The slides are on the disorders that affect the integumentary system, which is of the skin, nails.

1. Disorders of the
Integumentary
system
SEMESTER I, 2024
NUZHAT RUHI

2. Learning Outcome
Apply the skills of assessing the sick adult individual with
integumentary disorders, recognize the signs and symptoms, and
evaluate the diagnostic, therapeutic, supportive, corrective
surgical measures.

3. Contents of the Lecture
Review Skin Anatomy and Physiology
Assessment of skin
Diagnostic tests for skin disorders
Common Skin Medications
Skin disorders – Definition, Pathophysiology, Causes, Risk
Factors, Diagnostics, Treatment Plans, Nursing Care Plans
and Nursing Management
Reference

4. Skin Anatomy & Physiology
The integumentary system consists of the skin, hair, nails, glands, and nerves.
Its main function is to act as a barrier to protect the body from the outside world.
It also functions to retain body fluids, protect against disease, eliminate waste products, and regulate body
temperature.

5. Overview
Skin disorders can be divided into primary or secondary lesions.
Assessing for the presence of these lesions may be challenging when
providing telephonic care; however, a great deal of information can be
collected through asking focused questions.
Rashes or areas of the skin that are red and irritated can be caused by many
things. It can be difficult to assess rashes when providing telephonic care;
however, nurses can assess for possible causes for the disorder.
As with the skin disorders, assessing the appearance of skin trauma can be
challenging.
Encourage the patient to seek medical attention for any skin condition or
changes that do not appear to be healing, are becoming worse, or troubling
to the patient.

6. Assessment of
skin
Guideline for
collecting the
needed
information
about
symptoms:
Character - Describe the sign or symptom
 Onset - When did it begin?
Location - Where is it?
Duration - How long does it last? Does it recur?
 Severity - How bad is it? Does it bother you?
 Pattern - What makes it better or worse?
 Associated factors / How it affects the patient
-
 What other symptoms occur with it? How
does it affect you?

7. Assessment of skin
When assessing past health history, ask the patient:
To describe any previous skin problems and any
treatment or surgery that was done.
 Any allergic skin reactions?
 Any recent fever, N/V, or respiratory
problems?
 (For female patients) Are you pregnant? Are
menstrual cycles regular?
 Any history of smoking or drinking alcohol?
 Any history of anxiety, depression, or other
psychiatric problems?

8. Assessment of skin
Thephysicalassessmentof theskin involvesinspectionand palpation,
andmayreveallocal or systemicproblemsin thepatient.
INSPECTION involves looking at the following:
General skin color - abnormal findings would include pallor,
cyanosis, or jaundice
Color variations - look for rashes or erythema
Skin integrity - carefully check pressure point areas
Lesions - note the color, shape, and size

9. Assessment of skin
When PALPATING the skin, it is important to note:
Texture - it should be smooth and even.
 Thickness - very thin skin may indicate steroid
therapy or arterial insufficiency.
 Moisture - increased moisture is felt with fever
and hyperthyroidism, decreased moisture occurs
with dehydration or hypothyroidism.
Temperature - cool skin may accompany arterial
disease, cold skin is felt in shock or hypotension,
and very warm skin is felt with fever or
hyperthyroidism.
 Turgor - refers to the skin’s elasticity and
should pinch easily, then immediately return to its
original position.
 Edema - the skin should rebound and not
remain indented when pressure is released.

10. Assessment of skin
Chief complaint assessment tool
P = Provocative and Palliative factors
Q = Quality and Quantity
R = Region
S = Severity of the signs and symptoms
S = Severity of the signs and symptoms
T = Time the patient has had the disorder

11. Assessment of skin
Identification of a potential malignancy
A = Asymmetrical lesion
B = Borders irregular
C = Color (even or uneven)
D = Diameter of the growth (recent changes)
D = Diameter of the growth (recent changes)
E = Elevation of the surface

12. Psychosocial Assessment
May affect body image and self-esteem
Assess coping abilities
Nurse’s attitude should be nonjudgmental, warm, and
accepting
Provide consistent information
Include family in treatment plan
Provide positive feedback

