THE INTEGUMENT

Overview of the Integument System The skin covers the entire external surface of the human body and is the principal site of interaction with the surrounding world.

Structure of the Skin Epidermis The epidermis is stratified squamous epithelium. The main cells of the epidermis are the keratinocytes, which synthesise the protein keratin. Protein bridges called desmosomes connect the keratinocytes, which are in a constant state of transition from the deeper layers to the superficial. Epidermis is divided into the following 5 sublayers or strata: y Stratum corneum y Stratum lucidum y Stratum granulosum y Stratum spinosum y Stratum germinativum (also called the"stratum basale") Dermis The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors (nerve endings) that provide the sense of touch and heat. It contains the hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatic vessels and blood vessels. The blood vessels in the dermis provide nourishment and waste removal from its own cells as well as from the Stratum basale of the epidermis. The dermis is structurally divided into two areas: a superficial area adjacent to the epidermis, called the papillary region, and a deep thicker area known as the reticular region.

Hypodermis The hypodermis, also called the hypoderm, subcutaneous tissue, or superficial fascia is the lowermost layer of the integumentary system. The hypodermis consists primarily of loose connective tissue and lobules of fat. It contains larger blood vessels and nerves than those found in the dermis. Hair Hair can be found in varying densities of growth over the entire surface of the body, exceptions being on the palms, soles and glans penis. Follicles are most dense on the scalp and face and are derived from the epidermis and the dermis. Each hair follicle is lined by germinative cells, which produce keratin and melanocytes, which synthesise pigment. The hair shaft consists of an outer cuticle, a cortex of keratinocytes and an inner medulla. The root sheath, which surrounds the hair bulb, is composed of an outer and inner layer. An erector pili muscle is associated with the hair shaft and contracts with cold, fear and emotion to pull the hair erect, giving the skin `goose bumps'. Nails Nails consist of a dense plate of hardened keratin. Fingernails function to protect the tip of the fingers and to aid grasping. The nail is made up of a nail bed, nail matrix and a nail plate. The nail matrix is composed of dividing keratinocytes, which mature and keratinise into the nail plate. Underneath the nail plate lies the nail bed. Sebaceous glands These glands are derived from epidermal cells and are closely associated with hair follicles especially those of the scalp, face, chest and back; they are not found in hairless areas. They produce an oily sebum by holocrine secretion in which the cells break down and release their lipid cytoplasm. Sweat glands There are thought to be over 2.5 million on the skin surface and they are present over the majority of the body. They are located within the dermis and are composed of coiled tubes, which secrete a watery substance. They are classified into two different types: eccrine and apocrine. Functions of the Skin The structure and physiology of the skin are obviously much more complex than we have been able to describe. Nevertheless, by knowing them even in part it is easier to identify the functions that our skin fulfills: y barrier y protection y immunological y secretion y thermoregulation

y y

sensitivity absorption

Barrier Function The function of the skin's barrier is to protect the skin and, therefore, the body from the entry of chemical substances and also preventing the loss of bodily substances. This selective permeable barrier is mainly due to the basal membrane, horny layer, and intercellular lipids. Protective Function The skin performs a protective function against biological (bacteria, viruses, and mycetes), physical, and chemical agents. An alkaline substance placed on the skin is neutralized by the hydrolipid film and the horny layer before it can damage the organs below. In the same way the sun's radiation is neutralized, at least in part, by melanin or by the horny layer. Finally, the skin plays the essential role of mechanical protection that we all appreciate every day when large or small mechanical traumas are cushioned by our skin. Immunological Function The first site of entry for foreign substances and bacteria is the skin. With the Langerhan cells the skin is able to identify these and to prepare a defence. Sometimes, as in the case of contact dermatitis, the defences themselves do us harm, resulting in inflammation that is normally the essential response marking the invasion of a foreign agent. Secretory Function The skin's secretory functions are carried out both by the cutaneous glands and the epidermis itself. Sebum, sweat, and epidermal lipids are products that perform functions for the skin (protecting it) and for the whole body. In fact sweating, like keratinization, is one of the means by which drugs and harmful substances are removed from the body. Thermoregulatory Function The mechanisms used by our skin in thermoregulation are insensible perspiration, eccrine sweating, and changes in cutaneous vascularization. By these mechanisms the skin is able to adapt our body temperature as a function of the ambient temperature. Sensitivity Functions The chance of survival in an environment is linked to the capacity of the individual to be in contact with it. Together with the senses of sight, hearing, and smell, the skin's sensitivity provides the individual not only with the sense of touch, but also allows us to recognize our position and its variation in space. The skin also detects itching, which, together with pain, heat, and cold, is vital for the survival of the individual, as these sensations warn us of danger or injury. Without the skin and its sensitivity we could burn ourselves without being aware of it or we could freeze without knowing. Absorption Function

