Integumentary disorder for nursing students

1. Integumentary disorders
By
Ashagre Molla (BSc., MSc.)
ashagremolla@yahoo.com
October 2013
1

2. Subtopics
• Anatomy and physiology overview
• Bacterial infections
• Viral infections
• Secretary disorders
• Dermatitis
• Psoriasis
• Vitiligo
• Burn
• Cancer of skin
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3. Introduction
• The largest organ system of the body, the skin is indispensable
for human life.
• Skin forms a barrier between the internal organs and the
external environment
• The skin is contiguous with the mucous membrane at the
external openings of the digestive, respiratory, and urogenital
systems.
• Dermatologic complaints are commonly the primary reason
for a patient to seek health care.
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4. Anatomy- overview
• The skin is composed of three layers: epidermis, dermis, and
subcutaneous tissue
• The epidermis is an outermost layer of stratified epithelial cells
and composed predominantly of keratinocytes.
• It ranges in thickness from about 0.1 mm on the eyelids to about
1 mm on the palms of the hands and soles of the feet.
• Five distinct layers compose the epidermis: Stratum basale,
stratum germinativum, stratum granulosum, stratum lucidum,
and stratum corneum.
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5. 5

6. Epidermis
• The epidermis consists of live, continuously dividing cells
covered on the surface by dead cells.
• This external layer is almost completely replaced every 3 to 4
weeks.
• The dead cells contain large amounts of keratin - has the
capacity to repel pathogens and prevent excessive fluid loss
from the body.
• Keratin is the principal hardening ingredient of the hair and
nails.
6

7. Epidermis continued
• Melanocytes are the special cells of the epidermis that are
primarily involved in producing the pigment melanin, which
colors the skin and hair.
• The more melanin in the tissue, the darker is the color.
• Normal skin color depends on race
• Systemic disease affects skin color as well.
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8. Epidermis . . .
• It is believed that melanin can absorb ultraviolet light in
sunlight.
• Two other cells are common to the epidermis: Merkel and
Langerhans cells.
• Merkel cells are receptors that transmit stimuli to the axon
through a chemical synapse.
• Langerhans cells are believed to play a significant role in
cutaneous immune system reactions.
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9. Epidermis continued
• The epidermis is modified in different areas of the body.
• It is thickest over the palms of the hands and soles of the feet and
contains increased amounts of keratin.
• The junction of the epidermis and dermis is an area of many
undulations and furrows called rete ridges.
• This junction permits the free exchange of essential nutrients
between the two layers.
• This interlocking between the dermis and epidermis produces
ripples on the surface of the skin.
• On the fingertips, these ripples are called fingerprints.
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10. Dermis
• The dermis makes up the largest portion of the skin, providing
strength and structure.
• It is composed of two layers: papillary and reticular.
• The papillary dermis lies directly beneath the epidermis and is
composed primarily of fibroblast cells
•
The reticular layer lies beneath the papillary layer and also
produces collagen and elastic bundles.
• The dermis is also made up of blood and lymph vessels, nerves,
sweat and sebaceous glands, and hair roots.
• The dermis is often referred to as the “true skin.”
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11. Subcutaneous Tissue
• or hypodermis, is the innermost layer of the skin
• It is primarily adipose tissue, which provides a cushion between the skin
layers, muscles, and bones
• It promotes skin mobility, molds body contours, and insulates the body.
• Fat is deposited and distributed according to the person’s gender and in
part accounts for the difference in body shape between men and women.
• The subcutaneous tissues and amount of fat deposited are important
factors in body temperature regulation.
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12. Hair
• An outgrowth of the skin, hair is present over the entire body
except for the palms and soles.
• The hair consists of a root formed in the dermis and a hair shaft
that projects beyond the skin.
• It grows in a cavity called a hair follicle.
• Proliferation of cells in the bulb of the hair causes the hair to
form.
• Hair follicles undergo cycles of growth and rest.
• The rate of growth varies; beard growth is the most rapid,
followed by hair on the scalp, axillae, thighs, and eyebrows.
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13. Hair . . . .
• During telogen, hair sheds from the body.
• The hair follicle recycles into the growing phase
spontaneously, or it can be induced by plucking out hairs.
• Growing and resting hair can be found side by side on all parts
of the body.
• About 90% of the 100,000 hair follicles on a normal scalp are
in the growing phase at any one time, and 50 to 100 scalp hairs
are shed each day.
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14. 14

