[NCLEX] Adult : Integumentary Dz

Anatomy and Physiology :

Functions or the Integumentary System

1. 1. Functions or the Integumentary System
   2. Protect tissues
   3. Barrier against bacteria, viruses 1차 방어선
   4. Sensory percpetion 감각 수용체
   5. Body tempoerature regulation
   6. Secretion salts, water, and organic waste
   7. Synthesis(합성) of Vit D

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Burn

• Description

1. skin damage that results from heat, overexposure to the sun, chemical or electricl contact

• Stages

• First Degree Burn
  1. Only Epidermis = superficial partial thickness
  2. Red, Dry, Blanchable, painful, no edema, no blisters
• Second Degree Burn
  1. Epidermis & Dermis = Deep partial thickness
  2. Blisters, Edema , painful, weeping sound, shiny, pink, red, moist
• Third Degree Burn
  1. Epidermis, Dermis, Subcutaneous tissue, Underlying Bones, Muscles Nerve damage, Full thickness
  2. Waxy, Leathery, Exchar, Charred, yellow, red, brown, white, Non blanchable, No edema, pain free, shock, hematuria + NO 체온 조절

• ✨The Ruls of Nines
  1. head (9%)
  2. anterior torso(18%)
  3. posterior torso(18%)
  4. each arm(9%) - 여기서 앞쪽 팔만, 4.5%
  5. each leg(18%) - 여기서 앞쪽 다리만, 9%
  6. perineum(1%)

• • The parkland formula : 4ml/kg/TBSA% (화상 후 들어가야하는 수액량) → 8hour 1/2 - 16hour 1/2 (손상된 수분량 *4= 반은 8시간 동안, 나머지 반은 16시간 동안)
• Assessment
  • Total body capillary permeability↑, edema↑, blood volume↓, Hypovolemic shock, Death, protein↓ - Muscle weakness, Hct&Hg ↓, Na↓, albumin↓
    • ↓↓ BP, Oliguria U/O ,Na
    • ↑↑ P, Hct/Hb, USG, K, BST
    • leads to third spacing (fluid shifts to areas where normally minimal or absent), allowing proteins, plasma, and electrolytes to leave the vascular space and occupy other spaces and tissues.)
  • Hyperkalemia : peaked T wave, shortened QT interval : 세포 내에는 K+ 수치 많음, 화상으로 세포가 손상되며 혈중K+ 증가

• • GI : stress ulcer, curling’s ulcer , The sympathetic nervous system↑, bowel movement↓
  • Compatment syndrome
• ✨Treatment [ 1st: airway 2nd : fluid 3rd: Infection control ]
  • Assess ABC (pain 보다 airway가 우선순위!!)
  • monitor V/S, provide o2 as needed
  • initiate 2 large IV access for fluid replacement as prescribed
    • ✨Lactated Ringer’s or 0.9% NS 150ml/hr
    • assess fluid resuscitation U/O>30ml/hr, V/S(BP,HR)
  • administer a tetanus vaccine
  • keep the pt warm to prevent heat loss(Use warm blankets, space blankets)
  • cover with dry dx or sterile sheet 공기 접촉 되지 않도록
  • Avoid IM,PO or SC med
  • systemic IV antibiotics
  • NPO → gastrointestinal dysfunction
  • Escharotomy → full thickness to address circulation

• • elevate the burned extremities → edema↓
  • high cal, protein, vit, mineral
  • OTC(over the counter) - ibuprofen, acetaminophen
  • Water-Based lotion + Gentle massage / Topical antimicrobials(bacitracin, sulfadiazine)/ Aloe vera/ sun screen → No corticosteroid cream(피부손상위험)
  • provide ROM/ pressure garments/ circulation aid bed

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SKin cancer

• Description
  • a cancer that develops in the skin cells
• ✨Risk factors
  • sun exposure, UV radiation → 운동선수
  • Light skin tone, fair skin
  • age 60 , family history
  • atypical or high number of moles
  • HIV, Immunosuppressant med

• Type
  • Squamous cell carcinoma
  • Basal cell carcionoma
  • Melanoma

• ✨✨ABCDE rules
  • Asymmetry 비대칭성
  • Border irregularity 경계 모호
  • Color : irregular, variegated 흐려지거나 진해짐
  • Diameter of 6mm or large
  • Evolving ; shape and size 진화, 변화

