Download Chapter T64.65.66.CK43 Integumentary disorders

Chapter 43
Care of the Patient with an
Integumentary Disorder
By: Christensen, Kockrow, Timby, Ingersoll
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Skin
• Two layers


Epidermis: replaced ≈ every 35 to 45 days
Dermis: ridges: create a unique pattern of finger,
palm, and footprints; facilitate the ability to grip
and hold objects
• Subcutaneous tissue: skin attached to muscle,
bone; connective tissue, fat cells
• Melanin gives the skin its color.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 2
Question
Is the following statement true or false?
The epidermis is replaced with new cells every 35
to 45 days. The next layer, the dermis, contains
the ridges that comprise the fingerprints.
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Slide 3
Answer
False
The epidermis contains the ridges that comprise
the fingerprints.
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Slide 4
Skin Functions
• Protection
• Temperature regulation

Radiation; conduction
 Evaporation; convection
• Sensory processing
• Chemical synthesis
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Slide 5
Question
Is the following statement true or false?
One of the primary functions of the skin is to
protect the underlying structures.
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Slide 6
Answer
True
Rationale: One of the primary functions of the skin
is to protect the underlying structures, protection
from pathogens and also from dehydration.
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Slide 7
Overview of Anatomy and
Physiology
• Functions of the skin



Protection
Temperature regulation
Vitamin D synthesis
• Structure of the skin

Epidermis
•
•
•
•
The outer layer of the skin
No blood supply
Composed of stratified squamous epithelium
Divided into layers: Stratum germinativum,
pigment-containing layer, stratum corneum
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Slide 8
Skin
• Two layers


Epidermis: replaced ≈ every 35 to 45 days
Dermis: ridges: create a unique pattern of finger,
palm, and footprints; facilitate the ability to grip
and hold objects
• Subcutaneous tissue: skin attached to muscle,
bone; connective tissue, fat cells
• Melanin gives the skin its color.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 9
Question
Is the following statement true or false?
The epidermis is replaced with new cells every 35
to 45 days. The next layer, the dermis, contains
the ridges that comprise the fingerprints.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 10
Answer
False
The epidermis contains the ridges that comprise
the fingerprints.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 11
Skin Functions
• Protection
• Temperature regulation

Radiation; conduction
 Evaporation; convection
• Sensory processing
• Chemical synthesis
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 12
Question
Is the following statement true or false?
One of the primary functions of the skin is to
protect the underlying structures.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 13
Answer
True
Rationale: One of the primary functions of the skin
is to protect the underlying structures, protection
from pathogens and also from dehydration.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 14
Basic Structure of the Skin
• Structure of the skin

Dermis
• “True skin”
• Contains blood vessels, nerves, oil glands, sweat
glands, and hair follicles

Subcutaneous layer
• Connects the skin to the muscles
• Composed of adipose and loose connective tissue
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Slide 15
Figure 43-1
(From Thibodeau, G.A., Patton, K.T. [2005], The human body in health and disease. [4th ed.]. St. Louis: Mosby.)
Structures of the skin.
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Slide 16
Basic Structure of the Skin
• Appendages of the skin


Sudoriferous glands—sweat glands
Ceruminous glands—secrete cerumen (earwax)
• Located in the external ear canal

Sebaceous glands—“oil glands”
• Secrete sebum

Hair
• Composed of modified dead epidermal tissue, mainly
keratin

Nails
• Composed mainly of keratin
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Slide 17
Body Ornamentation: Tattoos
• Pigmenting the dermal layer of skin with needles
•
•
•
containing dye; select certified tattooist
Tattooing risks: allergic reaction, blood-borne infection,
granuloma, keloids
Skin care following tattooing: preventing infection,
supporting tissue regeneration, protecting skin from
further trauma
Tattoo removal: laser treatment, dermabrasion,
salabrasion, scarification, plastic surgery
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Slide 18
Question
Is the following statement true or false?
All tattoos must be created by certified tattooists.
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Slide 19
Answer
False
Rationale: Tattoos may be applied by anyone—the only
regulation for tattoos is by local jurisdictions. Only those
certified by the Alliance of Professional Tattooists certify
compliance with following FDA infection control guidelines
during tattooing.
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Slide 20
Body Ornamentation: Body
Piercing
• Common locations: lips, ear cartilage, cheeks, nose,
•
•
•
tongue, eyebrows, navel, etc.
Risks: tissue trauma, infection, allergies,
complications during procedure
Site care following body piercing: oral, personal
hygiene; avoid cosmetics, skin-drying agents; wear
loose clothing
Removal of body piercing jewelry: necessary when
antibiotics are ineffective against infection; typically
need special jeweler’s tools
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Slide 21
Assessment of the Skin
• Inspection and palpation