15. Hair . . .
• There is a small bulge on the side
of the hair follicle that houses the stem
cells that migrate down to the follicle
root and begin the cycle of reproducing
the hair shaft.
• The location of these cells on the
side of the hair shaft rather than at
the base is a factor in hair loss.
• In conditions in which inflammation causes damage to the root
of the hair, regrowth is possible.
• However, if inflammation causes damage to the bulge on the
side, stem cells are destroyed and hair does not grow.
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16. Hair . . . .
• Hair in different parts of the body serves different functions.
• The hairs of the eyes (ie, eyebrows and lashes), nose, and ears
filter out dust, bugs, and airborne debris.
• Hair color is supplied by various amounts of melanin within
the hair shaft.
• Gray or white hair reflects the loss of pigment.
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17. Nails
• On the dorsal surface of the fingers and toes, a hard, transparent
plate of keratin, called the nail, overlies the skin.
• The nail grows from its root, which lies under a thin fold of skin
called the cuticle.
• The nail protects the fingers and toes by preserving their highly
developed sensory functions, such as for picking up small objects.
• Nail growth is continuous throughout life, with an average growth of
0.1 mm daily.
• Growth is faster in fingernails than toenails and tends to slow with
aging.
• Complete renewal of a fingernail takes about 170 days, whereas
toenail renewal takes 12 to 18 months.
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18. Glands of the Skin
• There are two types of skin glands: sebaceous and sweat glands.
• The sebaceous glands are associated with hair follicles.
• The ducts of the sebaceous glands empty sebum (ie, oily secretion)
onto the space between the hair follicle and the hair shaft.
• For each hair there is a sebaceous gland, the secretions of which
lubricate the hair and render the skin soft and pliable.
• Sweat glands are found in the skin over most of the body surface.
• Only the glans penis, the margins of the lips, the external ear, and
the nail bed are devoid of sweat glands.
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19. Glands . . .
• Sweat glands are subclassified into two categories: eccrine and
apocrine.
• The eccrine sweat glands are found in all areas of the skin.
• Their ducts open directly onto the skin surface.
• The thin, watery secretion called sweat is produced in the basal
coiled portion of the eccrine gland and is released into its narrow
duct.
• Sweat is composed of predominantly water and contains about
one half of the salt content of the blood plasma.
• Sweat is released from eccrine glands in response to elevated
ambient and body temperature.
• Excessive sweating of the palms and soles, axillae, forehead,
and other areas may occur in response to pain and stress.
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20. FUNCTIONS OF THE SKIN
Protection
• It provides very effective protection against invasion by
bacteria and other foreign matter.
• The thickened skin of the palms and soles protects against the
effects of the constant trauma.
• The stratum corneum provides the most effective barrier to
epidermal water loss and penetration of environmental factors
such as chemicals, microbes, and insect bites.
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21. Protection . . .
• Various lipids are synthesized in the stratum corneum and are
the basis for the barrier function of this layer.
• The presence of these lipids in the stratum corneum creates a
relatively impermeable barrier for water loss and for the entry
of toxins, microbes, and other substances that come in contact
with the surface of the skin.
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22. Protection . . .
• Some substances do penetrate the skin but meet resistance in
trying to move through the channels between the cell layers of
the stratum corneum.
• Microbes and fungi cannot penetrate unless there is a break in
the skin barrier.
• The basal layer serves four functions.
– It acts as a scaffold for tissue organization and a template
for regeneration;
– it provides selective permeability for filtration of serum;
– it is a physical barrier between different types of cells;
– it adheres the epithelium to underlying cell layers.
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23. Sensation
• The receptor endings of nerves in the skin allow the body to
constantly monitor the conditions of the immediate environment.
• The primary functions of the receptors in the skin are to sense
temperature, pain, light touch, and pressure (or heavy touch).
• Different nerve endings respond to each of the different stimuli.
• Although the nerve endings are distributed over the entire body,
they are more concentrated in some areas than in others.
E.g. the fingertips are more densely innervated than the skin on the
back.
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24. Fluid Balance
• The stratum corneum has the capacity to absorb water, thereby
preventing an excessive loss of water and electrolytes from the
internal body and retaining moisture in the subcutaneous tissues.
• When skin is damaged, as occurs with a severe burn, large
quantities of fluids and electrolytes may be lost rapidly, possibly
leading to circulatory collapse, shock, and death.
• Small amounts of water continuously evaporate from the skin
surface.
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25. Fluid Balance
• This evaporation, called insensible perspiration, amounts to
approximately 600 mL daily in a normal adult.
• Insensible water loss varies with the body and ambient
temperature.
• In a person with a fever, the loss can increase.
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26. Temperature Regulation
• The body continuously produces heat as a result of the
metabolism of food, which produces energy.
• This heat is removed primarily through the skin.
• Three major physical processes are involved in loss of heat from
the body to the environment.
• Radiation, conduction and convection are the three ways of heat
transfer
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27. Temperature . . .
• Heat is conducted through the skin into water molecules on its
surface, causing the water to evaporate.
• The water on the skin surface may be from insensible
perspiration, sweat, or the environment.
• Normally, all of these mechanisms for heat loss are used.
• When the ambient temperature is very high, however, radiation
and convection are ineffective, and evaporation becomes the
only means for heat loss.
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28. 28

