INTEGUMENTARY

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INTEGUMENTARY

• Complex

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FACTORS THAT AFFECT INTEGUMENTARY FUNCTION

• Circulation
• Nutrition
• Lifestyle and Habits
• Condition of Epidermis
• Allergy
• Infections
• Age
• Environment

• Abnormal growth rates
• Systemic Diseases
• Trauma
• Accidental
• Surgical
• Excessive Exposure

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ALTERED INTEGUMENTARY FUNCTION

• Pain
• Pruritus
• Rash
• Lesions
• Wound healing
• Phases
• Types

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Diagnostic evaluations

• Skin biopsy
• Skin cultures
• Serum assays
• Skin testing

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Common Pathologies

• Skin cancer
• Lyme disease
• Psoriasis
• Kaposi sarcoma
• Herpes zoster
• Frostbite
• Burn injuries

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Skin cancer

• Very common
• Basal cell
• Most common type, contained in epidermis
• Squamous cell
• Affects epidermis but infiltrates surrounding
  areas. Metastasis to lymph nodes is common. Can
  be fatal
  
• Malignant Melanmona
• Affects melanocytes. Mets to brain, lungs, bone,
  liver. Usually fatal.
  

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Lyme disease

• Multi-system inflammatory disorder caused by an
  infection acquired through ticks
  
• Following tick bite, first symptoms occur several
  days to a month later
  

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Psoriasis

• Chronic, noninfectious skin inflammation
  involving keratin synthesis that results in
  psoriatic patches
  
• Usual causes are stress, trauma, infection and
  changes in climate.
  
• Look for shedding, silvery, white scales on a
  raised scalp, knees, elbows, extensor surfaces of
  arms legs and sacral regions

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Kaposi sarcoma

• Skin lesions that occur primarily in individuals
  with a compromised immune system
  
• Slow growing tumor that appears as raised,
  oblong, purplish, reddish, brown lesion and may
  be tender or nontender
  
• Organ involvement includes the lymph nodes,
  airways or lungs, or any part of the GI tract

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Herpes Zoster / Shingles

• Acute invasion of the peripheral nervous system
  due to reactivation of Varicella zoster virus
  
• Usually occurs during immunocompromised state
• Culture provides definite diagnosis.
• Contagious to individuals who have not had
  chickenpox
  

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Frostbite

• Damage to tissues and blood vessels as a result
  of prolonged exposure to cold
  
• Numbness, paresthesia, pallor
• Necrosis and gangrene may develop in severe
  cases
  
• Rewarm rapidly with warm water bath

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Medical/Surgical Management

• Topical pharmacological therapy
• Radiation
• Chemotherapy
• Debridement
• Grafting

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WOUNDS

• Types
• Acute
• Chronic
• Partial-thickness
• Full-thickness
• Pressure ulcers
• Leg ulcers

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Wounds, cont.

• Venous stasis ulcers
• Arterial ulcers
• Diabetic foot ulcers

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Wound Healing

• Moist environment
• Less subcutaneous tissue
• More fragile skin 2 to age and drug therapy
• Increased of precipitating risk factors for
  pressure ulcers
  

• Increased of precipitating risk factors for
  chronic wounds
  
• Nutrition - than body requirements
• Decreased ability to care for self with age

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Wound healing, cont

• Decreased immune system function
• Decreased pulmonary and cardiovascular function
• Increased potential for incontinence

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Methods of Wound Healing

• Primary
• Secondary
• Tertiary a.k.a.
• delayed primary intention

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Wound Assessment

• Location
• Size
• Depth
• Undermining
• Tunneling
• Wound bed
• Drainage
• Drains and tubes
• Pain

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Wound Closures

• VAC vacuum-assisted wound closure
• Sutures, staples, and wound adhesives

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Wound Dressings

• Wet to Dry dressings
• Calcium alginates and foam dressings
• Hydrocolloids

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Wound Debridement

• Several methods
• Autolytic
• Chemical
• Mechanical
• Laser

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WOUND HEALING

• Inflammatory phase
• Fibroblastic phase
• Maturation phase

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COMPLICATIONS OF WOUND HEALING

• Internal or external hemorrhage
• Interstitial fluid loss
• Hematomas
• Infection
• Dehiscence
• Evisceration
• Fistula

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Nutrition

• Body needs adequate carbohydrates, fats,
  proteins, minerals, calories, vitamins and
  hydration
  
• Calorie intake normal intake 25-30 kcal/kg/day.
  Normal protein intake is 0.8g/kg/day.
  