13. Stages of Wound Healing
Soft tissue wounds undergo several phases of healing, each merging seamlessly into the next.
These are classified as:
Coagulation (clotting) phase
Inflammatory phase
Proliferative (or healing) phase
Maturation (or reorganisation) phase

14. Coagulation
Coagulation begins immediately in healthy animals. Blood
vessels first spasm and contract to limit bleeding, but later
dilate to provide oxygenated blood and allow neutrophils to
reach the area. A platelet plug forms (primary haemostasis)
limiting contamination and blood loss. Later, this seal is
strengthened and reorganised as a result of the action of
clotting factors (secondary haemostasis) to add fibrin and
later collagen.

15. The Inflammatory Phase
The Inflammatory Phase also begins immediately post-injury
and should last approximately 3-5 days. Neutrophils dominate
this phase and are important in removing necrotic material and
protection from invasion by microorganisms. Inflammatory
mediators released from leukocytes and damaged cells attract
and activate circulatory cells important in the next phase of
healing

16. The Proliferative Phase
The Proliferative Phase is characterised by the presence of granulation tissue
and beings from about days 3-5 post-injury, lasting for approximately 3 weeks.
Healthy granulation tissue has a rich red appearance and a velvet smooth matt
finish. It contains fibroblasts (collagen producing cells), a developing collagen
matrix which is important for wound strength, macrophages and developing
blood vessels. As it matures, myofibroblasts produce myocollagen that results in
wound contraction. This can lead to a 30% reduction in wound surface area in
loose skinned areas, with maximal contraction about 7-10 days after injury.
Healthy granulation tissue is very resistant to infection and provides a
foundation for epithelial cells (skin cells) to migrate from the wound margins
across its surface. Sutured wounds with a small dermal gap epithelialise in 48hrs
since there is no intervening proliferative phase. Epithelialisation of open
wounds begins 4-5 days post-injury and may take weeks to complete.
Epithelialisation produces a fragile hairless scar compared with normal skin.

17. The Maturation
Phase
The Maturation Phase begins 2-4
weeks post-injury. Remodelling of
collagen confers strength to the tissue
(up to 80% of original strength for
skin). Fibre orientation parallel to
tension in the tissue allows it to better
resist lines of force. This can continue
for months to years after an injury,
depending on the tissue type and the
forces acting on it.

18. Diagnostic tests for skin disorders
Diagnostic tests are indicated when the cause
of a skin lesion or disease is not obvious from
history and physical examination alone. These
include:
Patch testing
• Biopsy –
• Punch
• Shave
• Wedge excision
• Scrapings
• Swabs
• Examination by Wood light
• Tzanck testing
• Diascopy

19. Patch Testing
A patch test is a diagnostic method used to determine which specific substances
cause allergic inflammation of a patient's skin.
Patch testing helps identify which substances may be causing a delayed-type
allergic reaction in a patient, and may identify allergens not identified by blood
testing or skin prick testing.

20. Swabbing
These can be taken for bacteriology and virology.

21. Biopsy
In a punch biopsy, a tubular punch (diameter usually 4 mm) is inserted into deep dermal or
subcutaneous tissue to obtain a specimen, which is snipped off at its base.
Shaving with a scalpel or razor blade may be done for more superficial lesions. Bleeding is controlled
by aluminum chloride solution or electrodesiccation; large incisions are closed by sutures.
Wedge excision of skin using a scalpel can be done for larger or deeper biopsies.
Pigmented lesions are often excised for histologic evaluation of depth; if too superficial, definitive
diagnosis may be impossible. Diagnosis and cure can often be achieved simultaneously for most small
tumors by complete excision that includes a small border of normal skin.

22. Scrapings
Skin scrapings help diagnose fungal infections and scabies.
For fungal infection, scale is taken from the border of the lesion and placed onto a microscope
slide. Then a drop of 10 to 20% potassium hydroxide is added. Hyphae, budding yeast, or both
confirm the diagnosis of tinea or candidiasis.
For scabies, scrapings are taken from suspected burrows and placed directly under a coverslip
with mineral oil; findings of mites, feces, or eggs confirm the diagnosis. However, a negative
scraping does not rule out scabies.