29. 29

30. Bacterial Infections: Pyodermas
• Pus-forming bacterial infections of the skin may be primary or
secondary.
• Primary skin infections originate in previously normal-appearing
skin and are usually caused by a single organism.
• Secondary skin infections arise from a preexisting skin disorder or
from disruption of the skin integrity from injury or surgery.
• The most common primary bacterial skin infections are impetigo
and folliculitis.
• Folliculitis may lead to furuncles or carbuncles.
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31. IMPETIGO
• Impetigo is a superficial infection of the skin caused by
staphylococci, streptococci, or multiple bacteria.
• Bullous impetigo, a more deep-seated infection of the skin
caused by S. aureus, is characterized by the formation of
bullae (i.e., large, fluid-filled blisters) from original vesicles.
• The bullae rupture, leaving raw, red areas.
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32. Impetigo pictures
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33. Bullous impetigo
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34. Impetigo . . . .
• Face, neck, and extremities are most frequently involved.
• Impetigo is contagious and may spread to other parts of the
patient’s skin or to other members of the family who touch the
patient or use towels or combs that are soiled with the exudate
of the lesions.
• Although impetigo is seen at all ages, it is particularly
common among children living in poor hygienic conditions.
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35. Impetigo . . . .
• It often follows pediculosis capitis (head lice), scabies (itch
mites), herpes simplex, insect bites, poison ivy, or eczema.
• Chronic health problems, poor hygiene, and malnutrition may
predispose an adult to impetigo.
• Some people have been identified as asymptomatic carriers of
S. aureus, usually in the nasal passages.
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36. Clinical Manifestations
• The lesions begin as small, red macules, which quickly
become discrete, thin-walled vesicles that soon rupture and
become covered with a loosely adherent honey-yellow crust.
• These crusts are easily removed to reveal smooth, red, moist
surfaces on which new crusts soon develop.
•
If the scalp is involved, the hair is matted, which distinguishes
the condition from ringworm.
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37. Medical Management
• Systemic antibiotic therapy is the usual treatment.
• It reduces contagious spread, treats deep infection, and prevents
acute glomerulonephritis
• In nonbullous impetigo, benzathine penicillin or oral penicillin
may be prescribed.
• Bullous impetigo is treated with a penicillinase-resistant
penicillin (eg, cloxacillin, dicloxacillin).
• In penicillin-allergic patients, erythromycin is an effective
alternative.
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38. Medical management . . .
• Topical antibacterial therapy (eg, mupirocin) may be
prescribed when the disease is limited to a small area.
• However, topical therapy requires that the medication be
applied to the lesions several times daily for a week.
– are not as effective as systemic therapy in eradicating or
preventing the spread of streptococci from the respiratory
tract.
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39. Medical management . . .
• When topical therapy is prescribed, lesions are soaked or
washed with soap solution to remove the central site of
bacterial growth, giving the topical antibiotic an opportunity to
reach the infected site.
• After the crusts are removed, a topical medication may be
applied.
• Gloves are worn when providing patient care.
• An antiseptic solution may be used to clean the skin, reduce
bacterial content in the infected area, and prevent spread.
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40. Nursing Management
• The nurse instructs the patient and family members to bathe at
least once daily with bactericidal soap.
• Cleanliness and good hygiene practices help prevent the spread
of the lesions from one skin area to another and from one
person to another.
•
Each person should have a separate towel and washcloth.
• Because impetigo is a contagious disorder, infected people
should avoid contact with other people until the lesions heal.
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41. FOLLICULITIS, FURUNCLES, AND CARBUNCLES
• Folliculitis is an infection of bacterial or fungal origin that
arises within the hair follicles.
• Lesions may be superficial or deep.
• Single or multiple papules or pustules appear close to the hair
follicles.
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42. Folliculitis . . .
• Folliculitis commonly affects the beard area of men who shave
and women’s legs.
• Other areas include the axillae, trunk, and buttocks.
• Pseudofolliculitis barbae (ie, shaving bumps) are an
inflammatory reaction that occurs as a result of shaving.
• The sharp in growing hairs have a curved root that grows at a
more acute angle and pierces the skin, provoking an irritative
reaction.
