Integumentary system

1. Infections of the skin

2. BACTERIAL SKIN DISORDERS
Cellulitis
Furunclosis /Boils
Carbuncles (multiple furuncles)
Folliculitis
Impetigo
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3. CELLULITIS
Is a diffuse, acute infection of skin and subcutaneous tissue
Causes
Bacteria’s like streptococcus/staphylococcus aureus
Results from break in skin
Infection rapidly spread through lymphatic system
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4. Sign and symptom of Cellulitis
Tender, red, hot, indurated and swollen area that is well demarcate
d
Possible fluctuant abscess or purulent drainage
Fever, Chills, Malaise
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5. Management
Immobilization and elevation of the affected limb to reduc
e edema and promote lymphatic drainage and reduce pai
n
E.g.: bed rest, sling, crutches
Oral antibiotics for milder cases
Hospitalization for patients with severe infections
Parenteral antibiotics
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6. Management...
Surgical drainage and debridement
Use meticulous hand washing practice to prevent the sp
read of infection
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7. FURUNCLOSIS/BOILS/
is a skin disease caused by the inflammation
of hair follicles, thus resulting in the locali
zed accumulation of pus & dead tissue.
Is an acute, localized, painful, deep seated, re
d, hot, very tender, inflammatory perifolli
cular abscess.
It is a deeper form of folliculitis
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8. FURUNCLOSIS...
Common microorganismes:
staphylococcus aureus
 The lesion begins in the opening of hair follicle or sebac
eous gland
It occurs at all age
Individual boils can cluster together and form an interconn
ected network of boils called carbuncles.
In severe cases, boils may develop to form abscesses
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9. Furunclosis/Boils/…
Most common on persons who are:
contact with oils or grease,
diabetes/obese
poor habits of personal hygiene,
immunosuppression, alcoholism,
malnutrited, etc.
Sites can be back of the neck, face, buttocks, thighs, perineum,
breasts, axilla, nose, genitallia, etc
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10. Sign & symptoms
Red, shiny, & swollen pus-filled lump
Tenderness, warm&/or painful
When the lump is ready to rupture, a pointy white or yello
w central area is noticed.
Fever & swollen lymph nodes if severe
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11. Diagnosis
Gram stain of the pus
Culture and sensitivity test of blood/pus
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12. Treatment
Warm compresses to sooth and hasten maturation and drain
age of the lesion
"bringing the boil to a head"
Warn patient not to squeeze or incise the lesion
Wash with antibacterial soap & apply dressing/bandage
Magnesium sulfate paste- can prevent growth of bacteria an
d reduce boils by absorbing pus & drying up lesion.
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13. Treatment...
For the sever pain codeine, morphine
Systemic antibiotics (cloxacillin, erythromycin, etc.)
Antifungal– ketoconazole cream
Vitamin A & E supply for recurring cases
Incision and drainage when it is fluctuant
Surgical drainage (incision & drainage)
Rest especially for genital areas.
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14. • A carbuncle is an abscess of the skin and subcutaneous tissue that r
epresents an extension of a furuncle that has invaded several follicl
es and is large and deep seated.
• Is an aggregation of interconnected furuncles that drain through
multiple openings in the skin.
• Carbuncles appear most commonly in areas where the skin is thick
and inelastic.
• Exposure to grease and oil increase the risk.
• Microorganism mostly involved is staphylococcus aureus
Carbuncles (multiple furuncles)

15. Carbuncles...
• more likely to occur in patients;
– with underlying systemic diseases. Eg. DM, hematolog
ic malignancies
– receiving immunosuppressive therapy for other disease
s.
• more prevalent in hot climates
• the extensive inflammation frequently prevents a complete
walling off the infection

16. Carbuncles...
• absorption may occur, resulting in high fever, pain, leuko
cytosis, and even extension of the infection to the bloodst
ream.
• Sites are back of the neck, shoulder, buttock, outer aspect
of the thigh and over the hip joints.

17. Sign and symptom
– Develop slowly than furuncle
– They can reach the size of an egg/small orange.
– Fever, chills, extreme pain, malaise.
– Because of the large size of the lesion and its delay
ed drainage the patient is much sicker.

18. Carbuncles (multiple furuncles)

19. Carbuncles...
Diagnosis
• Gram stain, and culture of the pus/blood
• Leucocytosis (WBC >= 12,000-20,000 mm3)

20. Treatment
• Avoid friction and irritation from tight clothing.
• In treating staphylococcal infections, it is important not to
rupture or destroy the protective wall of induration that lo
calizes the infection.
• Oral cloxacillin, dicloxacillin, and flucloxacillin are first-l
ine medications.
• Cephalosporins and erythromycin are also effective.