Strictly linked to the skin's barrier function, absorption allows substances applied to the skin to be conveyed into the blood system. This important function is being ever more exploited by medicine to avoid the damage that can be caused by gastrolesive drugs when administered orally, or to favour a continuous slow drug absorption. This function obviously varies according to the area and thickness of the epidermis. The skin receives ultraviolet rays and utilizes them in the production of vitamin D. The signs of ageing are most visible in the skin. Although, ageing skin is not a threat to a person, it can have a detrimental effect on the psychology of a person. A look into the causes of skin ageing, the available treatments and preventive measures for this inevitable change is important to help both the already aged, as well as, the youth. Normal Changes of Aging Epidermis The epidermal cells of the older person contain less moisture. After 50 yrs epidermal mitosis slows by 30%, resulting in a longer healing time for the older person. Rete ridges, which connect the dermis and the epidermis, flatten resulting in fewer contact areas between these two layers. Melanocytes decrease in number and activity with age. These contribute to a paler complexion and increased risk for damage and from UV rays for the light skinned older person. The remaining cells may not function normally resulting in scattered pigmented areas such as nevi, age spots or liver spots and an increase in number and size of freckles. Dermis The dermis decreases in thickness and functionality beginning on the third decade. Elastin decreases in quality but increases in quantity, resulting in the wrinkling and sagging of skin. Collagen become less organized and causes a loss of turgor. Men have thicker dermal layer than women which explains the more rapidly apparent age associated changes in the female facial appearance. The vascularity of the dermis decreases and contributes to a paler complexion in the light skinned older person. The capillaries become thinner and more easily damaged, leading to burised and discolored areas known as senile purpura. There is gradual decline in both touch and pressure sensations causing a person to be at risk for injury such as burns and pressure sores. Subcutaneous Layer There is gradual atrophy of subcutaneous tissue in some areas of the body and gradual increase in other. Subcutaneous tissue becomes thinner in the face, neck, hands and lower legs resulting in more visible veins in the exposed areas and skin is more prone to damage. There is gradual hypertrophy of subcutaneous tissue that leads to an overall increase in the proportion of body fat for the older person. Fat distribution is more pronounced in the abdomen and thighs in women and in abdomen in men.

Hair The hair of the older person looks gray or white due to a decrease in the number of functioning melanocyates and replacement of pigmented strands of hair with nonpigmented ones. The texture and thickness of the hair also changes becoming coarse and thin. Hormones decline resulting in gradual loss of hair in the pubic and axillary areas, and the appearance of facial hair on women and hair in the ears and nose in men. By 50, many older men have experienced a gradual loss of hair and often develop a symmetrical W-shaped balding pattern. Nails The nail of the older person becomes dull and yellow or gray in color. Nail growth slows which results in thicker nails that is likely to split. Longitudinal striations also appear due to damage at the nail matrix. Sweat glands With aging, there is decrease in the size, number and function of both the eccrine and apocrine glands. The decrease results in a decrease in the older person s ability to regulate body temperature through perspiration and evaporation from the skin. The ability to sweat decreases therefore there is a high risk for heat exhaustion. Sebaceous Glands The sebaceous glands increase in size with age, but the amount of sebum produced is decreased. The decrease hastens the evaporation of water from the stratum corneum which results in cracked, dry skin.

