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MEDSURG 7

Assessment: Integumentary System

STRUCTURES AND FUNCTIONS

The epidermis is the outermost skin layer. The dermis is the second skin layer; it contains

the collagen bundles while it supports the nerve and vascular network.

The subcutaneous layer is composed of fat and loose connective tissue.

The primary function of skin is to protect underlying body tissues by serving as a surface

barrier to the external environment. Skin also is a barrier against bacteria, viruses, and

excessive water loss. Fat in the subcutaneous layer insulates the body and provides

protection from trauma.

Two major types of epidermal cells include melanocytes (5%) and keratinocytes (90%).

o Melanocytes contain melanin, a pigment giving color to skin and hair and protectingthe body from damaging ultraviolet (UV) sunlight. More melanin results in darker

skin color.

o Keratinocytes produce fibrous protein, keratin, which is vital to protective barrier

function of skin.

The dermis is the connective tissue below the epidermis. It is highly vascular and assists in

the regulation of body temperature and blood pressure.

The dermis is divided into two layers: upper thin papillary layer and deeper, thicker reticular

layer.

Collagen forms the largest part of the dermis and is responsible for the mechanical strength

of the skin.

Skin appendages include hair, nails, and glands (sebaceous, apocrine, and eccrine). These

structures develop from the epidermal layer and receive nutrients, electrolytes, and fluids

from the dermis. Hair and nails form from specialized keratin that becomes hardened.

Nail color ranges from pink to yellow or brown, depending on the skin color. Pigmented

longitudinal bands (melanonychea striata) may occur in the nail bed in most people with

dark skin.

Sebaceous glands secrete sebum, which is emptied into hair follicles. Sebum prevents skin

and hair from becoming dry.

Apocrine sweat glands are located in the axillae, breast areolae, umbilical and anogenital

areas, external auditory canals, and eyelids. They secrete a thick, milky substance that

becomes odoriferous when altered by skin surface bacteria.

Eccrine sweat glands are widely distributed over the body, except in a few areas such as

lips. These glands cool the body by evaporation, excrete waste products through skin pores,

and moisturize surface cells.

With aging, the following changes occur in the skin: fewer melanocytes (gray and white

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hair), less volume in the dermis, nail plate thinning, nails become brittle and prone to

splitting and yellowing, skin wrinkling, decreased subcutaneous fat, hypothermia, and skin

shearing.

ASSESSMENT

Specific skin areas should be assessed during the examination of other body sites, unless the

chief complaint is of dermatologic nature.

Information related to sensitivities should be obtained. History of chronic or unprotected

exposure to UV light, including tanning bed use and radiation treatments, should be noted.

The patient should be questioned about skin-related problems occurring as result of taking

medications, self-care habits related to daily hygiene, family history of any skin disease, and

feelings related to altered body image in relation to skin condition.

Primary skin lesions develop on previously unaltered skin. These include macule, papule,

vesicle, plaque, wheal, and pustule.

Secondary skin lesions change with time or occur because of factors such as scratching or

infection and include fissure, scale, scar, ulcer, and excoriation.

The skin should be inspected for general color and pigmentation, vascularity, bruising, and

presence of lesions or discolorations, and palpated for information about temperature, turgor

and mobility, moisture, and texture.

Structures of dark skin are often more difficult to assess. Assessment is easier where the

epidermis is thin and pigmentation is not influenced by sun exposure such as lips, mucous

membranes, nail beds, and protected areas such as buttocks.

Palmar and plantar surfaces are lighter than other skin areas in darker-skinned individuals.

Rashes are often difficult to observe and may need palpation.

Individuals with dark skin are predisposed to pseudofolliculitis, keloids, and mongolian

spots. Cyanosis may be difficult to determine because normal bluish hue occurs in dark-

skinned persons.

DIAGNOSTIC STUDIES

Biopsy is one of most common diagnostic tests in evaluation of skin lesions. Techniques

include punch, incisional, excisional, and shave biopsies.

Other diagnostic procedures include stains and cultures for fungal, bacterial, and viral

infections.

****Chapter 24: Nursing Management: Integumentary Problems

Health promotion activities for good skin health include asvoidance of environmental

hazards, adequate rest and exercise, and proper hygiene and nutrition.

Sun safety includes sun avoidance, especially during midday hours, protective clothing, andsunscreen.

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Actinic keratoses, basal cell carcinoma, squamous cell carcinoma, and malignant melanoma

are problems associated with sun exposure.

