Integumentary

© USMLE Galaxy LLC

Part I:
Anatomy + Physiology

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Anatomy of the skin

Functions of the skin

● Epidermis
○ Protection from injury
○ Inhibits proliferation of microorganisms
○ Prevents dehydration and electrolyte loss
○ Sweat glands allow for temperature regulation and dissipation of heat
○ Transmits tactile stimulation through neuroreceptors
○ Synthesizes vitamin D
● Cells of the epidermis:
○ Keratinocytes
■ Produce keratin which forms the epidermis
○ Melanocytes
■ Produce melanin - skin pigment

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Functions of the skin
● Components of the dermis
○ Connective tissue
○ Hair follicles
○ Sweat glands and oil glands
○ Blood vessels
■ Sympathetic nervous system regulates blood flow to dermis
■ Regulates heat
○ Nerves
■ Signal skin injury and inflammation
○ Lymphatic vessels
■ Responds to inflammation

Functions of the skin

● Hypodermis
○ Absorbs mechanical shock - protects from injury
○ Temperature regulation
■ Fat cells insulate and retain body heat

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 Part II:
Integumentary Pharmacology

Topical Antimicrobials
● Applied directly to the skin to treat a bacterial, fungal, or viral infection
● These include creams, lotions, oils, ointments, powders, shampoos, and
cleansers
● Antibacterials ● Antifungals ● Antivirals
○ Clotrimazole ○ *topical use is very
○ Bacitracin
○ Ketoconazole uncommon… systemic
○ Neomycin
○ Miconazole use has been shown
○ Mupirocin
○ Nystatin much more effective!*

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Topical corticosteroids
Given to reduce inflammation, redness, and itching

● Triamcinolone
● Hydrocortisone

Part III:
Integumentary Disorders

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Types of Integumentary Disorders
● Lesions
○ Primary
○ Secondary
■ Pressure Ulcers
● Immune responses
● Infections
● Cancers
● Burns

Lesions

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Terminology
● Lesions → “area of tissue that has suffered damage”
○ Primary → direct result of a disease process
○ Secondary → develop as a consequence of the client’s activities
● Pruritus
○ Itching
● Urticaria
○ Hives
● Lichenified
○ Thickened

Terms to describe lesions

● Annular → ringlike with raised borders around flat centers of normal skin
● Circinate → circular
● Circumscribed → well defined, sharp borders
● Clustered → several lesions grouped together
● Diffuse →widespread
● Linear → occurs in a straight line
● Macular → flat
● Papular → raised

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Primary lesions
● Macule→ A discoloration of the skin that is flat and level with
the skin
● Fissure → A cleft or groove in the skin
● Nodule → Small, node-like structure that is solid and
elevated
● Papules → A skin lesion that is small, solid and raised
caused by thickening of the epidermis
● Vesicle → Small bladder or blister that contains clear fluid
● Polyp → A growth that forms on a mucous membrane or
other surface inside your body
● Cyst → a closed pouch under the skin that contains a fluid
or a semisolid substance.
● Pustule → A small elevation on the skin that contains pus
● Wheal → An area of the skin that is slightly raised and
appears either redder or paler than the surrounding skin

Secondary lesions
● Scales → flakes of cornified skin

● Crust → Dried exudate on skin

● Ulcers → area of destruction of the

epidermis

● Scar → Area with excess collagen

formation present after an injury has
healed

Image source: Original Archer Review illustrations

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 Pressure Ulcers

Risk factors
● Lack of mobility
● Exposure to excessive moisture
○ Urinary incontinence
○ Fecal incontinence
● Undernourishment
● Aging skin

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Shear & Friction

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Stage 1

Image source: Archer Review

Stage 2

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Stage 3

Stage 4

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Unstageable

Deep Tissue Injury

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Nursing Interventions
● Use a reliable scale (e.g., Braden Scale) to assess risk, and assess entire skin daily
● Use a proven skin care bundle so that all health care professionals are following
consistent interventions
○ Nutrition
■ Ensure that a nutrition consultation takes place
■ Ensure that fluid intake is 2000 to 3000 mL/day
■ Help the client consume the determined amount of protein and calories
○ Mobility
■ ROM, encourage mobility
○ Moisture
■ Reduce
● Address incontinence
■ Barrier creams