Common Integument Illness of the Elderly Common illness of the elderly includes skin cancer, skin tears, pressure ulcer, delayed skin healing, cellulitis and finger and toenail problems. Skin Cancer Skin cancer begins in the cells that make up the outer layer (epidermis) of your skin. Skin cancer is the abnormal growth of skin cells. It is most often develops on skin exposed to the sun. But skin cancer cells can also occur on areas of your skin not ordinarily exposed to sunlight. There are 3 types of skin cancer that typically impact older people: y Melanoma y Basal cell skin cancer y Squamous cell skin cancer Basal Cell Carcinoma The vast majority of basal cell carcinomas occur on the face. They start as a small, pink, pearly or waxy spot, often circular or oval in shape. As they grow, they become a raised, flat spot with a 'rolled' edge and they may develop a crust. Next, they begin to bleed from the centre and an ulcer develops. This is called a rodent ulcer and, if left long enough, it can become quite large and eat away the skin and tissue below. Squamous cell carcinoma Squamous cell carcinomas are most common on the limbs, head and neck. They are pink and irregular in shape, usually with a hard, scaly or horny surface, although they can sometimes become an ulcer. The edges are sometimes raised. They can be tender to the touch. Malignant Melanoma Melanoma is more aggressive than basal cell skin cancer or squamous cell skin cancer. Melanoma is a disease in which malignant cells form in the skin cells called melanocytes (cells that color the skin). Melanocytes are found throughout the lower part of the epidermis. They make melanin, the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes make more pigment, causing the skin to tan, or darken. The skin is the body's largest organ. It protects against heat, sunlight, injury, and infection. The skin has 2 main layers: the epidermis (upper or outer layer) and the dermis (lower or inner layer). When melanoma starts in the skin, the disease is called cutaneous melanoma. Melanoma can occur anywhere on the body. In men, melanoma is often found on the trunk (the area from the shoulders to the hips) or the head and neck. In women, melanoma often develops on the arms and legs. Risk Factors Risk factors for melanoma include the following: y Unusual moles. y Exposure to natural sunlight.

y y y y y y

Exposure to artificial ultraviolet light (tanning booth). Family or personal history of melanoma. Being white and older than 20 years. Red or blond hair. White or light-colored skin and freckles. Blue eyes.

Melanoma Warning Signs y A change in the appearance, including the size, shape and color of a mole or pigmented area. y Moles with irregular edges or borders y More than one color in a mole y An asymmetrical mole (if the mole is divided in half, the 2 halves are different in size or shape) y Itches, oozes or bleeds y Ulcerated tissue y Changes in pigment of skin. y Satellite moles (new moles that grow near an existing mole). The following tests and procedures may be used in the staging process: y Wide local excision: A surgical procedure to remove some of the normal tissue surrounding the area where melanoma was found, to check for cancer cells. y Lymph node mapping and sentinel lymph node biopsy: Procedures in which a radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through lymph ducts to the sentinel node or nodes (the first lymph node or nodes where cancer cells are likely to have spread). The surgeon removes only the nodes with the radioactive substance or dye. A pathologist then checks the sentinel lymph nodes for cancer cells. If no cancer cells are detected, it may not be necessary to remove additional nodes. y Chest x-ray y CT scan (CAT scan) y MRI (magnetic resonance imaging): y PET scan (positron emission tomography scan) y Laboratory tests: samples of tissue, blood, urine, or other substances The Clark levels are used for thin tumors to describe how deep the cancer has spread into the skin: y Level I. The cancer is in the epidermis only. y Level II. The cancer has begun to spread into the papillary dermis (upper layer of the dermis). y Level III. The cancer has spread through the papillary dermis (upper layer of the dermis) into the papillary-reticular dermal interface (the layer between the papillary dermis and the reticular dermis). y Level IV. The cancer has spread into the reticular dermis (lower layer of the dermis).