• ✨Prevention
  • Avoid sun exposure between 10am and 4pm
  • Do not exceed more than 15-30 mins
  • Wear long sleeves, hats, umbrellas
  • Use sunscreen
  • SPF>30, 15-30mins ago, re-apply every 2-3hrs
  • Do not use tanning beds
  • Apply sunscreen during cloudy weather
  • Self check up montly
  • Pressure Ulcer

Pressure Ulcer

• Def
  • Also called bedsore or pressure sore
  • Injury to the skin and underlying tissue caused by prolonged pressure or friction

• Risk factors
  • Obesity, Age
  • Prolonged pressure, Immobility
  • Skin shearing & friction
  • Incontinent
  • Malnutrition, Dehydration
  • Decreased Sensory perception(DM)
• ✨✨Stages of Pressure Ulcer

1st Epidermis	- intact skin - pink, redness(=erythema), warm, non-blanshable - No open wound - Transparent polyurethane film Dx(테가덤)
2nd Dermis	- Redness, pink, shiny, dry, blister+drain - hydrogel, hydrocollid Dx (듀오덤)
3rd Subcutaneous fat	- Full thickness tissue loss - subcutaneous tissue may be visible + moderate drain
4th Underlying tendon, muscle, bone	- Full thickness tissue loss - Exposed tender, muscle, bone - Slough or Eschar - Undermining and tunneling
Unstageable	- Full thickness tissue loss - Necrotic, Dead - Yellow, black, eschar, slough - hydrophilic Dx
Deep tissue injury	- Dark purple or maroon discoloration - Blood blister - Ischemic subcutaneous tissue → 혈액공급X

• • ↑ deep tissue injury
• Tx
  • Monitor skin daily
  • Reposition every 2 hours and keep the bec sheets wrinkle-free
  • Avoid rubbing, massaging directly to a reddened skin area
  • Limit time sitting in the bed with head elevated >30 to avoid pressure on the sacrum
  • Provide ROM every 8hours
  • Clean with normal saline, apply barrier cream
  • Provide wound care with vacuum, Wound foam or pad(Mepilex)

• • Use special Air mattress & pillows
  • Administer pain killers
  • Nutrition support - protein, vitamins and minerals(Juven powder)

​	Tx(Dx)
stage1 (Epidermis)	- Transparent Dx, Film Dx, Air mattress, hydrocolloid Dx, Postition change q2hr - Avoid : donut’s ring, rubber ring
stage2 (Dermis, shallow)	- N/S irrigation, Hydrocolloid Dx - Debridment + sulfadiazine silver cream - Foam Dx, Hydrogel - Sterile Wet gauze+Sterile Dry gauze - Elatic bandage compression - Wound culture & antibiotics
stage3 (Deep tender)	- Lotion apply every 2hr, Hydro colloid Dx - Clean wound with sterile solution - Form Dx, Hydrogel, Calcium alginate Gauze - Debridement, Vacuum Dx - Debridment + sulfadiazine silver cream - Wound culture & antibiotics, dietitian
stage4 (Bone)	- Hydro dolloid Dx, morphine for Dx pain - Cleaning, surgical debridement
unstagable	- Enzyme, adherent film Dx, debriment - Cleansing with a sterile, gentle solution (N/S) - Covering with a hydrophilic(water-loving) Dx that absorbs moisure - Frequent reposition and off-loading the affected area - A nutrient : rich, higt cal diet

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Herpes Zoster(Shingles) 대상포진

• Def
  • Reaction of Varicella-zoster virus

• Risk factors
  • A history of chickenpox
• Assessment
  • Clusters of vesicles along the course of peripheral sensory nerves
  • Itching, Pain, Burning, Fatigue, fever
  • Burning deep pain 2-3 weeks of longer
• ✨✨Tx
  • Isolate the client (Contact+Airborne precaution)
  • Antiviral therapy(Acyclovir PO or IV,Cream), Antipruritic agents, pain killer
  • Wear loose clothing, keep the room cool
  • Avoid those without chickenpox or with weakened immune systems
  • Do not scratch and rub , Use an air mattress
  • The zoster vaccine(Live) for adults 60 years of age and older

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Psoriasis 건선

• Def
  • A chronic autoimmune skin disease occurring with remission and exacerbations, Not contagious
  • Keratin in the epidermis grow too quickly