23. Wood light
A Wood light (black light) can help clinicians diagnose and define the extent of lesions (eg,
borders of pigmented lesions before excision).
It can help distinguish hypopigmentation from depigmentation (depigmentation of vitiligo
fluoresces ivory-white and hypopigmented lesions do not).
Erythrasma fluoresces a characteristic bright orange-red. Tinea capitis caused by Microsporum
canis and M. audouinii fluoresces a light, bright green.
(Note: Most tinea capitis in the US is caused by Trichophyton species, which do not fluoresce.)
The earliest clue to cutaneous Pseudomonas infection (eg, in burns) may be green fluorescence.

24. Tzanck testing
Tzanck testing can be used to diagnose viral disease, such as herpes simplex and herpes zoster, and is
done when active intact vesicles are present.
Tzanck testing cannot distinguish between herpes simplex and herpes zoster infections. An intact blister
is the preferred lesion for examination.
The blister roof is removed with a sharp blade, and the base of the unroofed vesicle is scraped with a #15
scalpel blade.
The scrapings are transferred to a slide and stained with Wright stain or Giemsa stain. Multinucleated
giant cells are a sign of herpes infection.

25. Diascopy
Diascopy is used to determine whether erythema in a lesion is due to blood within superficial
vessels (inflammatory or vascular lesions) or is due to hemorrhage (petechiae or purpura).
A microscope slide is pressed against a lesion (diascopy) to see whether it blanches.
Hemorrhagic lesions do not blanch; inflammatory and vascular lesions do.
Diascopy can also help identify sarcoid skin lesions, which, when tested, turn an apple jelly color.

26. Medications for Skin conditions Treatment
Medications used to treat skin conditions include topical and oral drugs.
Some common topical treatments for skin conditions include:
Antibacterials: These medicines, including mupirocin or clindamycin, are often used to
treat or prevent infection.
Anthralin : This drug, though not often used because it can be irritating and can stain,
helps reduce inflammation and can help treat psoriasis.
Antifungal agents: Clotrimazole (Lotrimin), ketoconazole (Nizoral), and terbinafine
(Lamisil AT), are a few examples of common topical antifungal drugs used to treat skin
conditions such as ringworm and athlete's foot.

27. Medications for Skin conditions Treatment
Benzoyl peroxide : Creams, gels, washes, and foams containing benzoyl peroxide are
used to treat acne.
Coal tar : This topical treatment is available with and without a prescription, with
strengths ranging from 0.5% to 5%. Coal tar is used to treat conditions including
seborrheic dermatitis (usually in shampoos) or psoriasis. Currently, coal tar is seldom
used because it can be slow acting and can cause severe staining of personal clothing
and bedding.
Corticosteroids: These are used to treat skin conditions including eczema.
Corticosteroids come in many different forms including foams, lotions, ointments, and
creams.

28. Medications for Skin conditions Treatment
Non-steroidal ointment: The ointments crisaborole (Eucrisa) and tacrolimus (Protopic)
and the cream pimecrolimus (Elidel) also are prescribed for eczema, including atopic
dermatitis.
Retinoids: These medications (such as Retin-A, Differin, and Tazorac) are gels, foams,
lotions, or creams derived from vitamin A and are used to treat conditions including
acne.
Salicylic acid : This drug is sold in lotions, gels, soaps, shampoos, washes, and patches.
Salicylic acid is the active ingredient in many skin care products for the treatment of
acne and warts.