Ask the patient about:
• Recent skin lesions or rashes


Where the lesions first appeared
How long the lesions have been present
• Recent skin color changes
• Exposure to the sun without sunscreen
• Family history of skin cancer


Observe the skin color
Assess any skin lesions
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Slide 22
Assessment of the Skin
• Inspection and palpation (continued)

Assess for rashes, scars, lesions, or ecchymoses
 Assess temperature and texture
 Inspect nails for normal development, color, shape,
and thickness
 Inspect hair for thickness, dryness, or dullness
 Inspect mucous membranes for pallor or cyanosis
 Assess the ceruminous and sebaceous gland for
overactivity or underactivity
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Slide 23
Assessment of the Skin
• Assessment of dark skin

Degree of lightness or darkness is genetically
determined
 Melanocytes account for skin color
 Lips and mucous membranes are easier to assess as
the skin is thinner
 Rashes may be difficult to see and will require
palpation
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Slide 24
Assessment of the Skin
• Primary skin lesions
 Bulla
 Macule
 Pustule
 Papule
 Cyst
 Patch
 Telangiectasia
 Plaque
 Scale
 Wheal
 Lichenification
 Nodule
 Keloid
 Tumor
 Vesicle
(See Table 43-1.)
•
•
•
•
•
•
•
Scar
Excoriation
Fissure
Erosion
Ulcer
Crust
Atrophy
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Slide 25
Assessment of the Skin
• Chief complaint assessment tool

P = Provocative and Palliative factors
 Q = Quality and Quantity
 R = Region
 S = Severity of the signs and symptoms
 T = Time the patient has had the disorder
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Slide 26
Assessment of the Skin
• Identification of a potential malignancy

A = Asymmetrical lesion
 B = Borders irregular
 C = Color (even or uneven)
 D = Diameter of the growth (recent changes)
 E = Elevation of the surface
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Slide 27
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
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Slide 28
Viral Disorders of the Skin
• Herpes simplex

Etiology/pathophysiology
• Herpesvirus hominis


Type 1
o Most common
o Common cold sore
Type 2
o Genital herpes
• Transmission


Direct contact with an open lesion
Type 2—primarily sexual contact
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Slide 29
Viral Disorders of the Skin
• Herpes simplex (continued)

Clinical manifestations/assessment
• Type 1



Vesicle at the corner of the mouth, on the lips, or on the
nose—“cold sore”
Erythematous and edematous
Malaise and fatigue
• Type 2


Various types of vesicles on the cervix or penis
Flu-like symptoms
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Slide 30
Figure 43-2
(From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)
Herpes simplex.
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Slide 31
Viral Disorders of the Skin
• Herpes simplex (continued)

Diagnostic tests
• Culture of lesion

Medical management/nursing interventions
• Pharmacological management

Antiviral medications and analgesics
• Comfort measures
• Patient education
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Slide 32
Viral Disorders of the Skin
• Herpes simplex (continued)

Prognosis
• No cure


Type 1
o Lesions heal within 10 to 14 days
o Recur with depression of immune system: physical
and/or emotional stress
Type 2
o Lesions heal within 7 to 14 days
o Recur with depression of immune system
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Slide 33
Shingles
• Pathophysiology and Etiology: varicella-zoster virus,
•
•
•
inflammation in dermatome
Assessment Findings: Signs and Symptoms
 Fever, headache, vesicles, itching
Medical Management: oral or topical acyclovir;
corticosteroids
Nursing Management
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Slide 34
Viral Disorders of the Skin
• Herpes zoster (shingles)

Etiology/pathophysiology
• Herpes varicella (same virus that causes chickenpox)
• Inflammation of the spinal ganglia (nerve)
• Occurs when immune system is depressed

Signs and symptoms
•
•
•
•
•
Erythematous rash along a spinal nerve pathway
Vesicles are usually preceded by pain
Rash usually in the thoracic region
Vesicles rupture and form a crust
Extreme tenderness and pruritus in the area
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Slide 35
Figure 43-3
(Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)
Herpes zoster.
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Slide 36
Viral Disorders of the Skin
• Herpes zoster (shingles) (continued)

