1. Alterations in Skin Integrity and Would Healing
Lisa M. Dunn MSN/Ed, RN, CCRN, CNE

2. Exemplar: Xerosis (Dryness)
A common problem among older patients
Fine flaking of the stratum corneum
Generalized pruritus
Scratching may result in secondary skin lesions, excoriations, lichenification, and infection

3. Collaborative Management
Nursing 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.

4. 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.

5. The nurse is applying a topical corticosteroid to a client with eczema
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?
Back
Axilla
Soles of the feet
Palms of the hands

7. Exemplar: Sunburn First-degree, superficial burn Cool baths
Soothing lotions
Antibiotic ointments for blistering and infected skin
Topical corticosteroids for pain

8. Exemplar: Urticaria (Hives)
Urticaria—presence of white or red edematous papules or plaques of varying sizes
Removal of triggering substances
Antihistamines helpful
Avoidance of overexertion, alcohol consumption, and warm environments, which can worsen symptoms

9. Exemplar: Trauma Phases of wound healing: Inflammatory phase
Fibroblastic or connected tissue repair phase
Maturation or remodeling phase

10. Question
The 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

11. Process of Wound Healing

12. Process of Wound Healing (Cont’d)
First intention resulting in a thin scar
Second intention (granulation) and contraction—a deeper tissue injury or wound
Third intention (delayed closure)—high risk for infection with a resultant scar

13. Exemplar: Partial-Thickness Wounds
Involve damage to the epidermis and upper layers of the dermis
Heal by re-epithelialization within 5 to 7 days
Skin injury immediately followed by local inflammation

14. Re-epithelialization

15. Exemplar: Full-Thickness Wounds
Damage 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

17. Exemplar: Pressure Ulcer
Tissue 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:
Pressure
Friction
Shear

18. Shearing Force

19. Identification of High-Risk Patients
Mental status changes
Independent mobility
Nutritional status
Incontinence

20. Pressure-Relieving Techniques
Adequate pressure relief key to prevention of pressure ulcers
Capillary closing pressure
Pressure-relief products and devices
Positioning

21. Question
The 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 skin
B. Full-thickness skin loss
C. Exposed bone, tendon, or muscle
D. Partial- thickness skin loss of the dermis

22. Wound Assessment
Pressure ulcers and their features are classified and assessed in four stages:
Stage I
Stage II
Stage III
Stage IV

23. Four Stages of Pressure Ulceration

24. Wound Assessment Location Size Color Extent of tissue involvement
Cell types in the wound base and margins
Exudate
Condition of surrounding tissue
Presence of foreign bodies

26. 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.

27. Nonsurgical Management
Dressings:
Mechanical débridement
Natural chemical débridement
Hydrophobic material
Hydrophilic material

28. Nonsurgical Therapy Physical therapy Drug therapy Nutrition therapy
New technologies:
Electrical stimulation
Vacuum-assisted wound closure (VAC)
Hyperbaric oxygen (HBO)
Topical growth factors
Skin substitutes

30. Hyperbaric Oxygen Therapy

31. Surgical Management
Surgical débridement
Skin grafting

33. Community-Based Care Home care management Health teaching
Health care resources

34. Exemplar: Bacterial Infections
Folliculitis—superficial infection involving only the upper portion of the follicle
Furuncle (boil)—much deeper infection in the follicle
Cellulitis—generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue

35. Furuncle

36. Cellulitis

37. Question
The 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 adolescent
B. An older female
C. A physical education teacher
D. An outdoor construction worker

38. Exemplar: Herpes Simplex Virus
Type 1 herpes simplex virus (HSV-1)—classic recurring cold sore
Type 2 herpes simplex virus (HSV-2)—genital herpes
Herpes zoster (shingles)

39. 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

40. Exemplar: Herpes Zoster/Shingles
Caused 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.

42. Exemplar: Fungal Infections (Dermatophyte)
Tinea pedis
Tinea manus
Tinea cruris
Tinea capitis
Tinea corporis
Candida albicans
S&P

43. Assessment History Laboratory assessment: Tzanck smear Swab culture
Potassium hydroxide (KOH) test

44. Interventions Skin care with proper cleansing Isolation Precautions
Drug therapy

45. 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.

46. Drug Therapy for Skin Disorders
Antibacterial drugs
Antifungal drugs
Anti-inflammatory drugs

47. A topical corticosteriod is prescribed for the client with dermatitis
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?
“I need to apply the medication in a thin film.”
“I should gently rub the medication into the skin.”
“The medication will help relieve the inflammation and itching.”
“I should place a bandage over the site after applying the medication.”

48. Exemplar: Cutaneous Anthrax
Infection caused by the spores of the bacterium Bacillus anthracis
Diagnosis based on appearance of the lesions and culture or anthrax antibodies in the blood
Oral antibiotics for 60 days—ciprofloxacin or doxycycline

49. Cutaneous Anthrax

50. Exemplar: Pediculosis
Pediculosis—infestation by human lice:
Head lice—pediculosis capitis
Body lice—pediculosis corporis
Pubic or crab lice—pediculosis pubis
Pruritus most common symptom
Drugs
Laundering of clothing and bed linen

52. Question
The 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 only
B. Wear a mask and gloves
C. Wear a gown and gloves
D. Avoid touching the client’s home furnishings

53. 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.
S&P

54. Common Inflammations Contact dermatitis, atopic dermatitis
Interventions include:
Steroids
Avoidance of oil-based products
Antihistamines
Compresses and baths

55. Psoriasis Lifelong disorder with exacerbations and remissions
Scaling disorder with underlying dermal inflammation; possibly an autoimmune reaction
Psoriasis vulgaris most often seen
Exfoliative psoriasis—an explosively eruptive and inflammatory form of the disease

56. Exemplar: Psoriasis Vulgaris

57. Treatment of Psoriasis
Corticosteroids
Tar preparations
Other topical therapies
Ultraviolet light therapy
Systemic therapy:
Biologic agents
Cytotoxic agents
Immunosuppressants
Emotional support

58. Exemplar: Benign Tumors
Cysts
Seborrheic keratoses
Keloids
Nevi (moles)

59. Exemplar: Skin Cancer Actinic keratoses Squamous cell carcinomas
Basal cell carcinomas
Melanomas—highly metastatic; survival depends on early diagnosis and treatment

60. Skin Cancer (Cont’d)

61. Surgical Management of Skin Cancer
Cryosurgery
Curettage and electrodesiccation
Excision
Mohs’ surgery
Wide excision

62. Nonsurgical Management of Skin Cancer
Drug therapy
Radiation therapy

63. Exemplar: Plastic Surgery
Rhytidectomy (face-lift)
Rhinoplasty (reconstruction of the nose)

64. Exemplar: Acne
Red pustular eruption affecting the sebaceous glands of the skin
Progressive disorder that manifests as noninflammatory comedones, inflammatory papules, pustules, and cysts
Topical agents
Systemic antibiotics and possibly isotretinoin (Accutane) helpful

65. Exemplar; Other Skin Disorders
Lichen planus with itchy papules
Pemphigus vulgaris with chronic blistering
Toxic epidermal necrolysis—a rare, acute drug reaction
Stevens-Johnson syndrome
Leprosy
S&P

68. Steven Johnson Syndrome

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