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Structure and Function
- Integumentary system is made up of skin, hair, nails
- skin is largest organ in body
- - 15-20% of body weight
- primary defense mechanism when intact
- intergral to self- image, self esteem
- 3 layers- epidermis, dermis, and subcutaneous
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Epidermis
- thin, avascular, outer layer
- four distinct cell types
- keratnocyte- major protective barrier
- melanocyte- pigment producing cell, protects the skin from ultraviolet rays
- merkel's- sensory information
- langerhan- macrophages of immune sys
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dermis
- dense layer
- fibrous connective tissue, hair follicles, sweat and sabaceous glands, macrophages, vascular and nerve
- separate subcuteous from dermis
- provides nutrition to epidermis
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Subcutaneous tissue
- connective tissue/fate cells- stores fate
- good storage space from certain drugs- insulin releasing slowly
- insulation from heat, regulation of temp
- cushion to trauma
- anatomic distribution varies
- contains larger blood vessels
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function of skin
- protection
- maintains homeostatis
- thermoregulation
- sensory reception
- vitamin synthesis- vit d
- consmetic adornment
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effects of aging
- uneven pigmentation, dec melanocytes- inc skin cancer
- fewer immune cells
- dec vitamin synthesis
- dec sensory perception
- inc dry skin
- dec elasticity, inc wrinkles
- the above life changes can be influenced by individual lifestyle, diet (eat good), genetics and other personal habits.
- thin skin
- bruising easily
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Assessment
- History
- - chief complaint
- - presenting sympt, onset**, location, description
- - primary/secondary
- symptoms analysis- pruritis, dryness, rash, lesions, ecchymoses, masses
- PMH
- - systemic/previous illnesses
- - childhood illness
- - meds: OTC, herbs
- - immunization- tdap
- - allergies- seasonal as well
- what is going- cc subjective
- systemic lupus- butterfly rash
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Assessment- fam hx
- genetic or lifestyle predisposition psychosocial hx
- occupation- construction workers
- habits- people pick on skin- nervousness,
- social hx- alcoholics, smoking
- cultural consideration- hos does this cultural see this issue
- environment- exposure
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Physical assessment
- well lit room
- thorough inspection, palpation of hair, scalp, nails, mucous membranes, skin
- primary/secondary lesion
- location, distribution, size, arrangement, color, configuration. drainage, consistency, mobility, tenderness, blanchable
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criteria for diagnosis/care
- description of lesion
- - primary results from a dx process, have not been altered by manipulation, tx, natural course of dx
- - sec. altered by outside manipulation, tx, natural course of dx
- distribution of lesion (shape)
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Common diagnostic test
- KOH ( potassium hydroxide solution)- fungal culture scrap part of infected skin area, place on a clean slide, add 2-3 gtts of koh- observe microscope
- scabies scraping- unscratched papule shave off, place on slide, microscope
- a wood's light exam
- - black light- UV light
- - detects superficial fungal and bacterial infection
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common diagnostic test cont'd
- patch testing- for allergic responses
- - suspected allergic subs are applied to pts skin with adhesive patches- examine for reaction- what is pt reacting too
- biopsy- for histologic assessment
- - shave, dermal punch, surgical excision
- - postop- keep area clean
- - abx, DSD
- - monitor for bleeding
- - teach pt s/s of infection
- - f/u for suture removal
- educate pt to
- - avoid touching
- - wash hands
- - redness, pain, drainage
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Common dermatological disorders
- pruritis
- dermatitis/exzema
- psoriasis vulgaris
- cellulitis
- folliculitis
- furuncles
- carbuncles
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Pruritis
- most common manifestation of skin problems
- sympt, not a disease
- causes- protective response, systemic disease (kidney), drug hypersensitivity, transfusion reaction, age related, emotional response
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pruritis- management
- ID cause & solve
- promote skin hydration
- - humidfy air
- - tepid H2O- avoid hot water
- - avoid frequent bathing
- - avoid soap or use only mild soap- dove
- - colloidal oatmeal baths (aveeno)
- - occlusive ointment, apply to damp skin: eucerin, aquaphor (wet skin- can hold this in)
- - encourage fluids: water H2O, cond
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Pruritis- management 2
- prevent skin irritation- clothing (cotton), short nails, mittens
- cool soaks
- systemic or topical antihistamines