Level V. The cancer has spread into the subcutaneous layer (below the skin). Treatments
y

y y y

y y

Local excision: Taking out the melanoma and some of the normal tissue around it. Wide local excision with or without removal of lymph nodes. Lymphadenectomy: A surgical procedure in which the lymph nodes are removed and examined to see whether they contain cancer. Sentinel lymph node biopsy: The removal of the sentinel lymph node (the first lymph node the cancer is likely to spread to from the tumor) during surgery. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed for biopsy. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. Skin grafting (taking skin from another part of the body to replace the skin that is removed) may be done to cover the wound caused by surgery. Even if the doctor removes all the melanoma that can be seen at the time of the operation, some patients may be offered chemotherapy after surgery to kill any cancer cells that are left. Chemotherapy given after surgery, to increase the chances of a cure, is called adjuvant therapy. Chemotherapy Radiation

Skin Tears A skin tear has been defined by Payne & Martin as a traumatic wound occurring principally on the extremities of older adults as a result of friction alone or shearing and friction forces which separate the epidermis from the dermis (partial-thickness wound) or which separate both the epidermis and dermis from underlying structures (full-thickness wound) . Factors: y It is known that the elderly are more predisposed to skin tears because of both changes to the structure and function of the skin and other functional abilities. y The skin of elderly adults becomes thinner and more fragile due to a reduction in the collagen and elastin within the skin and flattening of the dermal-epidermal junction. y Capillary fragility also increases; visible signs of this may include purpura and ecchymosis of the skin following minor trauma. y adults are also susceptible to disease processes that impair mobility, cognitive function and vision, placing them at greater risk of skin tears. y Nutrition in the older adult may also be sub-optimal, impacting on wound healing. y Environmental factors also contribute and it is known that skin tears often occur during patient handling, or are related to equipment such as wheelchairs and bed rails.

Common causes: A knock, eg the simple act of getting out of bed or bumping into bed rails, other furniture or equipment. Transferring out of beds or chairs Falls Bathing, dressing and putting on or taking off stockings The use of restraints Removal of tapes or adhesive dressings, and taking blood Staff jewellery, watches, fingernails and silverware Management Payne-Martin classification system for skin tears Category I Skin tears without tissue loss (the wound borders are able to be approximated within 1mm) A. Linear type B. Flap type Category II Skin tears with partial tissue loss (incomplete tissue loss) A. Scant tissue loss type (25% or less tissue loss) B. Moderate-to-large tissue loss type (more than 25% tissue loss, but not complete tissue loss) Category III Skin tears with complete tissue loss Dressings for skin tears There is no consensus as to a preferred wound dressing for skin tears. Often the skin flaps are stabilised or secured with skin closure strips. Almost all dressing categories have been reported for use on skin tears, often in combination with skin closure strips, and include: Paraffin gauze Low or non-adherent dry dressings Polyurethane transparent films Hydrogels Hydrocolloids Calcium alginates Foams Composite dressing (eg Combiderm ACD ) Hydrofibres Soft silicone net Soft silicone foam Antiseptic agents are also used for the treatment of skin tears, where contamination occurred at the time of injury or there is subsequent infection of the skin tear. The type of dressing selected often varies according to the classification of the skin tear, exudate amount, skin fragility and individual patient factors. General principles of management endorsed include cleaning the skin tear, removing any residual clot or debris, replacing and securing the skin flap where present and covering with a dressing.

Pressure Ulcer are lesions caused by many factors such as: unrelieved pressure; friction; humidity; shearing forces; temperature; age; continence and medication; to any part of the body, especially portions over bony or cartilaginous areas such as sacrum, elbows, knees, and ankles. Although often prevented and treatable if found early, they can be very difficult to prevent in frail elderly patients, wheelchair users (especially where spinal injury is involved) and terminally ill patients. Classification The definitions of the four pressure ulcer stages are revised periodically by the National Pressure Ulcer Advisory Panel (NPUAP) in the United States. Briefly, however, they are as follows: y Stage I is the most superficial, indicated by non blanchable redness that does not subside after pressure is relieved. This stage is visually similar to reactive hyperemia seen in skin after prolonged application of pressure. Stage I pressure ulcers can be distinguished from reactive hyperemia in two ways: a) reactive hyperemia resolves itself within 3/4 of the time pressure was applied, and b) reactive hyperemia blanches when pressure is applied, whereas a Stage I pressure ulcer does not. The skin may be hotter or cooler than normal, have an odd texture, or perhaps be painful to the patient. Although easy to identify on a light-skinned patient, ulcers on darker-skinned individuals may show up as shades of purple or blue in comparison to lighter skin tones. y Stage II is damage to the epidermis extending into, but no deeper than, the dermis. In this stage, the ulcer may be referred to as a blister or abrasion. y Stage III involves the full thickness of the skin and may extend into the subcutaneous tissue layer. This layer has a relatively poor blood supply and can be difficult to heal. At this stage, there may be undermining damage that makes the wound much larger than it may seem on the surface y Stage IV is the deepest, extending into the muscle, tendon or even bone. y Unstageable pressure ulcers are covered with dead cells, or eschar and wound exudate, so the depth cannot be determined.