• In critically ill pt calorie intake needs to
  increase to 35-40 and protein to 1.5-2
  

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Immune function

• Affected by nutrition, age, medications, disease,
  etc.
  
• Cells of immune system originate in marrow.

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Inflammation response

• Stage I - vascular
• Stage II cellular
• Stage III tissue repair and replacement
• Fever

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Immunity
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Diagnostic Tests

• WBC
• ESR
• Cultures
• Cultures and sensitivity

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BURNS
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Severity

• of body surface burned
• Depth of burn
• Anatomical location of the burn
• Age of the person
• Persons medical history
• Presence of concomitant injury
• Presence of inhalation therapy

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Calculate Total Body Surface Area

• Rule of nines
• Lund and Browder chart

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Systemic Response
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Localized response causing coagulation of
cellular proteins and causing irreversible cell
injury with localized production of inflammatory
factors
This inflammatory factors cause the increased
capillary permeability, causing leakage,
including electrolytes. Pts are initially
hyperkalemic
Pulmonary vascular system also is prone to
leakage and leads to edema inside the lungs. Can
lead to intra-alveolar hemorrhages. This is
thought to be precursor to ARDS
Tumor necrosis factor is released. This leads to
many complications with oxygen free radicals that
lead to injury of lungs, GI tract, kidneys,
initial hyperglycemia, hypotension, metabolic
acidosis, coagulopathy and activation of
coagulation cascade (can lead to DIC)
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SMOKE INHALATION

• Acute pulmonary insufficiency may occur during
  first 36 hours
  
• Pulmonary edema can occur between 6 to 72 hours
  after injury
  
• Bronchopneumonia can appear in 3-10 days after
  injury

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INFECTION

• Loss of mechanical barrier
• All aspects of immune system are compromised
• Phagocytosis
• T-cell production
• Antibody production
• Need to watch for signs of septic shock
• Hypotension, hypoxia, decreased pulmonary
  compliance, renal failure, poor hepatic function
  and glucosuria with normal blood sugar levels

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MANAGEMENT

• First hour is most crucial and next 24-36 are
  also important
  
• Primary survey
• Airway maintenance with cervical spine
  protection
  
• Breathing and ventilation
• Circulation and hemorrhage control
• Disability (assess neurological deficit)
• Exposure (completely undress pt, but maintain
  temperature

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MANAGEMENT, cont

• Secondary survey
• Detailed history
• Physical exam
• Find out what happened
• Look for burn marks on face
• Full labwork, ekg if possible, abgs with
  carboxyhemoglobin, urinalysis, BUN, Creatinine

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REPARATIVE PHASE

• Prevent hypovolemic shock
• Correct F/E and protein deficits
• Replace losses, and maintain balance
• Prevent excessive edema formation
• Maintain a urine output in adults of 30-70 mL/hr

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Fluid Resuscitation

• May be given as D5W, with or without added
  electrolytes
  
• LR
• Baxter (Parkland) is most common
• 4mL of LR solution per kilogram of body weight
  per percentage of TBSA burn to be administered
  within first 24 hours
  
• One half to be given within first 8 hours and
  remainder over the remaining 16 hours

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Example

• If a pt weighs 75 kg and has burns over 50 of
  body then they would require 15,000 mL of fluid
  
• (4 mL X 75 kg X 50 15,000 mL)
• 7,500 over first 8 hours and
• 3,750 over second and third 8 hour shifts

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NUTRITION

• Early enteral feeding has been proposed because
  it may reduce the translocation of bacterial from
  the intestinal lumen
  
• Slowly give enteral feedings through NG tube at
  rate of 10-20mL/hr.
  
• Parenteral nutrition can supplement
• Burn patients need as many as 7000-8000 kcal/day
  to maintain weight

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MAINTENANCE

• Prevent contractures
• Cleanse wound
• Application of topical antimicrobial agents
• Debridements
• Grafts
• Escharotomy

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Integumentary Medications
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• Emollients and lotions
• Rubs and liniments
• Antiinfective agents
• Antiseptics
• Antibacterials
• Antifungals
• Antivirals
• Antiparasitics

• Antiparastics
• Antipruritics
• Stimulants
• Protectives
• Enzymes
• Corticosteriods
• Burn products