Diagnostic tests
• Culture of lesion

Medical management/nursing interventions
• Pharmacological management


Analgesics, steroids, Kenalog lotion, corticosteroids,
acyclovir (Zovirax)
Ativan and Atarax: decrease anxiety
• Comfort measures
• Patient teaching
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Slide 37
Viral Disorders of the Skin
• Pityriasis rosea

Etiology/pathophysiology
• Virus

Clinical manifestation/assessment
• Begins as a single lesion that is scaly and has a raised
border and pink center
• Approximately 14 days later, smaller matching spots
become widespread

Diagnostic tests
• Inspection and subjective data from patient
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Slide 38
Figure 43-4
(Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)
Pityriasis rosea herald patch.
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Slide 39
Viral Disorders of the Skin
• Pityriasis rosea (continued)

Medical management/nursing interventions
•
•
•
•
Usually requires no treatment
Moisturizing cream for dryness
1% hydrocortisone cream for pruritus
Ultraviolet light may shorten the course of the disease
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Slide 40
Bacterial Disorders of the Skin
• Cellulitis

Common pathogens
• Staphylococcus aureus
• Haemophilus influenzae


Risk factors
Transmission of the infection
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Slide 41
Bacterial Disorders of the Skin
• Cellulitis

Clinical manifestations
•
•
•
•
•
Erythema
Pain
Tenderness
Vesicle formation
Enlarged lymph nodes
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Slide 42
Bacterial Infections of the Skin
• Cellulitis

Assessment parameters
 Diagnostic tests
 Medical management
 Nursing interventions
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Slide 43
Bacterial Disorders of the Skin
• Impetigo contagiosa

Etiology/pathophysiology
• Staphylococcus aureus or streptococci
• Common in children
• Highly contagious

Clinical manifestations/assessment
•
•
•
•
•
Lesions begin as macules and develop into pustules
Pustules rupture—form honey-colored exudate
Usually affects face, hands, arms, and legs
Highly contagious—direct or indirect contact
Low-grade fever; leukocytosis
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Slide 44
Bacterial Disorders of the Skin
• Impetigo contagiosa (continued)

Diagnostic tests
• Culture of exudate from lesion

Medical management/nursing interventions
• Pharmacological management

Antibiotic therapy
• Medical management
• Nursing interventions
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Slide 45
Furuncles, Furunculosis, and
Carbuncles
• Pathophysiology and Etiology: skin infections,
diabetes mellitus
• Assessment Findings: Signs and Symptoms

Painful pustule surrounded by erythema, fever,
anorexia, weakness, malaise
• Diagnostic Findings: C & S of exudate identifies
the pathogen.
• Medical and Surgical Management: hot, wet
soaks; antibiotics; surgical incision, drainage
(I&D)
• Nursing Management
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Slide 46
Bacterial Disorders of the Skin
• Folliculitis, furuncles, carbuncles, and felons

Etiology/pathophysiology
• Typically attributed to S. aureus
• Folliculitis

Infected hair follicle
• Furuncle (boil)

Infection deep in hair follicle; involves surrounding tissue
• Carbuncle

Cluster of furuncles
• Felons

Infected soft tissue under and around an area
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Slide 47
Bacterial Disorders of the Skin
• Folliculitis, furuncles, carbuncles, and felons
(continued)

Clinical manifestations/assessment
•
•
•
•
•

Pustule
Edema
Erythema
Pain
Pruritus
Diagnostic tests
• Physical examination
• Culture of drainage
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Slide 48
Bacterial Disorders of the Skin
• Folliculitis, furuncles, carbuncles, and felons
(continued)

Medical management/nursing interventions
• Warm soaks two to three times per day (promote
suppuration)
• May require surgical incision and drainage
• Topical antibiotic cream or ointment
• Medical asepsis
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Slide 49
Question
Is the following statement true or false?
Furuncles, furunculosis, and carbuncles are treated with
antibiotic therapy.
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Slide 50
Answer
True
Rationale: Furuncles, furunculosis, and carbuncles are
the result of skin infection or diabetes mellitus. A culture
and sensitivity lab result indicates the proper antibiotic to
use in treatment.
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Slide 51
Dermatophytoses
• Pathophysiology and Etiology: tinea: parasitic fungi;
•
•
•
invade skin, scalp, and nails
 Ringworm, athlete’s foot, jock itch
Assessment Findings: rings of papules or vesicles,
sore skin
Medical Management: oral, topical antifungal agents
Nursing Management
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Slide 52
Fungal Infections of the Skin
• Dermatophytoses