Actinic keratosis:

o Is a premalignant form of squamous cell carcinoma affecting nearly all the older

white population.

o A typical lesion is an irregularly shaped, flat, slightly erythematous papule withindistinct borders and an overlying hard keratotic scale or horn.

o Treatment includes cryosurgery, fluorouracil (5-FU), surgical removal, tretinoin

(Retin-A), chemical peeling agents, and dermabrasion.

Skin cancer is the most common malignant condition. Patients should be taught to self-

examine their skin monthly.

The cornerstone of self-skin examination is the ABCD rule. Examine skin lesions for

Asymmetry, Border irregularity, Color change/variation, and Diameter of 6 mm or more.

Risk factors for skin cancer include fair skin type (blonde or red hair and blue or green

eyes), history of chronic sun exposure, family history of skin cancer, and exposure to tar and

systemic arsenicals.

Nonmelanoma skin cancers do not develop from melanocytes, as melanoma skin cancers do.

Instead, they are a neoplasm of the epidermis. Most common sites are in sun-exposed areas.

Basal cell carcinoma (BCC):

o Is a locally invasive malignancy from epidermal basal cells.

o Is the most common type of skin cancer and the least deadly.

o Tissue biopsy is needed to confirm the diagnosis.o Treatments of electrodessication and curettage,cryosurgery, and excision all have

cure rate of more than 90%.

Squamous cell carcinoma (SCC):

o Is a malignant neoplasm of keratinizing epidermal cells.

o Is less common than BCC.

o Can be very aggressive, has the potential to metastasize, and may lead to death if not

treated early.

o Pipe, cigar, and cigarette smoking area are also risk factors for SCC; therefore SCC

is also found on mouth and lips.o Biopsy is performed when a lesion is suspected of being SCC.

o Treatment includes electrodesiccation and curettage, excision, radiation therapy,

intralesional injection of 5-FU or methotrexate, and Mohs surgery.

Malignant melanoma:

o Is a tumor arising in melanocytes.

o Melanomas can metastasize to any organ.

o Is the most deadly skin cancer, and its incidence is increasing faster than that of any

other cancer.

o Individuals should consult health care provider if moles or lesions show any clinical

signs (ABCDs) of melanoma.

o Melanoma can also occur in eyes, meninges, and lymph nodes.

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o Suspicious lesions should be biopsied using excisional biopsy.

o Important prognostic factor of melanoma is tumor thickness at time of diagnosis.

o Initial treatment for melanoma is surgery.

o Melanoma spread to lymph nodes or nearby sites often requires chemotherapy,

biologic therapy (e.g., -interferon, interleukin-2), and/or radiation therapy.

o Stage I is 100% curable with stage IV being mostly palliative care.

Abnormal nevus pattern called dysplastic nevus syndrome identifies individual at increased

risk of melanoma. Dysplastic nevi (DN), or atypical moles, are nevi >5 mm across with

irregular borders and varying color.

Staphylococcusaureus and group A -hemolytic streptococci are major types of bacteriaresponsible for primary and secondary skin infections. Herpes simplex, herpes zoster, and

warts are the most common viral infections affecting the skin.

Ultraviolet light, or a combination of two types (UVA and UVB), is used to treat many

conditions. UV wavelengths cause erythema, desquamation, and pigmentation and maycause temporary suppression of basal cell mitosis followed by rebound increase in cell

turnover.

Radiation use for treatment of cutaneous malignancies varies greatly. Lasers are used for

many dermatologic problems.

Antibiotics are used topically and systemically to treat dermatologic problems, and are often

used in combination. Common OTC topical antibiotics include bacitracin and polymyxin B.

Corticosteroids are particularly effective in treating a wide variety of dermatologic

conditions and are used topically, intralesionally, or systemically. High-potencycorticosteroids may produce side effects when use is prolonged, including skin atrophy,

rosacea eruptions, severe exacerbations of acne vulgaris, and dermatophyte infections.

Oral antihistamines are used to treat conditions that exhibit urticaria, angioedema, and

pruritus. Topical immune response modifiers such as pimecrolimus (Elidel) and tacrolimus

(Protopic) are newer nonsteroidal medications used in atopic dermatitis.

Diagnostic and surgical therapy techniques include skin scraping, electrodesiccation and

electrocoagulation, curettage, punch biopsy, cryosurgery, and excision.

Wet dressings are commonly used when skin is oozing from infection and/or inflammation,

and to relieve itching, suppress inflammation, and debride a wound.

Baths are used when large body areas need to be treated. They also have sedative and

antipruritic effects.