- antibiotics with open wounds
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dermatitis
- itchy, inflammation of skin
- not contagious/dangerous
- types:
- - contact allergy
- - stasis
- - atopic (eczema)
- - TEN (toxic epidermal necrolysis syndrome)
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dermatitis- 2
- acute- extensive erosions with serous exudate or intensely pruritic, erythematous papules
- subacute- erythmatous, excoriated, scaling papules grouped or scattered
- chronic- thickened skin, inc skin markings, excoriated papules & pigmentation changes
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contact dermatitis
- Inflam response to irritant, chemical or physical allergens
- manifestation range from mild erythematic to vesicles and ulcerations
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Contact dermatitis- diagnostics, management
- Diagnostics
- - H&P, patch test
- Management
- - find out that cause
- - avoid exposure to allergen
- - antihistamine & steriods
- - wet dressing
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stasis dermatitis
- intense dry skin to lower legs
- purities
- r/t circulatory problems
- cardiac issue
- take cardiac meds
- make sure to f.u PCP
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Exfoliative dermatitis- TEN (toxic epidermal necrolysis syndrome)
- life threatening skin disorder xterized by blistering and peeling of skin over large areas of the body
- fever, chills, malaise
- vesicles, bullae of epidermis, muccous membranes of the eyes
- can be confused with Steven Johnson Syndrome (SJS)
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Atopic Dermatitis (Eczema)
- inflammatory, relapsing
- non contagious and itchy skin disorder
- unknown cause- genetic component asso with it mostly with fam hx of asthma, hay fever
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patho of eczema
- mutation of the gene for filaggrin
- filaggrin is a protein that plays vital role in the retention of water in the epidermis
- lack of the this leads to;
- - dec H2o binding capacity
- - higher water loss
- - dec H2o content
- - leaving the skin dry
- - think dec water...
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Eczema manifestations
- pruritis
- acute dermatitis as child often becomes chronic as adult
- mainly on bends of elbows, backs of knees, neckm eyelids, back of hands & feet
- sec staphy aureus infections
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management eczema
- goal- break inflammatory cycle
- avoid allergens
- hydrate lubricate skin
- - tepid H2o soak, thick greasy moisturizer
- emollients, topical corticosteroids, tar preparations
- clothing soft/cotton
- systemic abx (if infection from scratching), antihistamine (think safety, drowiness)
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Xerotic eczema
- winter itchy
- patchy, dry, scaling, finely cracked, erythematous skin
- worsened by drying soap, infrequent use of moisturizers
- rx with hydration, moisturizers, avoiding irritants, humidifier
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Psoriasis vulgaris
- chronic, disorder xterized by reddish, scaly, plaques of inflam.
- noncontagious, prutitic
- cause unknown- ? genetic/environment
- triggers: immune system, emotional stress, anxiety, meds, smoking, trauma
- flare ups/remission
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manifestations of psoriasis
- plaques with red slivery scales/demarcated (follow track of it)
- mild discomfort to severe disability
- seen in kneed, elbow, scalp, lower back, genitalia, cracks/bleed, swelling/jt pain (psoriatric arthritis)
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Psoriasis management
- psychological & psychosocial implications (isoloation don't want to be seen)
- mild- sunlight tar preps, topical steriods
- scalp- tar shampoo, steriods lotions
- widespread- systemic treatment
- - methotrexate: s/e infection- supress immune system
- photosynthesizing therapy
- - side effects- skin cancer
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cellulitis
- infection of dermis and subcutaneous tissue
- erythema, edema, tenderness, warm skin, pain, regional lymphadenopathy
- asso sympt fever, chills, h/a, vomiting
- no demarcated borders
- cause: mosting staph aureus or beta hemolytic strep (gram +)
- management:
- warm, moist heat, elevate extremity, immobilization, antibiotics (unisen-ampillian & pain med
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folliculitis
- inflam of hair follicles
- bacterial staph/pseudo, aeruginosa
- white pustules on forehead, chest, upper back, neck, thighs, groin axillae
- management: warm, compresses, topical or oral abx
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furuncles/carbuncles
- abcesses that develop when the infection from folliculitis becomes deeper and involved more follicles
- staph
- boil, deep, painful, firm mass with pus, fever/chills
- carbuncles, larger, aggregate/multiple follicles
- diagnosis- assessment /culture
- Rx- bactroban, neosporin, I&D, diclozacillin/erytromycin
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