Etiology/pathophysiology
• Microsporum audouinii major fungal pathogen




Tinea capitis
o Ringworm of the scalp
Tinea corporis
o Ringworm of the body
Tinea cruris
o Jock itch
Tinea pedis (most common)
o Athlete’s foot
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Slide 53
Figure 43-7
(From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)
Tinea capitis.
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Slide 54
Fungal Infections of the Skin
• Dermatophytoses (continued)

Clinical manifestations/assessment
• Tinea capitis

Erythematous around lesion with pustules around the
edges and alopecia at the site
• Tinea corporis

Flat lesions—clear center with red border, scaliness, and
pruritus
• Tinea cruris

Brownish-red lesions in groin area, pruritus, skin
excoriation
• Tinea pedis

Fissures and vesicles around and below toes
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Slide 55
Fungal Infections of the Skin
• Dermatophytoses (continued)

Diagnostic tests
• Visual inspection
• Ultraviolet light for tinea capitis


Infected hair becomes fluorescent (blue-green)
Medical management/nursing interventions
•
•
•
•
•
Griseofulvin—oral
Antifungal soaps and shampoos
Tinactin or Desenex
Keep area clean and dry
Burow's solution (tinea pedis)
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Slide 56
Skin Disorders: Dermatitis
• Pathophysiology and Etiology: different types

•
•
•
•
Allergic contact; primary irritant
Assessment Findings: Signs and Symptoms
 Blood vessel dilation, itching, vesiculation
Diagnostic Findings: visual examination, skin patch test
Medical Management: flushing skin with cool water;
topical lotions; corticosteroids; wet dressings
Nursing Management
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Slide 57
Question
Is the following statement true or false?
There are many different etiologies for dermatitis.
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Slide 58
Answer
False
Rationale: While many different allergens may result in
dermatitis, dermatitis is an allergic reaction to specific
substance(s). So while there may be many irritants, the
etiology of dermatitis is the allergic reaction.
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Slide 59
Inflammatory Disorders of the
Skin
• Contact dermatitis

Etiology/pathophysiology
• Direct contact with agents of hypersensitivity


Detergents, soaps, industrial chemicals, plants
Clinical manifestations/assessment
•
•
•
•
•
Burning
Pain
Pruritus
Edema
Papules and vesicles
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Slide 60
Inflammatory Disorders of the
Skin
• Contact dermatitis

Diagnostic tests
• Health history
• Intradermal skin testing
• Elimination diets

Medical management/nursing interventions
•
•
•
•
•
Remove cause
Burow's solution
Corticosteroids to lesions
Cold compresses
Antihistamines (Benadryl)
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Slide 61
Inflammatory Disorders of the
Skin
• Dermatitis venenata, exfoliative dermatitis, and
dermatitis medicamentosa

Etiology/pathophysiology
• Dermatitis venenata: Contact with certain plants
• Exfoliative dermatitis: Infestation of heavy metals,
antibiotics, aspirin, codeine, gold, or iodine
• Dermatitis medicamentosa: Hypersensitivity to a
medication

Clinical manifestations/assessment
• Mild to severe erythema and pruritus
• Vesicles
• Respiratory distress (especially with medicamentosa)
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Slide 62
Inflammatory Disorders of the
Skin
• Dermatitis venenata, exfoliative dermatitis, and
dermatitis medicamentosa (continued)

Medical management/nursing interventions
• All dermatitis


Colloid solution, lotions, and ointments
Corticosteroids
• Dermatitis venenata



Thoroughly wash affected area
Cool, wet compresses
Calamine lotion
• Dermatitis medicamentosa

Discontinue use of drug
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Slide 63
Inflammatory Disorders of the
Skin
• Urticaria

Etiology/pathophysiology
• Allergic reaction (release of histamine in an
antigen-antibody reaction)
• Drugs, food, insect bites, inhalants, emotional stress,
or exposure to heat or cold