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43. Folliculitis . . . .
• The only entirely effective treatment is to avoid shaving.
• Other treatments include using special lotions or antibiotics or
using a hand brush to dislodge the hairs mechanically.
• If the patient must remove facial hair, a depilatory cream or
electric razor may be more appropriate than a straight razor.
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44. Furuncle (Boil)
• A furuncle (ie, boil) is an acute inflammation arising deep in
one or more hair follicles and spreading into the surrounding
dermis.
• It is a deeper form of folliculitis.
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45. Furunculosis
• Furunculosis refers to multiple or recurrent lesions.
• Furuncles may occur anywhere on the body but are more
prevalent in areas subjected to irritation, pressure, friction, and
excessive perspiration, such as the back of the neck, the axillae,
and the buttocks.
• A furuncle may start as a small, red, raised, painful pimple.
• Frequently, the infection progresses and involves the skin and
subcutaneous fatty tissue, causing tenderness, pain, and
surrounding cellulitis.
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46. Furunculosis
• The area of redness and induration represents an effort of the
body to keep the infection localized.
• The bacteria (usually staphylococci) produce necrosis of the
invaded tissue.
• The characteristic pointing of a boil follows in a few days.
• When this occurs, the center becomes yellow or black, and the
boil is said to have “come to a head.”
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47. Carbuncles
• A carbuncle is an abscess of the skin and subcutaneous tissue
that represents an extension of a furuncle that has invaded
several follicles and is large and deep seated.
•
It is usually caused by a staphylococcal infection.
• Carbuncles appear most commonly in areas where the skin is
thick and inelastic.
• The back of the neck and the buttocks are common sites.
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48. Carbuncles picture
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49. • Furuncles and carbuncles are more likely to occur in patients
with underlying systemic diseases and in those receiving
immunosuppressive therapy for other diseases.
• Both are more prevalent in hot climates, especially on skin
beneath occlusive clothing.
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50. Medical Management
• In treating staphylococcal infections, it is important not to
rupture or destroy the protective wall of induration that
localizes the infection.
• The boil or pimple should never be squeezed.
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51. Management . . . .
• Systemic antibiotic therapy is generally indicated.
• Oral cloxacillin, dicloxacillin, and flucloxacillin are first-line
medications.
• Cephalosporins and erythromycin are also effective.
• Bed rest is advised for patients who have boils on the perineum
or in the anal region, and a course of systemic antibiotic therapy
is indicated to prevent the spread of the infection.
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52. Management
• When the pus has localized and is fluctuant, a small incision
with a scalpel can speed resolution by relieving the tension and
ensuring direct evacuation of the pus and slough.
• The patient is instructed to keep the draining lesion covered
with a dressing.
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53. Nursing Management
• Intravenous fluids, fever reduction, and other supportive treatments are
indicated for patients who are very ill or suffering with toxicity.
• Warm, moist compresses increase vascularization and hasten resolution of the
furuncle or carbuncle.
• The surrounding skin may be cleaned gently with antibacterial soap, and an
antibacterial ointment may be applied.
• Soiled dressings are handled according to standard precautions.
• Nursing personnel should carefully follow isolation precautions to avoid
becoming carriers of staphylococci.
• Disposable gloves are worn when caring for these patients.
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54. Burns
• Burns are caused by a transfer of energy from a heat source to
the body.
• Heat may be transferred through conduction or
electromagnetic radiation.
• Burns are categorized as thermal (which includes electrical
burns), radiation, or chemical.
• Tissue destruction results from coagulation, protein
denaturation, or ionization of cellular contents.
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55. Burns . . .
• The skin and the mucosa of the upper airways are the sites of
tissue destruction.
• Deep tissues, including the viscera, can be damaged by
electrical burns or through prolonged contact with a heat
source.
• Disruption of the skin can lead to increased fluid loss,
infection, hypothermia, scarring, compromised immunity, and
changes in function, appearance, and body image.
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56. Types of Burn
• Chemical burn
• Flame burn
• Scald burn
• Electric burn
• Inhalation burn/injury
56