29. Medications for Skin conditions Treatment
Some common oral or injection treatments for skin conditions include:
Antibiotics: Oral antibiotics are used to treat many skin conditions. Common antibiotics include
dicloxacillin, erythromycin, and tetracycline.
Antifungal agents: Oral antifungal drugs include fluconazole and itraconazole. These drugs can
be used to treat more severe fungal infections. Terbinafine is an oral antifungal medicine that
may be used to treat fungal infections of the nails. Griseofulvin, whitfields ointment.
Antiviral agents: Common antiviral agents include acyclovir (Zovirax), famciclovir (Famvir), and
valacyclovir (Valtrex). Antiviral treatments are used for skin conditions including those related to
herpes and shingles.
Corticosteroids: These medications, including prednisone, can be helpful in treating skin
conditions linked to autoimmune diseases including vasculitis and inflammatory diseases such as
eczema. Dermatologists prefer topical steroids to avoid side effects; however, short-term use of
prednisone is sometimes necessary.

30. Medications for Skin conditions Treatment
Immunosuppressants: Immunosuppressants, such as azathioprine (Imuran) and
methotrexate (Trexall), can be used to treat conditions including severe cases of
psoriasis and eczema.
Biologics: These new therapies are the latest methods being utilized to treat psoriasis
and other conditions. Examples of biologics include adalimumab (Humira), adalimumab-
atto (Amjevita), a biosimilar to Humira, etanercept (Enbrel), etanercept-szzs (Erelzi), a
biosimilar to Enbrel, infliximab (Remicade), ixekizumab (Taltz), secukinumab (Cosentyx),
brodalumab (Siliq), ustekinumab (Stelara), guselkumab (Tremfya), risankizumab (Skyrizi)
and tildrakizumab (Ilumya).
Enzyme inhibitors: Enzyme inhibitors such as apremilast (Otezla) shuts down an enzyme
in the immune system to fight inflammation. Eucrisa ointment is an enzyme inhibitor
FDA approved for mild to moderate atopic dermatitis/eczema.

31. Classification of topical preparations
• Creams – have a light effect due to high water content. They rub in easily and cool the skin.
• Lotions – used if skin is ‘weeping’. Good for scalp treatment as they are not greasy to apply.
• Ointments – greasy preparations used as a base for the drug being applied. They last for 6–8 h
on the skin, encouraging absorption by a barrier effect.
• Pastes – ointments applied to medicated bandages for occlusive use or used in combination as
a stiffer paste to apply treatment directly to lesions. This permits a slower, more effective
absorption on the target sites.

32. Advantages and disadvantages of topical
therapy
ADVANTAGES
• Drug delivered directly to target area
• Reduces systemic absorption
• Patient can view improvement
• Side-effects easily identified
DISADVANTAGES
• Time-consuming
• Messy and potential to stain clothing
• Preparations smell or stain the skin
• Patient can see deterioration or lack of
improvement
• Inability to apply to oneself due to lack of
dexterity

33. Activities
What are five characteristics of the skin that a nurse must routinely assess?

34. Emollients
Agents which moisturize and lubricate the skin are the mainstay of dermatological treatment.
They are used in different forms such as soap substitute/bath additives or leave-on preparations.
The choice of emollient depends on the disorder:
• Dry, hyperkeratotic skin – use oily occlusive ointments.
• Flaky, rough, excoriated skin – use grease-based preparations.
• Erythematous, inflamed skin – benefits from the cooling effect of water-soluble creams.

35. Topical corticosteroids
Topical corticosteroids should be applied after the topical emollient or bathing with a bath oil or
soap substitute to the affected areas only. Advice given about the use of topical corticosteroids
should be balanced: they are safe to use but often patients are anxious because there is
emphasis on thinning of the skin
The potential side-effects, such as skin thinning, bruising/purpura, hirsutism, systemic effects,
etc., depend on the age, site and frequency of the product used. A recent review stated that ‘the
intermittent use of topical corticosteroids is highly effective; bears little risk, and is relatively
inexpensive’ (Hengge et al 2006, p. 12).

36. Other topical therapies
• vitamin D analogues or dithranol for psoriasis
• cleansers, vitamin A analogues or antibiotics for acne
• fluorouracil, diclofenac sodium, imiquimod for sun-damaged skin or basal cell carcinoma
(BCC).