Etiology: y Pressure, or the compression of tissues. In most cases, this compression is caused by the force of bone against a surface, as when a patient remains in a single decubitus position for a lengthy period. After an extended amount of time with decreased tissue perfusion, ischemia occurs and can lead to tissue necrosis if left untreated. y Shear force, or a force created when the skin of a patient stays in one place as the deep fascia and skeletal muscle slide down with gravity. This can also cause the pinching off of blood vessels which may lead to ischemia and tissue necrosis. y Friction, or a force resisting the shearing of skin. This may cause excess shedding through layers of epidermis.

Treatment The best treatment outcomes will result from using a multidisciplinary team of specialists, this will ensure all problems are addressed. There are seven major contributors to healing. y Proper care The most important care for a patient with bedsores is the relief of pressure. Once a bedsore is found, pressure should immediately be lifted from the area and the patient turned at least every two hours to avoid aggravating the wound. For individuals with paralysis, pressure shifting on a regular basis and using a cushion featuring pressure relief components can help prevent pressure wounds. Pressure-distributive mattresses are used to reduce high values of pressure on prominent or bony areas of the body. Antidecubitus mattresses and cushions can contain multiple air chambers that are alternately pumped. However, methods to evaluate the efficacy of these products have only been developed in recent years. y Debridement The removal of necrotic tissue is an absolute must in the treatment of pressure sores. Because dead tissue is an ideal area for bacterial growth, it has the ability to greatly compromise wound healing. There are at least seven ways to excise necrotic tissue. 1. Autolytic debridement is the use of moist dressings to promote autolysis with the body's own enzymes. It is a slow process, but mostly painless. 2. Biological debridement, or maggot debridement therapy, is the use of medical maggots to feed on necrotic tissue and therefore clean the wound of excess bacteria. Although this fell out of favour for many years, in January 2004, the FDA approved maggots as a live medical device. 3. Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal of necrotic tissue. 4. Mechanical debridement is the use of outside force to remove dead tissue. A quite painful method, this involves the packing of a wound with wet dressings that are allowed to dry and then are removed. This is also unpopular because it has the ability to remove healthy tissue in addition to dead tissue. Lastly, with Stage IV ulcers, there is the chance that overdrying of the dressings can lead to bone fractures and ligament snaps. 5. Sharp debridement is the removal of necrotic tissue with a scalpel or similar instrument. 6. Surgical debridement is the most popular method, as it allows a surgeon to quickly remove dead tissue with little pain to the patient. 7. Ultrasound-assisted wound therapy is the use of ultrasound waves to separate necrotic and healthy tissue. y Infection control Infection has one of the greatest effects on the healing of a wound. Symptoms of systemic infection include fever, pain, redness, swelling, warmth of the area, and purulent discharge. Additionally, infected wounds may have a gangrenous smell, be discoloured, and may eventually exude even more pus.