Careful hand washing and safe disposal of soiled dressings are the best means of preventing

spread of skin problems.

Cosmetic procedures include chemical peels, toxin injections, collagen fillers, laser surgery,

breast enlargement and reduction, laser surgery, face-lift, eyelid-lift, and liposuction.Preoperative management includes informed consent and realistic expectations of what

cosmetic surgery can accomplish.

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A primary concern is the onset of hypovolemic shock and edema formation. Toward the end

of the phase, if fluid replacement is adequate, the capillary membrane permeability is

restored. Fluid loss and edema formation cease. The interstitial fluid gradually returns to the

vascular space. Diuresis occurs with low urine specific gravities.

Manifestations include shock from the pain and hypovolemia. Areas of full-thickness and

deep partial-thickness burns are initially anesthetic because the nerve endings are destroyed.Superficial to moderate partial-thickness burns are painful.

Shivering occurs as a result of chilling, and most patients are alert. Unconsciousness or

altered mental status is usually a result of hypoxia associated with smoke inhalation, head

trauma, or excessive sedation or pain medication.

Complications:

o Cardiovascular system: dysrhythmias and hypovolemic shock

o Respiratory system: vulnerable to upper airway injury causing edema formation and

obstruction of airway, and inhalation injury

o Renal system: if patient is hypovolemic, kidney blood flow may decrease, causing

renal ischemia. If it continues, acute renal failure may develop. With full-thickness

and electrical burns, myoglobin and hemoglobin are released into the bloodstream

and occlude the renal tubules.

Management includes a rapid and thorough assessment and intervention of airway

management, fluid therapy, and wound care. Analgesics are ordered to promote patient

comfort. Early in the postburn period, IV pain medications are given.

Early and aggressive nutritional support decreases mortality and complications, optimizes

healing of burn, and minimizes negative effects ofhypermetabolism and catabolism.

ACUTE PHASE

Begins with the mobilization of extracellular fluid and subsequent diuresis. Phase concludes

when burned area is completely covered by skin grafts or when wounds are healed. This

may take weeks or many months.

Manifestations include eschar from partial-thickness wounds. Once removed, re-

epithelialization appears as red or pink scar tissue.

Margins of full-thickness eschar take longer to separate. As a result, they require surgical

debridement and skin grafting for healing.

Because the body is trying to reestablish fluid and electrolyte homeostasis, it is important for

the nurse to follow the patients serum electrolyte levels closely (hypo- or hypernatremia,

hypo- or hyperkalemia).

Complications include wound infection progressing to transient bacteremia as result of

manipulation (e.g., after hydrotherapy and debridement). Same cardiovascular and

respiratory system complications as in emergent phase may continue.

Patient can become extremely disoriented, withdraw, or be combative.

This is a transient state, lasting from a day to several weeks. Range of motion may be

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limited and contractures can occur. Paralytic ileus results from sepsis. Diarrhea and

constipation may also occur.

Management involves wound care with daily observation, assessment, cleansing,

debridement, and dressing reapplication.

Individualized and consistent pain assessment and care are essential. Note two kinds of pain:continuous, background pain existing throughout day and night, and treatment pain

associated with dressing changes, ambulation, and rehabilitation activities.

First line of treatment is pharmacologic. Then use nonpharmacologic strategies, such as

relaxation tapes, visualization, hypnosis, guided imagery, and biofeedback. Rigorous

physical therapy throughout recovery is imperative to maintain joint function. Nutritional

therapy provides adequate calories and protein to promote healing.

REHABILITATION PHASE

Begins when wounds have healed and patient is able to resume self-care activity. Phase

occurs as early as 2 weeks or as long as 7 to 8 months after the burn.

Goals are to assist the patient in resuming a functional role in society and accomplish

functional and cosmetic reconstructive surgery.

Manifestations include new skin appearing flat and pink, then raised and hyperemic; itching

occurs with healing. Complications are skin and joint contractures and hypertrophic

scarring.

Management includes positioning, splinting, and exercise to minimize contracture. Burned

legs may be wrapped with elastic (e.g., tensor/Ace) bandages to assist the circulation to theleg graft and donor sites. Patient education and hands-on instruction need to be provided

in dressing changes and wound care.

Continuous exercise and physical/occupational therapy cannot be overemphasized.

Encouragement and reassurance are necessary for patient morale, attaining independence,

and returning to preburn activities.

For patient with emotional needs, it is important that the nurse have understanding of

circumstances of burn, family relationships, and prior coping experiences with stressful

situations. Patient may experience fear, anxiety, anger, guilt, and depression.