37. Systemic therapies
A range of oral medication, from antibiotics to immunosuppressant to biological drugs, is used
to treat long-term inflammatory conditions as well as acute inflammatory or bullous conditions.
Monitoring of patients on oral medication is often undertaken by dermatology nurses who work
as non-medical prescribers: they interpret blood results and alter doses or initiate alternative
therapies used in conjunction with topical therapies (see Useful websites, e.g. The British
Association of Dermatologists).
Nurses must know the potential side-effects of topical and systemic therapies in order to
provide safe care and when necessary be able to adjust therapy accordingly.

38. Phototherapy (ultraviolet light B)
Certain skin disorders, most commonly psoriasis and eczema, can be treated with ultraviolet
light B (UVB) in measured doses.
UVB is the wavelength in natural sunlight responsible for sunburn.
Treatment requires outpatient attendance two to three times weekly over a period of weeks.
Phototherapy is given in a cabinet with fluorescent lamps emitting UVB.

39. Complementary therapies
The increasing interest in complementary therapies to treat skin disorders reflects a rise in
public awareness of non-traditional approaches to treatment, perhaps stimulated by the failure
of orthodox medicine to provide ‘cures’.
The nurse is ideally placed to discuss both the orthodox and complementary options available
Discussion should focus on the safe use of complementary therapies initiated by referral to a
practitioner who has undergone accredited training and is a licensed practitioner with
insurance. Complementary therapy should be considered as an adjunct and not as an alternative
to routine therapies.

40. Four major objectives of management
Protect skin
Prevent additional damage & secondary infections
Reverse the inflammatory process
Relieve symptoms

41. Advances in Wound Treatment
Growth factors: cytokines or proteins that have potent mitogenic activity (Vaneau et al., 2007).
Regranex gel: contains becaplermin, a recombinant human platelet-derived growth factor,
promotes chemotactic recruitment and proliferation of the cells involved in wound healing
(Fonder et al., 2008).
Bioengineered skin substitutes: cultures of keratinocytes delivered on a petrolatum gauze.eg.
AlloDerm, Apligraf, Dermagraf, Epicel and Laserskin.
Oral Medications e.g. Pentoxifylline (Trental

42. Healing of Chronic Wounds
Mechanical debridement is contraindicated
Recommend use of commercial cleansing agent
Initial selection of dressing type-crucial
Documenting presence of bacteria is important before appropriate antibiotic is prescribed

43. Types of Skin diseases:
Viral Disorders of the Skin
Bacterial Disorders of the Skin
Fungal Infections of the Skin
Inflammatory Disorders of the Skin
 Parasitic Diseases of the Skin
Tumors of the Skin
Disorders of the Appendages
Skin Disorders

44. Pruritis
Common symptom of skin problems/disease
Scratching the pruritic area causes the inflamed cells and nerve endings to release histamine,
which produces more pruritus, generating a vicious itch–scratch cycle.
Responds to an itch by scratching, can alter integrity of the skin,
and excoriation, redness, raised areas (i.e. wheals), infection, or changes in pigmentation may
result.
Pruritus usually, more severe at night →there are less distractions and less frequently reported
during waking hours, probably because the person is distracted by daily activities

45. Nursing Management
Reinforces therapeutic treatment prescribed by the doctor
Counsels on specific care to be undertaken
Avoid situations that cause pruritis
Drinking alcohol
Exposure to overly warm environments
Hot foods/liquids
Wear cotton material clothes and not synthetic ones – especially at night
Nails to be kept short

46. Medications Used in Treatment
Topical corticosteroids
Oral antihistamines
Diphenhydramine (Benadryl) or hydroxyzine (Atarax), nocte,is often effective in producing a
restful and comfortable sleep.
Non-sedating antihistamine medications.e.g.fexofenadine (Allegra) are more appropriate to
relieve daytime pruritus.
Tricyclic antidepressants.e.g.doxepin (Sinequan), may be prescribed for pruritus of
neuropsychogenic origin.
If pruritus continues, further investigation of a systemic problem is advis