21. Treatment...
• The boil or pimple should never be squeezed
• Warm, moist compresses increase vascularization and has
ten resolution of the furuncle or carbuncle.
• The surrounding skin may be cleaned gently with antibact
erial soap/ointment may be applied.
• Nursing personnel should carefully follow isolation preca
utions to avoid becoming carriers of staphylococci.

22. Folliculitis
• is an inflammation of hair follicle caused by bacterial or fungal orig
in that arises within the hair follicles.
• Commonly affects beard area of men who shave and women’s legs
• Other areas include the axillae, trunk, and buttocks.
Sign and symptom
• Lesions may be superficial or deep
• single or multiple papules or pustules appear close to the hair follicl
es.

23. Folliculitis

24. Management
• Warm compress to relieve pain
• Clean with antibacterial soap
• Apply topical antibiotic ointment
• Systemic antibiotics for recurrent cases
• Only entirely effective treatment is to avoid shaving.
• If the patient must remove facial hair, a depilatory cream
or electric razor may be more appropriate than a straight r
azor.

25. Impetigo
• is a common superficial bacterial skin infection.
• Is an acute, contagious, rapidly spreading cutaneous infec
tion
• Causative agents are staphylococcus aureus or a B-hemol
ytic streptococcus or both
• Bullous impetigo- a more deep-seated infection of the sk
in caused by S. aureus

26. Impetigo...
• Is characterized by the formation of bullae (i.e, large, fluid-filled bli
sters) from original vesicles.
• The bullae rupture, leaving raw, red areas.
• It is particularly common among children living in poor hygienic c
onditions
• often follows pediculosis capitis (head lice), scabies (itch
mites), herpes simplex, insect bites or eczema.

27. Sign and Symptom
• Superficial pustules or blisters which becomes oozing wi
th yellow crusts
• Blisters break easily and form golden crusts
• If the scalp is involved, the hair is matted, which distingu
ishes the condition from ringworm.

28. Impetigo...

29. Medical Management
• Reduces contagious spread, treats deep infection and prev
ents acute glomerulonephritis
• Nonbullous impetigo;
– benzathine penicillin or oral penicillin
• Bullous impetigo
– cloxacillin, dicloxacillin, erythromycin

30. Management...
– KMNO4 bath or wet dressing-in mild forms
– Prevent spreading by not sharing towels and ointmen
t
– Change clothes, towels and sheets frequently
– Cut finger nails short to minimize damage to lesion
– Don’t use Vaseline (use aqueous creams instead)

31. Fungal skin disorder
Dermatophytosis (Mycosis)
– Is a fungal infection of the skin, hair and nails
Types
a. Tinea pedis (Athlete’s foot)
– Is itchy, whitish scaling lesions and inflammation of th
e superficial skin of the feet and inter-digital spaces of
the toes
– Often seen in people wearing rubber boots/shoes

32. Tinea pedis (Athlete’s foot)

33. Clinical Manifestations
• Tinea pedis may appear as an acute or chronic infection o
n the soles of the feet or between the toes.
• The toenail may also be involved.
• Lymphangitis and cellulitis occur occasionally when bact
erial superinfection occurs.
• Sometimes, a mixed infection involving fungi, bacteria, a
nd yeast occurs.

34. Management
• Keep the space in between the toes dry:
– after washing, expose to air
• wear cotton socks, don’t wear shoe that are too tight/hot,
• changing socks daily prevents reinfection.
• Treat secondary bacterial infection if presen

35. Management
• topical antifungal creams
– Imidazole cream/ whitfield’s ointment BID until sym
ptoms disappear for a total of 4 weeks
• oral antifungal therapy
– terbinafine 250 mg Po daily for two weeks
– itraconazole 200 mg PO BID for one week
– fluconazole150 mg PO once weekly for 2 to 6 weeks

36. Tinea corporis (Tinea circinata)
• Is fungal infection of the skin most common on the expos
ed surfaces of the body.
• Lesions are round and scaling at the periphery with a tend
ency to central healing
• Intensive itching is there
• Frequent causes of tinea corporis is the presence of an inf
ected pet in the home.

