Lisa M. Dunn MSN/Ed, RN, CCRN, CNE

Exemplar: Xerosis (Dryness)A common problem among older patientsFine flaking of the stratum corneumGeneralized pruritusScratching may result in secondary skin

lesions, excoriations, lichenification, and infection

Collaborative ManagementNursing interventions aim to rehydrate the

skin and relieve itching.Bathing with moisturizing soaps, oils, and

lotions may reduce dryness.Water softens the outer skin layers; creams

and lotions seal in the moisture provided by water.

Exemplar: Pruritus (Itching) Pruritus is caused by stimulation of itch-

specific nerve fibers at the dermal-epidermal junction.

Itching is a subjective symptom similar to pain.

“Itch-scratch-itch” cycle.Cool sleeping environment is helpful.Fingernails should be trimmed short.Antihistamines.Topical steroids.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

a.Backb.Axillac.Soles of the feetd.Palms of the hands

Exemplar: Sunburn First-degree, superficial burnCool bathsSoothing lotionsAntibiotic ointments for blistering and

infected skinTopical corticosteroids for pain

Exemplar: Urticaria (Hives)Urticaria—presence of white or red

edematous papules or plaques of varying sizes

Removal of triggering substancesAntihistamines helpfulAvoidance of overexertion, alcohol

consumption, and warm environments, which can worsen symptoms

Exemplar: Trauma Phases of wound healing:

Inflammatory phaseFibroblastic or connected tissue repair phaseMaturation or remodeling phase

QuestionThe nurse manager is observing a new nursing

graduate caring for a burn patient in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique?

A. Using sterile sheets and linens B. Performing strict hand-washing technique C. Wearing gloves and a gown only when giving

direct care to the patient. D. Wearing protective garb, including a mask,

gloves, cap, shoe covers, gowns, and plastic apron

Process of Wound Healing

Process of Wound Healing (Cont’d)First intention resulting in a thin scarSecond intention (granulation) and

contraction—a deeper tissue injury or woundThird intention (delayed closure)—high risk

for infection with a resultant scar

Exemplar: Partial-Thickness WoundsInvolve damage to the epidermis and upper

layers of the dermisHeal by re-epithelialization within 5 to 7 days Skin injury immediately followed by local

inflammation

Re-epithelialization

Exemplar: Full-Thickness WoundsDamage extends into the lower layers of the

dermis and underlying subcutaneous tissue.Removal of the damaged tissue results in a

defect that must be filled with granulation tissue to heal.

Contraction develops in healing process.Wound may tunnel

Exemplar: Pressure UlcerTissue damage caused when the skin and

underlying soft tissue are compressed between a bony prominence and an external surface for an extended period.

Mechanical forces that create ulcers: PressureFrictionShear

Shearing Force

Identification of High-Risk PatientsMental status changesIndependent mobilityNutritional statusIncontinence

Pressure-Relieving TechniquesAdequate pressure relief key to prevention of

pressure ulcersCapillary closing pressurePressure-relief products and devicesPositioning

QuestionThe evening nurse reviews the nursing

documentation in the patient’s chart and notes that the day nurse has documented that the patient has a stage II pressure ulcer in the sacral area. Which of the following would the nurses expect to note on assessment of the patient’s sacral area?

A. Intact skinB. Full-thickness skin lossC. Exposed bone, tendon, or muscleD. Partial- thickness skin loss of the dermis

Wound AssessmentPressure ulcers and their features are

classified and assessed in four stages:Stage IStage IIStage IIIStage IV

Four Stages of Pressure Ulceration

Wound AssessmentLocationSizeColorExtent of tissue involvementCell types in the wound base and marginsExudateCondition of surrounding tissuePresence of foreign bodies

Exemplar: Wound Contamination/Wound Infection

A wound that is exposed is always contaminated but not always infected. Contamination is the presence of organisms without any manifestations of infection.

Wound infection is contamination with pathogenic organisms to the degree that growth and spread cannot be controlled by the body’s immune defenses.

Nonsurgical ManagementDressings:

Mechanical débridementNatural chemical débridementHydrophobic materialHydrophilic material

Nonsurgical Therapy Physical therapyDrug therapyNutrition therapyNew technologies:

Electrical stimulationVacuum-assisted wound closure (VAC) Hyperbaric oxygen (HBO) Topical growth factorsSkin substitutes

Hyperbaric Oxygen Therapy

Surgical ManagementSurgical débridementSkin grafting

Community-Based CareHome care managementHealth teachingHealth care resources

Exemplar: Bacterial Infections Folliculitis—superficial infection involving

only the upper portion of the follicleFuruncle (boil)—much deeper infection in the

follicleCellulitis—generalized infection with either

Staphylococcus or Streptococcus involving deeper connective tissue

Furuncle

Cellulitis

QuestionThe nurse is reviewing the health record of

the patients scheduled to be seen at the health clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder?