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Ways to reduce pressure
● Examine the source of pressure, and determine how to reduce it
● Do not keep the head of the bed elevated above 30 degrees to prevent shearing
● Help clients in chairs or wheelchairs to stand and march in place, five steps per hour (if
they are able)
● Use pressure-offloading devices or foam dressings for bony prominences (e.g., float the
heels off of a sturdy pillow
● Use devices such as air-fluidized beds or surfaces and powered mattress overlays to
manage the microclimate (the area between the client’s skin and the support surface)
● Refrain from using donut-shaped pillows; these can damage capillary beds and increase
tissue necrosis
● For clients who cannot stand or turn themselves, turn and reposition a minimum of every
2 hours or as needs are assessed

Immune Responses

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Dermatitis
● Inflammation of the dermis
● Several types
○ Contact dermatitis
■ Hypersensitivity when exposed to a certain
allergen
○ Atopic dermatitis (eczema)
■ Intense itching, red, dry, scaly skin.
■ Can have flare ups
■ More common in children and people with
allergies

Psoriasis
● Chronic autoimmune T-cell mediated inflammatory skin disease
● Periods of exacerbations and remissions
● Thickening of epidermis and dermis
● Scaly, erythematous, pruritic plaques
● Interventions
○ Light therapy
○ Systemic therapy
■ Methotrexate
■ Folic acid
■ Systemic retinoids
■ Infliximab

User:The Wednesday Island (of the English Wikipedia), CC BY-SA 3.0

<http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons

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Stevens-Johnson Syndrome
● Cytotoxic T-cell drug reaction
● Keratinocyte cell death
● Causes extensive blistering
● Treatment
○ Stop all possible medications
○ Fluids
○ Nutrition
○ Wound care
○ Pain
○ Corticosteroids

Dr. Thomas Habif, Stevens-johnson-syndrome, CC BY-SA 3.0. View here.

Infections of the skin

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Bacterial skin infections
● Cellulitis
○ Diffuse infection of dermis and hypodermis
○ Red, warm, swollen, and painful skin
○ Most common cause - staph, MRSA, or group B strep
○ Systemic treatment with antibiotics needed
● Impetigo
○ Bullous or ulcerative
■ Cause - staph or strep
■ More common in children
● Methicillin-resistant Staphylococcus Aureus (MRSA)
○ Ranges from mild to moderate
○ Contact precautions

Viral skin infections

● HSV
○ Type 1- mouth and face
○ Type 2 - Genital lesions
○ Groups of vesicles on an erythematous base
■ Vesicles can turn into pustules, rupture, and form crusts
■ Last 2 to 6 weeks
○ Topical/oral antiviral drugs
● Herpes Zoster
○ Grouped lesions with weeping and crusting
■ Unilaterally along segment of skin that follows a cranial nerve
○ Pain and paresthesia
○ Antiviral drugs
○ Vaccination

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Fungal skin infections
● Tinea
○ Classified by location
■ Tinea pedis (Athlete’s foot)
■ Tinea corporis
■ Tinea capitis
○ Annular patches with elevated borders and scaling
○ Client education: keep areas clean and dry, no public showers or pools, don’t share footwear
○ Topical antifungal therapy
● Candidiasis
○ Yeast like fungal infection
○ Erythematous macular eruption with isolated pustules at the border
○ Burning and itching
○ Common in skin folds
○ Oral lesions (thrush) are creamy white

Skin Cancers

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Squamous cell carcinoma
● Very top layer of the epidermis grows out of control
● Form on areas of the body exposed to sun
○ Face
○ Ears
○ Neck
● Treatment
○ Removal
● More likely to grow into deeper layers of the skin

Basal cell carcinoma

● Most common type of skin cancer
● Start in the basal cell layer (bottom layer) of the epidermis
● Form on areas of the body exposed to sun - head, face, neck
● Slow growing and rarely spread
● Treatments
● Surgery
● Local therapies
○ Cryotherapy
○ Topical chemotherapy
○ Immune response modifiers
○ Laser surgery
○ Chemical peeling
● Radiation
● Chemotherapy
● Targeted therapy
● Immunotherapy