47. Perineal & Perianal Pruritis
Genital and anal regions: caused by small particles of faecal material lodged in the perianal
crevices or attached to anal hairs.
Can result from perianal skin damage caused by scratching, moisture and decreased skin
resistance as a result of corticosteroid or antibiotic therapy
Other Causes
scabies and lice
local lesions such as haemorrhoids
fungal or yeast infections
pinworm infestation.
Conditions such as diabetes mellitus, anaemia, hyperthyroidism and pregnancy may also result
in pruritus

48. Nursing Management
Proper hygiene
Discourage home & Over The Counter remedies
Perineal and perianal area should be washed with lukewarm water and pat dry
- Use pre-moistened tissue to wipe area after defecation
No bubble baths, sodium bicarbonate, detergent soaps
Encourage wearing of cotton underwear instead of synthetic ones

49. Burns
Etiology/pathophysiology
May result from radiation, thermal energy, electricity,
chemicals
Clinical manifestations/assessment
Superficial (first degree)
• Involves epidermis
• Dry, no vesicles, blanches and refills, erythema, painful
• Flash flame or sunburn

50. Burns
Clinical manifestations/assessment (continued)
Partial-thickness (second degree)
• Involves epidermis and at least part of dermis
• Large, moist vesicles, mottled pink or red, blanches and
refills, very painful
• Scalds, flash flame
• Scalds, flash flame
Full-thickness (third degree)
• Involves epidermis, dermis, and subcutaneous
• Fire, contact with hot objects
• Tough, leathery brown, tan or red, doesn’t blanch, dry,
dull, little pain

51. Burns

52. Burns

53. Burns
Medical management/nursing interventions
Emergent phase (first 48 hours)
• Maintain respiratory integrity
• Prevent hypovolemic shock
• Stop burning process
• Establish airway
• Fluid therapy
• Foley catheter; nasogastric tube
• Analgesics
• Monitor vital signs
• Tetanus

54. Burns
Medical management/nursing interventions
(continued)
Acute phase (48 to 72 hours after burn)
• Treat burn
• Prevention and management of problems
Infection, heart failure, contractures, Curling’s ulcer
• Most common cause of death after 72 hours is infection
• Assess for erythema, odor, and green or yellow exudate
• Diet: High in protein, calories, and vitamins
• Pain control
• Wound care: Strict surgical aseptic technique

55. Medical management/nursing interventions
(continued)
Acute phase (continued)
• Range of motion
• Prevent linens from touching burned areas
• CircOlectric bed
• Clinitron bed
• Topical medication: Sulfamylon; Silvadene
• Skin grafts
Autograft
Homograft (allograft)
Heterograft

56. Rule of 9’s

57. Burns
Medical management/nursing interventions
(continued)
Rehabilitation phase
• Goal is to return the patient to a productive life
• Mobility limitations: Positioning, skin care, exercise,
ambulation, ADLs
• Patient teaching
Wound care and dressings

58. Burns
Signs and symptoms of complications
Bacterial infection, which may lead to a bloodstream infection (sepsis)
Fluid loss, including low blood volume (hypovolemia)
Dangerously low body temperature (hypothermia)
Breathing problems from the intake of hot air or smoke.
Scars or ridged areas caused by an overgrowth of scar tissue (keloids)
Exercises
Clothing and ADLs
Social skills

59. Nursing Process
Nursing diagnoses
Anxiety
Pain
Knowledge, deficient related to disease
Infection, risk of
Trauma, risk for
Trauma, risk for
Social interaction, impaired
Self-esteem, risk for situational low

60. ANY Questions????

61. Group Work
A – Herpes Simplex, Shingles,
B - Fungal Skin Infections (Tinea pedis, Tinea corporis, Tinea capitis, Tinea cruris) & Contact
Dermatitis.
C – Folliculitis, Furuncles, carbuncles & Impetigo
D – Cellulitis, Scabies & Pediculosis
E – Keloids & Basal Cell Carcinoma
F - Psoriasis & Acne Vulgaris

62. Task
Discuss each of the conditions under the following headings:
Definition
Risk Factors
Pathophysiology
Assessment/Clinical Manifestations/Signs and Symptoms
Diagnostic Tests
Medications – route, side effects, dosage
Nursing care plans/ Management