Clinical manifestations/assessment
• Pruritus
• Burning pain
• Wheals
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Slide 64
Inflammatory Disorders of the
Skin
• Urticaria (continued)

Diagnostic tests
• Health history
• Allergy skin test

Medical management/nursing interventions
•
•
•
•
•
Identify and alleviate cause
Antihistamine (Benadryl)
Therapeutic bath
Epinephrine
Teach patient possible causes and prevention
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Slide 65
Inflammatory Disorders of the
Skin
• Angioedema

Etiology/pathophysiology
•
•
•
•
Form of urticaria
Occurs only in subcutaneous tissue
Same offenders as urticaria
Common sites: eyelids, hands, feet, tongue, larynx, GI,
genitalia, or lips
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Slide 66
Inflammatory Disorders of the
Skin
• Angioedema (continued)

Clinical manifestations/assessment
•
•
•
•

Burning and pruritus
Acute pain (GI tract)
Respiratory distress (larynx)
Edema of an entire area (eyelid, feet, lips, etc.)
Medical management/nursing interventions
• Pharmacological management

Antihistamines, epinephrine, corticosteroids
• Comfort measures
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Slide 67
Inflammatory Disorders of the
Skin
• Eczema (atopic dermatitis)

Etiology/pathophysiology
• Allergen causes histamine to be released and an
antigen-antibody reaction occurs
• Primarily occurs in infants

Clinical manifestations/assessment
• Papules and vesicles on scalp, forehead, cheeks, neck,
and extremities
• Erythema and dryness of area
• Pruritus
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Slide 68
Inflammatory Disorders of the
Skin
• Eczema (atopic dermatitis) (continued)

Diagnostic tests
• Health history (heredity)
• Diet elimination
• Skin testing

Medical management/nursing interventions
• Pharmacological management


Corticosteroids
Coal tar preparations
• Reduce exposure to allergen
• Hydration of skin
• Lotions—Eucerin, Alpha-Keri, Lubriderm, or Curel three
to four times/day
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Slide 69
Acne Vulgaris
• Pathophysiology and Etiology: overproduction of sebum
• Assessment Findings: Signs and Symptoms

•
•
•
Oily scalp; comedones
Diagnostic Findings: visual examination
Medical and Surgical Management: gentle facial
cleansing; drying agents containing benzoyl peroxide;
topical, oral drugs; antibiotics; removal with instruments;
dermabrasion
Nursing Management
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Slide 70
Inflammatory Disorders of the
Skin
• Acne vulgaris

Etiology/pathophysiology
• Occluded oil glands

Androgens increase the size of the oil gland
• Influencing factors




Diet
Stress
Heredity
Overactive hormones
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Slide 71
Inflammatory Disorders of the
Skin
• Acne vulgaris (continued)

Clinical manifestations/assessment
•
•
•
•
•

Tenderness and edema
Oily, shiny skin
Pustules
Comedones (blackheads)
Scarring from traumatized lesions
Diagnostic tests
• Inspection of lesion
• Blood samples for androgen level
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Slide 72
Inflammatory Disorders of the
Skin
• Acne vulgaris (continued)

Medical management/nursing interventions
• Pharmacological management


•
•
•
•
Topical therapies (benzoyl peroxide, vitamin A acids,
antibiotics, sulfur-zinc lotions)
Systemic therapies (tetracycline, isotretinoin)
Keep skin clean
Keep hands and hair away from area
Wash hair daily
Water-based makeup
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Slide 73
Rosacea
• Pathophysiology and Etiology: Helicobacter pylori,
•
•
•
mites, telangiectases
Assessment Findings: Signs and Symptoms
 Intermittent blushing, papules, pustules, facial
swelling, rhinophyma
Medical and Surgical Management: oral antibiotics,
topical medications, pulsed light treatment
Nursing Management
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Slide 74
Psoriasis
• Pathophysiology and Etiology: likely genetic
•
•
•
•
predisposition, keratinocytes, plaque
Assessment Findings: Signs and Symptoms
 Erythema with silvery scales, lesions
Diagnostic Findings: visual examination, skin biopsy
Medical Management: symptomatic treatment, drug
therapy, biologic therapy, photochemotherapy
Nursing Management
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Slide 75
Inflammatory Disorders of the
Skin
• Psoriasis

Etiology/pathophysiology
• Noninfectious
• Skin cells divide more rapidly than normal

