papules or nodules. Invasive and mets by blood or lymph system, mets account for 75% of deaths from it
assessing rash
gently stretch skin, penlight might be helpful, skin texture, boarders of the rash (circular? disffuse? spreading?), mouth and ears, temp, lymph nodes
palms, soles, lips
hair is everywhere except?
assessment
health hx, skin allergies, previous skin problems, skin cancer, names of cosmetics, soaps, shampoos if recent change, specific onset of s/s, location, duration, pain, itching, rash, discomfort, tattoos
TEN & Stevens-Johnson Syndrome risk factors
immunocompromised, abnormal metabolism of medication
precursor for melanoma: atypical/dysplastic nevus
indicates increased risk for melanoma, white population, TX: biopsy and surgical removal, know ABCDE
cellulitis
inflammation to subq area, secondary to infection, s/s hot, tender, erythema, edema, possible systemic symptoms, Tx: moist heat, immobilize, evaluation, antibiotics, admission if severe
B
irregular Boarder
vitamin synthesis
skin exposed to UV light can convert substances that are needed to make Vit D, helps prevent osteoporosis and rickets, function of the skin
confluent
skin lesions that merge together
assessment of skin
skin should be warm, includes mucous membranes, scalp, hair, nails, observe temp, moisture, skin texture, lesions, vascularity, mobility, condition of hair and nails, color, touch the skin
Psoriasis management
slow rapid turnover, no known cure, decrease stress, photo chemotherapy, pharmacologic therapy, follow up with MD, psychological component- could be lonely, people may feel they are contagious
vesicle
small, clear, fluid filled blisters less than 0.5 mm in diameter, ex: varicella, herpes zoster, second degree burn, primary skin lesion
telangiesctases
spider veins
striae
stretch marks, elastic fibers in the reticular dermis rupture
environmental hazards
sun- premature aging of the skin (decrease in thickness of dermis), irritants and allergens: patch testing, OTC meds, radiation: erythema, dry skin, edema, hypopigmentation, hyperpigmentation- goes through the skin
hypodermis
the layer of skin beneath the dermis, which serves as a storage repository for fat
functions of the skin
thermoregulation, body is always producing heat, heat leaves through the skin, > blood flow to the skin will decrease the temp and vice versa, could lose 2-4L/hr in hot environments, emotional stress can cause excessive sweating
dermis
thickest layer, made up of fibroblast cells, contains nerve endings, sensory receptors, capillaries and elastic fibers
Lichenification
tightly packed set of papules that thickens skin; caused by prolonged intense scratching, secondary skin lesion
Merkel cells
transmit stimuli, situated next to sensory nerve endings, slow adapting
assessing wound edges and margins
undermining or tunnelling
asymmetric
unilateral distribution
assessing skin lesions
vary in size, shape and cause, primary (disease), secondary (scratching, trauma, infections), darker skinned: may be black, maroon, purple or grey, lighter skin: tan or red, how the lesions look: scabies vs shingles
C
veriegated Color
diffuse
widely spread out
jaundice
yellowing skin, elevation of serum bilirubin and is first seen in sclerae and mucous membranes, Icterus: yellowing of sclerae
keratinocytes
The most abundant epidermal cells, they function mainly to produce keratin. Form in basal layer and work their way up to the top where they die
keloid
Thick scar resulting from excessive growth of fibrous tissue, secondary skin lesion
eccrine glands
found in most areas of the body, Fx: cool the body by evaporation, excrete waste products, and moisturize, temp regulation, not smelly
assessing wound size
centimeters, diameter and depth of the wound and surrounding erythema
how a scar is formed
clot forms, fibroblasts are attracted to it, break down clot and replace it with collagen, it is not functional skin, and sweat glands and hair follicles are not able to grow
grouped
clusters of lesions
assessing surrounding skin
color, suppleness and moisture, irritation, induration, and scaling
assessment of skin cont
color: ranges from person to person and different areas, almost every process involving skin will have a skin change, hypopigmentation vs hyperpigmentatoin, pink or reddish hue: vasodilation, pallor: best observed in the conjunctivae or around mouth, or palms and soles of dark skinned people, dark skin: melanin is more and produces faster
psoriasis
common, chronic, noninfectious, inflammatory dz, hereditary defect causes overproduction of keratin, cyclin in nature