• Risk factors
  • Stress, Trauma, infection, hormonal changes, obesity, and an autoimmune reaction
• Sx
  • Red patches with silvery-white scales(Shedding), Scaling, Pruritus, and erythema(redness)
  • Common on scalp, elbows, back and knees
  • Pitting or crumbling nails, joint inflammation with psoriatic arthritis
• Tx
  • Administer Corticosteroids, Coal Tar(연고;각질 용해제), Methotrexate, Acitretin(아시트레틴, 신생아 기형 유발), Cyclosporine(면역억제제)→ monitor of CBC, lipids, LFTs
  • Help boost self esteem, avoid triggers - Reduce stress
  • Wear light cotton clothes, Shampoo frequently
  • Avoid selt-medication OTC → 건선 증상 악화
  • Ultraviolet light/Phototherapy → 광선 용법으로 치료
  • NO! Avoid sunlight → 오히려 햇빛을 많이 쐬도록.

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Candidiasis

• Def
  • Inflammation caused by the fungus Candida albicans(Yeast)
  • On the skin or the mucous membranes
  • person to person, Breatfeeding, kissing

• Risk factors
  • Immunosuppression, Long term antibiotic therapy, DM, Obesity
• Sx
  • Skin
    • Moist, itchy, burning patches with vesicles and pustules in warm moist skin fold areas such as under breast, Axilla, groin
  • Vaginal infection
    • Thick, white “cottage cheese” like vaginal discharge, itching and burning
  • Thrush
    • Plaques of oral thrush, Red and Whitish patches of the mouth
• Tx
  • Antifungal medications(-zole) → Ketoconazole(Nizoral), fluconazole(Diflucan), Nystatin
  • Good hand washing, provide frequent mouth care
  • Clean the skin fold area

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Impetigo 농가진

• Def
  • Highly Contagious superficial skin infection
  • Beta hemolytic streptococcus of Staphylococcus aureus

• Risk factors
  • Childhood, poor nutrition or health, poor hygiene
  • Tropical climate
• Sx
  • Small red spots, vesicles that rupture and ooze fluid
  • Honey-colored crusts form lesions on the face, arms and legs
  • Itching, soreness
• Tx
  • Antibiotic ointments or creams, Oral antibiotics
  • Antimicrobial soaps and washes
  • Practice good hand washing
  • Avoid sharing towels and clothing
  • Avoid contaching with others until the sores have healed
    • 상처가 다 나을 때 까지 다른 사람과 접촉 피하기.

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Scabies 옴, 진드기

• Def
  • Highly Contagious, Infection by scabies mite
  • Risk factors
  • Crowded living environments, Shared clothing, towels
  • Close skin to skin contact
• Sx
  • Intense itching especially at night, Rash
  • Thread-like linear or serpentine grey-brown burrows
• Tx
  • Permethrin(페르메트린; 살충제) cream from head to toe under nails at bedtime(눈을 제외한 전신)
  • Wash clothes, towels, Take a shower
  • Gamma benzene hexachloride(Lindane) and wash off in 8-12 hrs

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Frostbite 동상

• Def
  • A damage to tissues and blood vessels caused by prolonged exposure to cold

• Sx
  • White plaque, White or blue skin
  • Large blisters, small hemorrhagic blisters, eschar
  • Cold skin, Numbness, Tingling, Loss of feeling
• Tx
  • Rewarm with Warm water(tepid water) bath or towels for 15-30 mins
    • NO. use Hot water/Hot pack → warm water
  • Oral pain medication
  • Elevate the burned extremities - edema↓
  • Handle the affected area gently
  • Avoid rubbing or massaging due to further issue damage
    • 괴사 위험
  • Avoid compression of the injured tissues and smoking
  • Amputation may be required

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Acne Vulgaris

• Def
  • Teenagers and young adults(in puberty), especially male
  • The menstrual cycle in females with hormonal activities
  • Overproduction of oil on the face, neck, chest, shoulders, and back
• Sx
  • non-inflammatory lesions : opened comedones(blackheads) or closed comedones(whiteheads)
  • Inflammatory lesions: papules, pustules, nodules, cysts
• Tx
  • Avoid scrubbing the face, avoid squeezing, picking at lesions, avoid alcohol bases products
  • Avoid triggers - heat, cold, sunlight, alcohol, and spicy food& Apply sun product daily(=sunscreen)
  • ✨✨Rx(약물)
    • Isotretinoin(Vit A), Tretinoin(Vit A)
    • Side effect : Birth defects , suicidal thoughts, Dry skin
    • Can’t be used if pregnant or likely become pregnant&suicide risks, check LMP and Possibility of pregnancy
    • Avoid additional Vit A supplements due to increase side effects
    • Do not take Isotretinoin and Tetracyclines together (Hypertension)
  • ABx - Sulfa, erythromycin, Metromidazole to reduce inflammation
  • Do not overexposure to sun - Tretinoin, sulfa d/t photosensitivity