In order to eliminate this problem, it is imperative to apply antiseptics at once. Hydrogen peroxide is not recommended for this task as it is difficult to balance the toxicity of the wound with this. New dressings have been developed that have cadexomer iodine and silver in them, and they are used to treat bad infections. Duoderm can be used on smaller wounds to both provide comfort and protect them from infection. Systemic antibiotics are not recommended in treating infection of a bedsore, as it can lead to bacterial resistance. y Nutritional support Upon admission the patient should have a consultation with a dietitian to determine the best diet to support healing, as a malnourished person does not have the ability to synthesize enough protein to repair tissue. If the patient is found to be at risk for malnutrition, it is imperative to begin nutritional intervention with dietary supplements and nutrients including, but not limited to, arginine, glutamine, vitamin A, vitamin B complex, vitamin E, vitamin C, magnesium, manganese, selenium and zinc. There is anecdotal evidence that high protein diet helps healing of sores. High protein diet seems to be especially helpful in sores that do not heal in eight weeks. y Educating the caregiver In the case that the patient will be returning to home care, it is very important to educate the family about how to treat their loved one's pressure ulcers. The cross-specialization wound team should train the caregiver in the proper way to turn the patient, how to properly dress the wound, how to properly nourish the patient, and how to deal with crisis, among other things. As this is a very difficult undertaking, the caregiver may feel overburdened and depressed, so it may be best to bring in a psychological consult. y Wound intervention Once the patient has reached the point that intervention is possible, there are many different options. For patients with Stages I and II ulcers, the wound care team should use guidelines established by the American Medical Directors Association (AMDA) for the treatment of these low-grade sores. For those with Stage III or IV ulcers, most interventions will likely include surgery such as a tissue flap, free flap or other closure methods. A more recent intervention is Negative Pressure Wound Therapy, which is the application of topical negative pressure to the wound, uses foam placed into the wound cavity which is then covered in a film which creates an airtight seal. Once this seal is established, the technician is able to remove exudate and other infectious materials in addition to aiding the body produce granulation tissue, the best bed for the creation of new skin. There are, unfortunately, contraindications to the use of negative pressure therapy. Most deal with the unprepared patient, one who has not gone through the previous steps toward recovery, but there are also wound characteristics that bar a patient from participating: a wound with inadequate circulation, a raw debrided wound, a wound with necrotised tissue and eschar, and a fibrotic wound. After Negative Pressure Wound Therapy, the patient should be reevaluated every two weeks to determine future therapy. y Prevention

A wide variety of techniques are used to mitigate the risk of pressure ulcers in at risk groups including: nutritional supplements, topical skin protection and mechanical devices to mimic the effect of movement, such as alternating pressure mattresses. The most commonly used method of reducing the risk of pressure ulcers is regular nursing intervention and a 'turning schedule' to ensure the weight of the immobile patient is redistributed, reducing sustained pressure on a vulnerable area. Delayed skin healing The process of wound healing is complex and continuous. Three major stages are: 1. Inflammation and destruction 2. Proliferation 3. Maturation Signs of delayed wound healing y Wound size increasing y Exudates, slough or eschar is present y Tunnels, fistula or undermining has developed y Epithelial edge is not smooth Types of wound healing Primary intention -involves epidermis and dermis without total penetration of dermis healing by process of epithelialization y When wound edges are brought together so that they are adjacent to each other (reapproximated) y Minimizes scarring y Most surgical wounds heal by primary intention healing y Wound closure is performed with sutures (stitches), staples, or adhesive tape y Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery Secondary intention y The wound is allowed to granulate y Surgeon may pack the wound with a gauze or use a drainage system y Granulation results in a broader scar y Healing process can be slow due to presence of drainage from infection y Wound care must be performed daily to encourage wound debris removal to allow for granulation tissue formation y Examples: gingivectomy, gingivoplasty, tooth extraction sockets, poorly reduced fractures. Tertiary intention

(Delayed primary closure or secondary suture): y The wound is initially cleaned, debrided and observed, typically 4 or 5 days before closure. y The wound is purposely left open y Examples: healing of wounds by use of tissue grafts.

Cellulitis Cellulitis is a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Cellulitis can be caused by normal skin flora or by exogenou bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters, burns, insect bites, surgical wounds, intravenous drug injection or sites of intravenous catheter insertion. Skin on the face or lower legs is most commonly affected by this infection, though cellulitis can occur on any part of the body. Causes: Cellulitis is caused by a type of bacteria entering the skin, usually by way of a cut, abrasion, or break in the skin. This break does not need to be visible. y Group A Streptococcus and Staphylococcus are the most common of these bacteria, which are part of the normal flora of the skin, but normally cause no actual infection while on the skin's outer surface. y Predisposing conditions for cellulitis include insect or spider bite, blistering, animal bite, tattoos, pruritic (itchy) skin rash, recent surgery, athlete's foot, dry skin, eczema, injecting drugs (especially subcutaneous or intramuscular injection or where an attempted IV injection "misses" or blows the vein), pregnancy, diabetes and obesity, which can affect circulation, as well as burns and boils, though there is debate as to whether minor foot lesions contribute. y Occurrences of cellulitis may also be associated with the rare condition hidradenitis suppurativa. Signs and Symptoms: y Pain and tenderness y Edema (swelling caused by fluid in the tissues) y Redness of the skin y Skin that is warm to the touch y Fever y Chills Risk Factors: You are at risk for developing cellulitis if you have the following: y Older age -- as your circulation grows weaker with age, it' s easier for skin abrasions to become infected