TEN & Stevens-Johnson Syndrome manisfestations
conjunctival burning or itching, fever, cough, sore throat, HA, extreme malaise, rapid onset of erythema, large bullae develop in some areas, others have sheets of epidermis that slough off, finger/toenails, eyebrows and eyelashes may be shed, skin is excrutiatingly tender
management for impetigo
contact isolation, topical antibiotic after removal of crust, maintain meticulous hygiene
TEN & Stevens-Johnson Syndrome managment
control fluid and electrolyte balance, prevention of sepsis, prevention of ophthalmic complications, treated in burn center
keratin
dead cells have this fibrous protein that forms the outer barrier of the skin, it has hardening ingredient of hair and nails
malignant melanoma management
depends on level and depth of lesion, surgical excision, regional lymph node dissection (helps prevent cancer from traveling), chemo/radiation for mets, chemo directly to site S/E- nausea, tired
D
diameter > 6mm
papule
elevated lesions usually less than 0.5 mm in diameter that can be felt or palpated, Ex: wart, elevated moles, lipoma, basal cell cancer, primary skin lesion
Nodule, tumor
elevated, solid, palpable mass with irregular border- may be malignant (cancerous) or benign, primary skin lesion ex. tumor
Pustule
elevated, usually yellow topped lesions that contain pus, acne, impetigo, primary skin lesion
basement membrane
epidermis and dermis are separated by this
nonmelanoma skin cancer management
eradicate the tumor, once determined, may need additional surgery, possibly radiation
E
evolution/elevation
lipoma
fatty tumor, below skin (harmless)
immune response function
function of the skin, langerhans cells
TEN & Stevens-Johnson Syndrome complications
sepsis, conjunctival retraction, scars, and corneal lesions
solitary
single lesion
diagnostic evaluation
skin biopsy, patch testing, skin scrapings, clinical photographs
functions of integumentary system
-Protection -Barrier from bacteria and viruses -Insulation -Sensory perception -Control of heat regulation -Aesthetic function -Fluid balance
generalized
Diffuse distribution
bulla
Large blister containing watery fluid, primary skin lesion
epidermis
Outer layer of skin, has 5 layers
cyanosis
a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood. light colored skin: lips fingertips, and nail bells, dark skin: may appear blue or dull, central cyanosis: mucous membranes, peripheral cyanosis: vasoconstriction, cold, clammy, etc, look at conjunctivae for pallor to petechiae, go from peripheral to central when assessing for cyanosis
wheal
firm, edematous, and irregularly shaped area, sizes vary, may last only a few hours, Ex: insect bite, urticaria, angioedema, primary skin lesion
macule
flat, nonpalpable lesion usually less than 0.5 mm in diameter, red, blue, or brown, ex: freckles, petechiae, measels, flat mole (nevus), vitiligo, primary skin lesion
sweat glands
found all over but highly concentrated in palms of hands and soles of feed
Herpes Zoster Pathophysiology
after chickenpox runs its course the virus lies dormant inside nerve cells, later can become active again effect peripheral nerves to the skin where you see a rash of small fluid filled vesicles, about 10% of adults get shingles during their lifetime
herpes zoster management
antiviral within 72 hours, pain may continue when when skin lesions disappear (postherpetic neuralgia- persistent pain patterns, may need analgesics and systemic corticosteroids
scar, cicatrix
areas of fibrosis, become thickened and raised, Ex: surgical incision, healed wound, secondary skin lesion
psoriasis complications
asymmetric rheumatoid factor-negative arthritis of multiple joints occurs in about 5% of people with it, relationship is not understood
A
asymmetry
Impetigo
bacterial skin infection characterized by isolated pustules that become crusted and rupture, vesiculopustular, honey colored crust, surrounded by erythema, pruritus, primarily on face
Zosteriform
bandlike distribution along a dermatome area
symmetric
bilateral distribution
Malignant melanoma manisfestation
biopsy, H&P, chest x ray, blood count, liver function tests, CT scan, tumor staging- T- tumor size, N- Nodal involvement, M-metastasis
petechiae
broken capillaries or platelet abnormalities
herpes zoster (shingles)
caused by varicella zoster virus, painful vesicular eruption along the area of distribution of the sensory nerves from one or more posterior ganglia, follows a nerve pathway, if it's in/around your eyes it is a medical emergency
melanocytes