Clinical manifestations/assessment
• Raised, erythematous, circumscribed, silvery, scaling
plaques
• Located on scalp, elbows, knees, chin, and trunk
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Slide 76
Figure 43-10
(Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)
Psoriasis.
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Slide 77
Inflammatory Disorders of the
Skin
• Psoriasis (continued)

Medical management/nursing interventions
• Pharmacological management



Topical steroids
Keratolytic agents
o Tar preparations
o Salicylic acid
Photochemotherapy: PUVA
o Oral psoralen
o Ultraviolet light
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 78
Inflammatory Disorders of the
Skin
• Systemic lupus erythematosus

Etiology/pathophysiology
• Autoimmune disorder
• Inflammation of almost any body part

Skin, joints, kidneys, and serous membranes
• Affects women more than men
• Contributing factors

Immunological, hormonal, genetic, and viral
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Slide 79
Inflammatory Disorders of the
Skin
• Systemic lupus erythematosus (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
Erythema butterfly rash over nose and cheeks
Alopecia
Photosensitivity
Oral ulcers
Polyarthralgias and polyarthritis
Pleuritic pain, pleural effusion, pericarditis, and
vasculitis
• Renal disorders
• Neurological signs (seizures)
• Hematological disorders
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Slide 80
Figure 43-11
(From Habif, T.P., et al. [2005]. Skin disease: diagnosis and treatment. [2nd ed.]. St. Louis: Mosby.)
Systemic lupus erythematosus (SLE) flare.
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Slide 81
Inflammatory Disorders of the
Skin
• Systemic lupus erythematosus (continued)

Diagnostic tests
•
•
•
•
•
Antinuclear antibody
DNA antibody
Complement
CBC
Erythrocyte
sedimentation rate
• Coagulation profile
• Rheumatoid factor
•
•
•
•
•
•
•
Rapid plasma reagin
Skin and renal biopsy
C-reactive protein
Coombs’ test
LE cell prep
Urinalysis
Chest x-ray film
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Slide 82
Inflammatory Disorders of the
Skin
• Systemic lupus erythematosus (continued)

Medical management/nursing interventions
• No cure; treat symptoms, induce remission, alleviate
exacerbations
• Pharmacological management

Nonsteroidal anti-inflammatory agents, antimalarial
drugs, corticosteroids, antineoplastic drugs, anti-infective
agents, analgesics, diuretics
• Avoid direct sunlight
• Balance rest and exercise
• Balanced diet
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Slide 83
Scalp and Hair Disorders: Seborrhea,
Seborrheic Dermatitis, and Dandruff
• Pathophysiology and Etiology: Pityrosporum ovale
• Assessment Findings: Signs and Symptoms

•
•
•
Oily hair, red or scaly patches on scalp, white
flakes from hair, itching
Diagnostic Findings: laboratory blood work, skin
biopsy
Medical Management: medicated shampoos,
corticosteroids
Nursing Management
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Slide 84
Alopecia
• Pathophysiology and Etiology: alopecia areata,
•
•
•
•
androgenetic alopecia (male pattern baldness)
Assessment Findings: Signs and Symptoms
 Thinning hair
Diagnostic Findings: determined by suspected
physical disorder
Medical and Surgical Management: treating the
underlying medical disorder, drug therapy, hair
replacement surgery, hair grafting, scalp reduction,
skin flap transfer
Nursing Management
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 85
Head Lice
• Pathophysiology and Etiology: transmitted
through direct contact
• Assessment Findings: Signs and Symptoms

Itching of scalp; small, yellowish-white ovals (nits)
attached to hair shafts; small grey nymphs; silvery
eggs (nits) attached to hair shafts
• Diagnostic Findings: scalp, hair inspection
• Medical Management: pediculicides, mechanical
removal
• Nursing Management
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 86
Parasitic Diseases of the Skin
• Pediculosis

Etiology/pathophysiology
• Lice infestation
• Three types of lice



Head lice (capitis)
o Attaches to hair shaft and lays eggs
Body lice (corporis)
o Found around the neck, waist, and thighs
o Found in seams of clothing
Pubic lice (crabs)
o Looks like crab with pincers
o Found in pubic area
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Slide 87
Parasitic Diseases of the Skin
• Pediculosis (continued)