37. Tinea corporis (Tinea circinata)

38. Management
• Imidazole cream/whitfield’s ointment BID for 4 wks
– Continue Rx until one week, after symptoms have cleared
• Multiple, widespread lesions may be treated systematically
– Griseofulvin 500mg once daily for 2-6 wks (10-15mg/kg)
– Ketoconazole 200mg once/twice daily x 2-4wks
• When there is sever itching antihistamines /mild steroids can
be added

39. Burn Care

40. Burns Care
BURN: Cellular destruction of the layers of the skin and th
e resultant depletion of fluids and electrolytes.
Types of Burns according to Etiology
1. Thermal: most common type; caused by flame, flash,
scalding, and contact (hot metals, grease)
2. Smoke inhalation: occurs when smoke (particulate pr
oducts of a fire, gases, and superheated air) causes res
piratory tissue damage

41. Types of Burns…
3. Chemical: caused by tissue contact, ingestion or inhalati
on of acids, alkalies
4. Electrical: injury occurs from direct damage to nerves a
nd vessels when an electric current passes through the bo
dy
5. Radiation Burns- caused by exposure to ultraviolet rays
, x-rays and radioactive sources

42. Pathophysiology
• Burns caused by transfer of energy from source to body
• Tissue destruction results from
– Coagulation, Protein denaturation, or Ionization of cellular
contents from a thermal, radiation or chemical source.
• Following burns, Vasoactive substances released from injured
tissue
– cause an increase in the capillary permeability allowing the
plasma to escape to the surrounding tissues

43. Pathophysiology...
• The generalized edema, evaporation of fluids and capillar
y membrane permeability result to Decreased circulating
blood volume
– BP and Cardiac output decrease
– Results decrease organ perfusion
• Oliguria, intestinal ileus and GI dysfunction
– the body compensates by increasing heart rate

44. Pathophysiology...
• Hypovolemia is the immediate consequence of fluid loss resulting i
n decreased perfusion and oxygen delivery.
• As fluid loss continues and vascular volume decreases, CO continu
es to fall and BP drops---onset of burn shock
• In response, SNS releases catecholamines, resulting in vasoconstric
tion and an increase in pulse rate.
– Peripheral vasoconstriction further decreases CO.
• Immediate fluid resuscitation maintains the blood pressure in the lo
w-normal range and improves CO

45. Pathophysiology...
• Immediately after burn injur;
– Tissue destruction causes Hyperkalemia because injure
d tissues release K+
• Hypokalemia may occur later with fluid shifts and inadeq
uate potassium replacement
• Hyponatremia may be expected because of Plasma loss (
with Na+) into the interstitial space

46. Effects/hazards of the burn accident
 Immediate effects/hazards:
 Burns and wounds of the body;
 Severe pain;
 Oozing and reduction of body fluid from the wound;
 Difficulty in breathing because of suffocation from s
moke, severe burns around the throat and face;
 Drowsiness, restlessness and unconsciousness.

47. Effects/hazards of the burn accident
 Delayed effects/hazards:
 Infections of the wound, septicemia, and high fever;
 Disability;
 Scar;
 Contracture;
 Tetanus infection

48. Burn classification as to depth
Superficial Partial thickness (1st degree) Burn
– the epidermis is injured and a portion of the dermis m
ay be injured
– It may be painful and appear red and dry, as in sunbur
n
– Local Erythema, pain up to 48 hrs
– No Blister formation
– Rapid healing without permanent scarring

49. Burn classification…
Deep Partial thickness (2nd degree) Burn
– involves destruction of the epidermis, upper layers of t
he dermis, and portion of deeper dermis
– wound is frequently quite painful, appears red, and exu
des fluid.
– Blisters & edema
– Takes longer time (14-21 days) to heal and are more li
kely to result in hypertrophic scars

50. 1st degree burn 2nd degree burns

51. Burn classification…
Full thickness (3rd degree) Burn
– total destruction of epidermis and dermis and, in some
cases, subcutaneous fat, connective tissue, muscle, and
bone may involved
– hair follicles and sweat glands are destroyed
– Wound color ranges widely from white to red, brown,
or black
– Not painful because of the destruction of nerve fibers

52. 3rd degree burn...