57. Classification Of Burns
• Burn injuries are described according to the depth of the injury
and the extent of body surface area injured.
Burn Depth
• Superficial partial-thickness injuries
• Deep partial-thickness injuries
•
Full-thickness injuries
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58. Superficial partial-thickness burn
• the epidermis is destroyed or injured and a portion of the
dermis may be injured.
• The damaged skin may be painful and appear red and dry, as in
sunburn, or it may blister.
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59. Deep partial-thickness burn
• Involves destruction of the epidermis and upper layers of the
dermis and injury to deeper portions of the dermis.
• The wound is painful, appears red, and exudes fluid.
• Capillary refill follows tissue blanching.
• Hair follicles remain intact.
• take longer to heal and are more likely to result in
hypertrophic scars.
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60. Full-thickness burn
•
involves total destruction of epidermis and dermis and, in
some cases, underlying tissue as well.
• Wound color ranges widely from white to red, brown, or black.
• The burned area is painless because nerve fibers are destroyed.
• The wound appears leathery; hair follicles and sweat glands are
destroyed.
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61. 61

62. 1st Degree Burn
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63. 2nd Degree Burn
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64. 3rd Degree Burn
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65. Factors those determine the depth of burn
• How the injury occurred
• Causative agent, such as flame or scalding liquid
• Temperature of the burning agent
• Duration of contact with the agent
• Thickness of the skin
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66. Extent of Body Surface Area Injured
• Various methods are used to estimate the TBSA affected by
burns
• among them are the rule of nines, the Lund and Browder
method, and the palm method.
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67. RULE OF NINES
• An estimation of the TBSA involved in a burn is simplified by
using the rule of nines
• The rule of nines is a quick way to calculate the extent of
burns.
• The system assigns percentages in multiples of nine to major
body surfaces.
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68. 68

69. PALM METHOD
• In patients with scattered burns, a method to estimate the
percentage of burn is the palm method.
• The size of the patient’s palm is approximately 1% of TBSA.
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70. 70

71. Extent of Burn injury
Minor Burn Injury
• Second-degree burn of less than 15% total body surface area
(TBSA) in adults or less than 10% TBSA in children
• Third-degree burn of less than 2% TBSA not involving special
care areas (eyes, ears, face, hands, feet, perineum, joints)
• Excludes electrical injury, inhalation injury, concurrent trauma,
all poor-risk patients (eg, extremes of age, concurrent disease)
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72. Extent of Burn injury
Moderate, Uncomplicated Burn Injury
• Second-degree burns of 15%–25% TBSA in adults or 10%–
20% in children
• Third-degree burns of less than 10% TBSA not involving
special care areas
• Excludes electrical injury, inhalation injury, concurrent trauma,
all poor-risk patients (eg, extremes of age, concurrent disease)
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73. Extent of Burn injury
Major Burn Injury
• Second-degree burns exceeding 25% TBSA in adults or 20% in
children
• All third-degree burns exceeding 10% TBSA
• All burns involving eyes, ears, face, hands, feet, perineum,
joints
• All inhalation injury, electrical injury, concurrent trauma, all
poor-risk patients
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74. Management of Patients With Burn Injury
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75. Emergency management of burn
• Extinguish the flame
• Cool the burn
• Remove restrictive objects
• Cover the wound
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76. Fluid loss management
• Output totals of 30 to 50 mL/hour have been used as
goals.
• Other indicators of adequate fluid replacement are a
systolic blood pressure exceeding 100 mmHg and/or
a pulse rate less than 110/minute.
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77. Fluid Requirements
77

78. Example
• The following example illustrates use of the formula in a 70-
kg patient with a 50% TBSA burn:
1. Consensus formula: 2 to 4 mL/kg/% TBSA
2. 2 × 70 × 50 = 7,000 mL/24 hours
3. Plan to administer: First 8 hours = 3,500 mL, or 437 mL/
hour; next 16 hours = 3,500 mL, or 219 mL/hour
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79. Management . . .
• Wound care
79