cells that produce melanin, provides protection against UV light
scars
keloid goes outside the boarder, hypertrophic does not
ecchymoses
large bruised area
vericose vein
larger bulging veins
apocrine glands
larger, found in axillae, anal region, scrotum, and labia majora, associated with puberty, bacteria is what gives us the odor
integumentary system
largest organ of the body, 12% of body weight, responsible for temp, maintenance of fluid and electrolytes, protection from infection and environment, is made up of skin, hair, nails, sweat and sebaceous glands
psoriasis manisfestations
lesions appear red, raised patches, and covered with silvery scales, if scales are scraped away a dark red base of the lesion is exposed, producing multiple bleeding points, may be pruritic ---> scratching ---> increased risk of infection, more likely to happen at scalp, elbows, knees, lower part of back, and genitalia, usually bilateral, nails may also be affected
localized
limited areas of involvement that are clearly defined
ulcer
loss of epidermis and at least part of the dermis, Ex: pressure injury, chancre
basal cell carcinoma (BCC)
malignant tumor of the basal layer of the epidermis; the most common type of skin cancer, can happen in sun and sun protected areas, rarely metastases, recurrence common
gerontologic considerations of skin
many skin changes and lesions are normal
nevi
moles
assessing wound bed
necrotic, slough, granulation, exudate, color, and odor
sebaceous glands
oil, associated with hair follicles
herpes zoster manifestations
pain, usually around the nerve that is affected or itching and tenderness, early vesicles contain serum, later can be purulent, inflammation is usually unilateral, lasts 1-3 weeks, may have eye pain if ophthalmic nerve involved
Plaque
palpable lesions greater than 0.5 mm in diameter that are elevated or depressed compared to the skin surface, may be flat topped or rounded, Ex: psoriasis, seborrheic and actinic keratoses, primary skin lesion
assessing skin lesions cont
palpation, moisture, temp, texture, turgor, nails: lines through nails, paronychia (inflammation), clubbing: straightening of the normal angle- chronic low O2
nonmelanoma skin cancer
papules and plaques on sun exposed areas, older white population, most common precancerous skin lesion, Tx: surgery, meds, dermabrasion, biopsy if needed
langerhans cells
play a role in the skin immune system reactions, traffic controllers, regulate immune responses, decide whether youre going to have a full body or local reaction
Toxic Epidermal Necrolysis (TEN) and Stevens-Johnson syndrome (SJS)
potentially fatal skin disorders, both are triggered by a reaction to meds, sulfa drugs, anticonvulsant agents, NSAIDS are the most frequent cases, your skin sloughs off, you are treated in a burn center
subcutaneous tissue
primarily adipose tissue, source of energy, cushions and insulates, promotes skin mobility, molds body contours, temp regulation
Psoriasis pathophysiology
primary cause unknown, evidence suggest immunologic basis, stress and anxiety aggravate it as well as trauma, infections, and seasonal and hormonal changes, epidermal cells are produced 6-9 times faster than normal, profuse scales or plaques
patch
primary skin lesion
erythema
redness of the skin, look for increased warmth or smoothness or hardness
providing skin care, health promotion
rest and sleep, exercise, hygiene, nutrition, self treatment- teach to follow OTC directions, protect skin, prevent infection, reverse inflammation
hair, nails, and glands
root is formed in dermis and hair shaft that comes out, grows in a hair follicle, cycles of growth and rest, if hair follicle and stem cells are destroyed, hair does not grow, shaving doesn't change its thickness, color or rate, eyebrows, lashes, nose and ear hair filters out particles, pigment gives you color, white or gray means no pigment
cyst
sac containing fluid, primary skin lesion
seborrheic keratosis
scaly patches, on oily places on the body
crust
secondary skin lesion
erosion
secondary skin lesion
fissure
secondary skin lesion, a linear crack in the skin extending from the epidermis to the dermis, Ex: athletes foot, chapping, eczema
scales
secondary skin lesion, heaped up keratinized cells, flakey exfoliation, irregular, thick or thin, dry or oily, and variable in size, Ex: flaking of skin after a drug reaction or sunburn
atrophy
secondary skin lesion, thinning of the skin, which may appear dry, and wrinkles, and resembling ciggarette paper, Ex: aged skin, striae
discrete
separate from other lesions