53. Depth of Burn

54. Total Body Surface Area (BSA) Estimation of Burns
 Various methods are utilized for estimating the extent of burn inju
ry
 The Rule of Nines in adults- Uses multiples of nine
– Head and Neck- 9%
– Anterior trunk- 18%
– Posterior trunk- 18%
– Upper extremities 18% (9% each x 2)
– Lower extremities 36% (18% each X 2)
– Perineum- 1%

55. Rules of Nines

56. Body Surface Area (TBSA) Estimation of Burns…
 Rule of Palms
– A burn equivalent to the size of the
patient’s hand is equal to 1% body
surface area (BSA)

57. Severity Classification of Burn
 Minor Burn Injury
Second-degree burn of <15% TBSA in adults or <10% TB
SA in children
Third-degree burn <2% TBSA not involving special care a
reas (eyes, ears, face, hands, feet, perineum, joints)
Excludes electrical injury, inhalation injury, concurrent tra
uma, all poor-risk patients (eg, extremes of age, concurren
t disease)

58. Severity Classification…
 Moderate, Uncomplicated Burn Injury
Second-degree burns of 15%–25% TBSA in adults or
10%–20% in children
Third-degree burns of <10% TBSA not involving spec
ial care areas
Excludes electrical injury, inhalation injury, concurren
t trauma, all poor-risk patients (eg, extremes of age, co
ncurrent disease)

59. Severity Classification…
 Major Burn Injury
Second-degree burns >25% TBSA in adults or >20% i
n children
All third-degree burns >10% TBSA
All burns involving eyes, ears, face, hands, feet, perin
eum, joints
All inhalation injury, electrical injury, concurrent trau
ma, all poor-risk patients

60. First-aid measures
• If the victim is burned with fire;
– apply cold applications,
– immerse the burned area in cold water
– role the burned person on the ground, or cover with wa
ter socked thick cloth or blanket and put out the fire

61. First-aid measures…
• If the accident is of electric source
– quickly disconnect at the electric meter or check point, or
– use rope wooden stick, dried cloth etc. to disconnect;
– Move victim from accident place to avoid further injury;
– Loosen and/or remove burned dresses
– lay down the victim on his/her back and let him/her breath
e fresh air

62. First-aid measures…
• If the accident is of electric source
– ensure that no foreign objects have entered and blocked
the passage of the respiratory system;
– If the victim is not breathing properly, initiate mouth to
mouth artificial respiration;
– Thoroughly check the wound to determine the size, and t
he degree of burn;

63. Take immediately to health facility:
• For burn victims with the following signs:
 First degree burn with sizeable area;
 2nd and 3rd degree burns;
 If the victim is drowsy, restless and has breathing pro
blem;
 If the victim has burns on his face, eye, extremities, jo
ints and around genital organs;

64. Take immediately health facility…
 For burn victims with the following signs:
If the source of the burn is electrical, chemical
If the patient has chronic disease such as epilepsy, diab
etes etc.
If the burn accident is on elderly persons or children,

65. Measures for 1st degree burn
 Apply cold water or submerge burned area in cold water;
 Apply a dry dressing if it is necessary
 If the wound is minor and small,
clean daily the area with boiled cold water
cover it with clean cloth to prevent contact with flies,
 if the wound located is in a joint,
immobilize the joint area until the wound is cured;
 If the wound is from boiled water, chemical (acid),
take out his/her dress and cover it with clean cloth

66. Measures for 2nd or 3rd degree burn
 Cover the wound with clean cloth;
 Advise the victim to get tetanus toxoid vaccine;
 If the victim is conscious and respiratory parts such as mo
uth, nose and throat are free from burn injury;
give frequently plenty of liquid such as ORS or similar
solution

67. Measures for 2nd or 3rd degree…
 If the victim is a child below two years old
give one spoon of ORS every two minutes
 If the child is over two years
give ORS with a cup or glass in small amount every tw
o minutes;
 Refer the victim to the nearest health facility

68. Burn Management
 Supportive therapy: fluid management, catheterization
– Parkland formula: 4ml Ringer lactate x %TBSA x weight (kg)
– Half in first 8 hours; half over next 16 hours
 Wound care
 Drug therapy
Antibiotics (Topical, Systemic)
Tetanus Anti-toxoid
Analgesics
 Surgery: excision and grafting

69. Guidelines in Burn management
Burns should be cooled with cold water as soon as possible for a
minimum of ten minutes
Ice & ice water should NOT be applied to burn wounds
After cooling, it is recommended that burn wounds should be dres
sed with a sterile dressings
In cases of minor burns, honey or aloe vera may be applied
NO remedies should be applied before a medical practitioner has r
eviewed the wounds
Care must be taken when cooling large burns or burns in infants a
nd small children so as not to induce hypothermia
A first aid provider should NOT burst the blister(s)

70. Measures to prevent burns
 Keep away from children items such as matches, burning lamp
and candles;
 Prepare and place stoves and other cooking installations in a saf
e way.
 Keep away from fire inflammable materials and don’t‘ come wi
th materials such as nylon close to fire-place;
 Educate smokers not to smoke inside a house and if they smoke
give them strict advice to put off the burning left over cigarette

71. Thank You!!