Clinical manifestations/assessment
•
•
•
•
•

Nits and/or lice on involved area
Pinpoint raised, red macules
Pinpoint hemorrhages
Severe pruritus
Excoriation
Diagnostic tests
• Physical examination
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 88
Figure 43-12
(From Baran R., Dawber, R.R., & Levene, G.M. [1991]. Color atlas of the hair, scalp, and nails. St. Louis: Mosby.)
Eggs of Pediculus attached to shafts of hair.
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Slide 89
Parasitic Diseases of the Skin
• Pediculosis (continued)

Medical management/nursing interventions
• Pharmacological management


•
•
•
•
Lindane (Kwell); pyrethrins (RID)
Topical corticosteroids
Cool compresses
Assess all contacts
Wash bed linens and clothes in hot water
Properly clean furniture or nonwashable materials
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 90
Scabies
• Pathophysiology and Etiology: itch mite; spread by
•
•
•
•
skin-to-skin contact
Assessment Findings: Signs and Symptoms
 Itching, excoriation
Diagnostic Findings: visual examination, ink or mineral
oil test
Medical Management: scabicide application; thorough
bathing, clean clothing, avoiding contact with those
infected
Nursing Management
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Slide 91
Parasitic Diseases of the Skin
• Scabies

Etiology/pathophysiology
• Sarcoptes scabiei (itch mite)
• Mite lays eggs under the skin
• Transmitted by prolonged contact with infected area

Clinical manifestations/assessment
• Wavy, brown, threadlike lines on the body
• Pruritus
• Excoriation
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 92
Parasitic Diseases of the Skin
• Scabies (continued)

Diagnostic tests
• Microscopic examination of infected skin

Medical management/nursing interventions
• Pharmacological management

Lindane (Kwell), pyrethrins (RID), crotamiton (Eurax), 4%
to 8% solution of sulfur in petrolatum
• Treat all family members
• Wash linens and clothing in hot water
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Slide 93
Tumors of the Skin
• Keloids

Overgrowth of collagenous scar tissue; raised, hard,
and shiny
 May be surgically removed, but may recur
 Steroids and radiation may be used
• Angiomas



A group of blood vessels dilate and form a tumor-like
mass
Port-wine birthmark
Treatment: electrolysis; radiation
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Slide 94
Figure 43-15
(From Zitelli, B.J., Davis, H.W. [2007]. Atlas of pediatric physical diagnosis. [5th ed.]. St. Louis: Mosby.)
Keloids.
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Slide 95
Skin Cancer
• Pathophysiology and Etiology: exposure to UV radiation;
•
•
•
•
low skin melanin
Assessment Findings: Signs and Symptoms
 New appearance of growth; change in skin color; skin
lesion
Diagnostic Findings: visual inspection, biopsy
Medical and Surgical Management: electrodesiccation,
surgical excision, cryosurgery, radiation therapy
Nursing Management
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Slide 96
Tumors of the Skin
• Verruca (wart)



Benign, viral warty skin lesion
Common locations: Hands, arms, and fingers
Treatment: Cauterization, solid carbon dioxide, liquid
nitrogen, salicylic acid
• Nevi (moles)




Congenital skin blemish
Usually benign, but may become malignant
Assess for any change in color, size, or texture
Assess for bleeding or pruritus
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Slide 97
Tumors of the Skin
• Basal cell carcinoma




Skin cancer
Caused by frequent contact with chemicals,
overexposure to the sun, radiation treatment
Most common on face and upper trunk
Favorable outcome with early detection and removal
• Squamous cell carcinoma




Firm, nodular lesion; ulceration and indurated margins
Rapid invasion with metastasis via lymphatic system
Sun-exposed areas; sites of chronic irritation
Early detection and treatment are important
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Slide 98
Figure 43-16
(From Belcher, A. E. [1992]. Cancer nursing. St. Louis: Mosby.)
Basal cell carcinoma.
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Slide 99
Figure 43-17
(Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)
Squamous cell carcinoma.
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Slide
Tumors of the Skin
• Malignant melanoma

Cancerous neoplasm
• Melanocytes invade the epidermis, dermis, and
subcutaneous tissue

Greatest risk
• Fair complexion, blue eyes, red or blond hair, and
freckles

Treatment
• Surgical excision
• Chemotherapy

Cisplatin, methotrexate, dacarbazine
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Figure 43-18
(From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)
The ABCDs of melanoma.
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Slide
Disorders of the Appendages
• Alopecia