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Cellulitis

• Def
  • A group A streptococcus of Streptococcus aureus infection of the dermis and underlying hypodermis

• Risk factors
  • Diabetes (slow healing and infection risk)
  • HIV
  • oldage
• Sx
  • Painful and tenderness, red and warmth, Fever
  • Tight and shiny, edema, swollen lymph nodes - Tissue death, abscesses
• ✨Tx
  • Maintain rest of the affected area
  • Apply warm compresses to promote circulation
  • Antibacterial dressing and ointments
  • Elevate the affected areas - Edema ↓ ↔ Flat or dependent postioning- edema↑ →delays recovery and painful
  • Administer pain medications - Ibuprofen or acetaminophen
  • IV ABx → 가장 효과적임
  • Debridement → 괴사 조직 제거
  • Daily marking and dating of reddened areas(monitoring the size of cellulitis)
  • Standard precaution
    • BUT gown, glove for bating and body fluid contact (e.g urine, stool)

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Poison Ivy

• Def
  • Caused by an allergic reaction to the leaves, stems, and roots of plant
• Sx
  • Linear Rash, itchy, Swelling

• ✨Tx
  • Wash the area where the contact occurred immediately!!
  • Apply cool, wet compresses to reduce itchiness
  • Apply Topical cortisone products to reduce discomfort
  • Do not rub and scratch

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Tinea

• Def
  • Highly contagious fungal infection on the superficial keratin layers of the skin, hair, and/or nails
  • Transmitted via direct contact with infected individuals, pets, or surface objects(eg. hairbrushes, bedding, towels)
• Sx
  • Tinea corporis (ringworm)
    • Scaly, pruritic patch
    • Circular or oval

• • Tinea capitis
    • Round, scaly patches on the scalp
    • Red and itchy
    • Alopecia(hair loss)

• • Tinea pedis(athlete’s foot)
    • Scaly, red, itchy rash typically between the toes or on the sole of the foot

• • Tinea unguium(onychomycosis)
    • Thick, brittle nail with yellow discoloration

• • Tinea cruris (jock itch)
    • Red, itchy, scaly patches in groin area
    • Most common in athletes

• Tx
  • Topical antifungal cream(miconazole)
  • Oral antifungals (griseofulvin)
    • May be indicated if unresolved with topical therapy
  • Prevention
    • Keep skin dry and clean
    • Avoid sharing personal items(towels, hairbrushes)
    • Clip finger and toe nails short
    • Change socks and underwear every day
    • Wear shoes with adequate circulation

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Stevens-Jonhson syndrome(SJS) / Toxic epidermal nercrolysis

• Def
  • Severe form of Stevens-Johnson syndrome, an immune-mediated, acute skin reaction triggered by certain medications (eg, lamotrigine, rifampin).

• Cz
  • A rare and unpredictable reaction to medication (Acetaminophen, atenolol, captopril, diltiazem…)
  • HIV, Viral infection, immune ↓, Family Hx of SJS, Genetic (HLA-B 1502 and HLA-B1508), Southeast Asian, Indian
• Sz
  • Early Sx
    • flu like symptoms (fever, fatigue)
    • Sore throat, difficulty swallowing
    • Runny nose and cough
    • sore red eyes, congunctivitis
    • General aches and pains
  • Late Sx (Life-threatening, skin reaction and mucosal loss)
    • Blister, peel, erosion, like hot-water burn skin (start from face and chest to other part of body)

• • • Damages mucous membranes (including mouth and airway)

• • • irrtation and redness of the conjunctiva and damage to the cornea

• Cx
  • Dehydration and acute malnutrition
  • ARDS(acute Respiratory Disease Syndrome)
  • Gastrointestinal ulceration
  • Shock and multiple organ failure
• Tx
  • Hospitalization in burn unit
  • Stop non-essential medication (Usually stop all medication)
  • Nutritional an fluid replacement (Cyrstalloid)
  • Pain relief
  • Sterile handling and reverse isolation procedures
  • Wound care, Eye care.
    • lubricating eye drops or ointment to relieve dryness and prevent corneal abrasion and keratoconjunctivitis
  • Providing cotton blankets and maintaing a warm room temp to prevent hypothermia