y y y y y y y

Diabetes Chickenpox and shingles Lymphedema (swelling of arms or legs) -- swollen arms and legs may cause skin to crack Fungal infections of the feet -- can also cause cracks in the skin Contaminated wounds A weakened immune system A general infection

Treatment Options: y Prevention To help prevent cellulitis, follow these steps: If you have a cut or scrape, wash the area gently with soap and water. Apply an antibiotic cream or ointment, and cover the area with a bandage. Change the bandage every day and watch for signs of infection. If you have diabetes or circulatory problems, check your hands and feet daily for scrapes or cuts, or a fungus such as athlete' s foot. Keep your skin moisturized and don' t go barefoot. Medications y Cellulitis is treated with antibiotics. To help ease pain, raise the affected arms or legs, keep still, and apply cool, wet, sterile bandages. If your symptoms aren't better after a few days, you may need hospitalization so doctors can give you antibiotics intravenously (IV). Surgical and Other Procedures y surgery to drain any underlying abscess (infected tissue). Nutrition The following supplements may strengthen the immune system and help skin heal: y Vitamin C (1,000 mg two to six times per day in adults for short periods) y Vitamin E (400 - 800 IU per day) y Zinc (30 mg per day) y Bromelain (250 mg two to three times per day), taken between meals, reduces inflammation. It is often used with turmeric (Curcuma longa), an anti-inflammatory that makes the effects of bromelain stronger. Bromelain and turmeric can increase the risk of bleeding. If you take blood-thinning medications such as warfarin (Coumadin) or aspirin, do not take bromelain and turmeric without asking your doctor. y Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day, for gastrointestinal and immune health. Taking antibiotics can upset the balance between good and bad bacteria in your gut and cause diarrhea. Taking probiotics, or friendly bacteria, helps restore the right balance.

Fingernail and Toenail Problems Onychomycosis Onychomycosis, commonly known as a fungal nail infection, is infection of the fingernails or toenails by forms of fungi and yeast. Fungal nail infections account for nearly one-half of all nail disorders. In the most common form of fungal nail infections, fungus grows under the growing portion of the nail and spreads up the finger (proximally) along the nail bed and the grooves on the sides of the nails. Risk Factors: y Fungal nail infection may occur at any age but is more common in adults, particularly in older individuals. y Diabetics may be more likely than other people to develop a fungal nail infection. Signs and symptoms: y Discolored (usually white or yellow) y Brittle y Crumbly, or have rough, jagged edges y Thick y Separated from the nail bed y Curled up or down, or are distorted in shape y You may also have pain or discomfort in the affected toes or fingers. Treatment: y Topical therapy with ciclopirox nail lacquer, which requires daily application for 9 12 months. y Oral antifungal treatments offer the best chance for curing fungal nail infection. The most commonly used agents are terbinafine, itraconazole, and fluconazole. The medications may cause liver problems or may affect blood cell counts. Blood tests are usually performed before starting therapy and during therapy to look for possible side effects. y In stubborn (refractory) fungal nail infection, surgical removal of part of the nail or the entire nail, removing the nail by applying a chemical, or thinning the nail by applying 40% urea ointment may be used, in addition topical or oral antifungal agents. Nursing Diagnosis: y y y y y Impaired skin integrity related to lesions and inflammatory response Risk for impaired tissue integrity related to decreased circulation Risk for infection related to pressure ulcer Pain related to destruction of tissue due to pressure and shear Risk for impaired skin integrity related to physical immobility