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Melanoma
● Melanocytes grow out of control
○ The cells that produce melanin
● Less common; more dangerous - can spread more easily
● Appearance: dark brown or black
○ The cells are making lots of melanin!
○ Most commonly located on trunk or legs
● Treatments
○ Surgery
○ Immunotherapy
○ Targeted therapy drugs
○ Chemotherapy
○ Radiation

Burns

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Burn Staging

1st degree
● Most superficial burn
● The skin remains intact; no break in integrity
of epidermis
● Redness (erythema)
● No blisters
● Can be painful to the touch

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2nd degree
● Partial thickness burn
● Blisters form
● Affects the epidermis and dermis
● Skin is moist and red
● These burns are very painful

3rd degree
● Full thickness burn
● Penetrate all the way from the
epidermis to the dermis and down
into the subcutaneous tissue
● Destroy the nerve endings, so are
not as painful as 2nd degree burns
● Appear red, tan, or black
● Are dry and leathery
● Areas of eschar

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4th degree
● Full thickness, plus
involvement of bone and
muscle underneath
● These burns are dry and
dull https://i.imgur.com/2K7Bxe6.jpg

● Exposed tissue may include

bones and muscles as well
as ligaments and tendons

Classification of burn depth chart

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 Stages of Burn Management

Emergent
● First 24-48 hours
● Large shift in capillary membrane permeability
○ Capillary membrane becomes more permeable
○ Fluid shifts from the intravascular space into the interstitial space
● Client is at high risk for hypovolemic shock, electrolyte imbalances, and renal
failure
● Fluids are the priority intervention
○ Parkland burn formula

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Acute
● 48-72 hours after injury until the wounds heal
● Capillary membrane permeability is stabilized
● Focus on healing
○ Prevent infection
○ Alleviating pain
○ Nutrition
○ Wound care

Rehabilitative
● Burn is now healed
● Focus is on regaining function
○ Psychosocial care
○ ADL assistance
○ Physio/occupational therapy
○ Cosmetic correction

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Rule of 9’s

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 Anterior left arm
Anterior chest

Anterior left arm = 4.5%

Anterior chest = 9%
=13.5%

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 Complications of Burn Injuries

Hypovolemic Shock
● Increase in capillary permeability
● Third spacing occurs
○ Plasma moves from the intravascular space, to the interstitial space
○ Sodium
○ Albumin
● Decreased intravascular volume = decreased BP = hypovolemia
● Cardiovascular system recognizes hypovolemia - increases HR to
compensate
○ Increased HR
○ Decreased cardiac output
○ Decreased blood pressure
● Hypovolemic shock leads to decreased perfusion of kidneys and renal
damage

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Renal Failure
● Decreased perfusion to the kidneys
● Insufficient UOP
○ <30 ml/hr
● Increased
○ BUN
Cr
● Monitor UOP closely
○ Foley catheter
○ Fluid adjustments as needed

Hyperkalemia
● Most potassium is stored in the cells
● Injury causes lysis of cells, which then release potassium into bloodstream
● Causes hyperkalemia
● K >5.5
● Signs and symptoms:
○ Muscle weakness
○ Cramps
○ Nausea
○ Chest pain
○ Arrhythmias
○ Tall, peaked T-waves

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Hyponatremia
● Water follows sodium
● Sodium is leaving the intravascular space and going to the interstitial space
● Due to increased capillary membrane permeability
● Water follows this sodium and the client becomes hyponatremic
● Na < 135
● Signs and symptoms:
○ Headache
○ Confusion
○ Restlessness
○ Irritability
○ Seizures
○ Coma

Fluid Replacement
● Crucial in the first 24 hours
● Due to the increase in capillary permeability, this is when the client is losing
large volumes of fluid and is at risk for hypovolemic shock
● Fluids:
○ Lactated Ringers
■ Expands the intravascular volume
○ Colloids
■ Albumin
● Helps pull fluids back into the intravascular system
● Monitor urine output
● Fluids are titrated to ensure adequate UOP (30 mL/hr)
● Correction of imbalances
○ Sodium? Potassium?

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20% TBSA burned
100 kg

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 1st 24 hrs =
4 ml x 20% TBSA x 100 kg

8L

In the first 8 hours??

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8L/2=
4L

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