A. An adolescentB. An older femaleC. A physical education teacherD. An outdoor construction worker

Exemplar: Herpes Simplex Virus Type 1 herpes simplex virus (HSV-1)—classic

recurring cold soreType 2 herpes simplex virus (HSV-2)—genital

herpesHerpes zoster (shingles)

Herpes Simplex Virus (Cont’d) • Herpetic whitlow—a form of herpes simplex

infection occurring on the fingertips of medical personnel who have come in contact with viral secretions

Exemplar: Herpes Zoster/ShinglesCaused by reactivation of the dormant

varicella-zoster virus in patients who have previously had chickenpox.

Multiple lesions occur in a segmental distribution on the skin area innervated by the infected nerve.

Eruption lasts several weeks.Postherpetic neuralgia occurs after lesions

have resolved.

Exemplar: Fungal Infections (Dermatophyte)Tinea pedisTinea manusTinea crurisTinea capitisTinea corporisCandida albicans

Assessment History Laboratory assessment:

Tzanck smearSwab culturePotassium hydroxide (KOH) test

Interventions Skin care with proper cleansingIsolation PrecautionsDrug therapy

Skin Care Bathe daily with an antibacterial soap.Remove any pustules or crusts gently.Apply warm compress twice a day to

furuncles or areas of cellulitis.Apply Burow's solution to viral lesions.Avoid excessive moisture.Ensure optimal patient positioning.

Drug Therapy for Skin Disorders Antibacterial drugsAntifungal drugsAnti-inflammatory drugs

A topical corticosteriod is prescribed for the client with dermatitis. The nurse provides instructions to the client regarding the use of the medication. Which of the following, if stated by the client, would indicate a need for further instruction?

a.“I need to apply the medication in a thin film.”b.“I should gently rub the medication into the

skin.”c.“The medication will help relieve the

inflammation and itching.”d.“I should place a bandage over the site after

applying the medication.”

Exemplar: Cutaneous AnthraxInfection caused by the spores of the

bacterium Bacillus anthracisDiagnosis based on appearance of the lesions

and culture or anthrax antibodies in the bloodOral antibiotics for 60 days—ciprofloxacin or

doxycycline

Cutaneous Anthrax

Exemplar: Pediculosis Pediculosis—infestation by human lice:

Head lice—pediculosis capitisBody lice—pediculosis corporisPubic or crab lice—pediculosis pubis

Pruritus most common symptomDrugsLaundering of clothing and bed linen

QuestionThe home health nurse visits a client

suspected of having scabies. Which of the following precautions will the nurse institute during the assessment of the client?

A. Wear gloves onlyB. Wear a mask and glovesC. Wear a gown and glovesD. Avoid touching the client’s home

furnishings

Scabies Scabies is a contagious skin disease caused

by mite infestations.Scabies is transmitted by close and

prolonged contact or infested bedding.Examine skin between fingers and on the

palms.Infestation is confirmed by an examination of

a scraping of a lesion under a microscope.

Common Inflammations Contact dermatitis, atopic dermatitisInterventions include:

SteroidsAvoidance of oil-based productsAntihistaminesCompresses and baths

PsoriasisLifelong disorder with exacerbations and

remissionsScaling disorder with underlying dermal

inflammation; possibly an autoimmune reaction

Psoriasis vulgaris most often seenExfoliative psoriasis—an explosively eruptive

and inflammatory form of the disease

Exemplar: Psoriasis Vulgaris

Treatment of Psoriasis Corticosteroids Tar preparationsOther topical therapies Ultraviolet light therapySystemic therapy:

Biologic agentsCytotoxic agentsImmunosuppressants

Emotional support

Exemplar: Benign Tumors CystsSeborrheic keratoses KeloidsNevi (moles)

Exemplar: Skin CancerActinic keratosesSquamous cell carcinomasBasal cell carcinomasMelanomas—highly metastatic; survival

depends on early diagnosis and treatment

Skin Cancer (Cont’d)

Surgical Management of Skin Cancer

Surgical management:Cryosurgery Curettage and electrodesiccationExcisionMohs’ surgeryWide excision

Nonsurgical Management of Skin CancerDrug therapyRadiation therapy

Exemplar: Plastic SurgeryRhytidectomy (face-lift)Rhinoplasty (reconstruction of the nose)

Exemplar: Acne Red pustular eruption affecting the

sebaceous glands of the skinProgressive disorder that manifests as

noninflammatory comedones, inflammatory papules, pustules, and cysts

Topical agentsSystemic antibiotics and possibly isotretinoin

(Accutane) helpful

Exemplar; Other Skin Disorders Lichen planus with itchy papulesPemphigus vulgaris with chronic blisteringToxic epidermal necrolysis—a rare, acute

drug reactionStevens-Johnson syndromeLeprosy

Steven Johnson Syndrome

Ignatavicius, D., & Workman, M.L. (Ed.). (2010). Medical-Surgical Nursing Critical Thinking For Collaborative Care. (6th Ed.) St. Louis: Elsevier Saunders.

MedicineNet.com: We Bring Doctors’ Knowledge To You. (2010) Skin Health Center. Retrieved April 8, 2010, from: http://www.medicinenet.com/skin/focus.htm

Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed). St. Louis, Missouri: Mosby.

References