Loss of hair
Cause: Aging, drugs, anxiety, disease
Usually grows back unless from aging
• Hypertrichosis (hirsutism)



Excessive growth of hair
Causes: Heredity, hormone dysfunction, medications
Treatment: Dermabrasion, electrolysis, chemical
depilation, shaving, plucking
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Disorders of the Appendages
• Hypotrichosis



Absence of hair or a decrease in hair growth
Causes: Skin disease, endocrine problems,
malnutrition
Treatment: Identify and remove cause
• Paronychia

Disorder of the nails
 Infection of nail spreads around the nail
 Treatment: Wet dressings, antibiotic ointment, surgical
incision and drainage
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Nail Disorders: Onychomycosis
• Pathophysiology and Etiology: fungal infection
• Assessment Findings: Signs and Symptoms

•
•
•
Thick, distorted; yellow, friable nails
Diagnostic Findings: visual inspection, microscopic
examination
Medical and Surgical Management: prolonged
systemic drug therapy, nail removal, surgery
Nursing Management
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Nail Disorders: Onychocryptosis
• Pathophysiology and Etiology: inherited trait; fungal
•
•
•
•
nail infections
Assessment Findings: Signs and Symptoms
 Swelling, pain, purulent drainage, odor
Diagnostic Findings: physical examination
Medical and Surgical Management: local, systemic
antibiotic therapy; surgery
Nursing Management
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Depth of Burn Injuries
•
•
•
•
Superficial
Superficial partial thickness
Deep partial thickness
Full thickness


Third degree
Fourth degree
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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
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Slide
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

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
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Slide
Figure 43-19
(From Hockenberry MJ, Wilson D [2007]. Wong’s nursing care of infants and children. [8th ed.] . St. Louis: Mosby.)
Classification of burn depth.
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Slide
Extent of Burns
• Quick initial method of estimating how much of the
client’s skin surface is involved
• Another quick assessment technique is to compare
the client’s palm with the size of the burn wound.
The palm is approximately 1% of a person’s total
body surface area.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Burn Injuries
• Pathophysiology and Etiology: heat, chemicals,
electricity

Heat: cell damage, protein coagulation
• Severity: temperature of heat source, duration of
contact, thickness of tissue exposed, burn location


Chemicals: liquefy tissue, loosen cell attachment
Electrical: cardiac dysrhythmias, central nervous
system complications
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Question
Is the following statement true or false?
A burn’s severity is affected by the temperature of
the heat source.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Answer
True
Rationale: A burn’s severity is affected by the
temperature of the heat source. Additional factors,
which affect a burn’s severity, include duration of
contact, thickness of tissue exposed to the heat,
and the location of the burn.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Burn Injuries—(cont.)
• Pathophysiology





Effect of inflammatory process
Neuroendocrine changes; edema
Fluid, electrolyte status alteration
Anemia; hemoconcentration
Factors affecting mortality
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Life-Threatening Complications
• Inhalation injury
• Hypovolemic shock
• Infection
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Question
Is the following statement true or false?
Burns can affect fluid balance.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Answer
True
Rationale: As a response to the trauma of a burn,
fluid shifts, which results in edema. Not only does
it result in edema but the fluid is also trapped and
unavailable to the rest of the body. Decreased
blood pressure (due to decreased fluid volume)
can result in irreversible shock.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Burn Injuries—(cont.)
• Assessment Findings: Signs and Symptoms

Light pink to black skin color; edema; blistering;
pain; compromised breathing; symptoms of
hypovolemic shock; entrance, exit wounds
• Diagnostic Findings: physical inspection,
radiographs
• Medical Management: potential life-threatening
complications: inhalation injury, hypovolemic
shock, infection

Major burns: transport to regional burn center
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Question
Is the following statement true or false?
An infection within a burn wound can be lifethreatening.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Answer
True
Rationale: An infection within a burn wound can be
life-threatening. Outcome of a burn injury depends
on the initial first aid and subsequent acute
treatment. Three complications of burns can be lifethreatening: inhalation injury, hypovolemic shock,
and infection.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Burn Injury Medical Management
• Initial first aid: first priority: prevent further injury;
observe for respiratory difficulty
• Acute care: assess extent of burn injury, additional
trauma

Interventions: ventilation, fluid resuscitation
• Endotracheal tube, bronchoscopy
• Mechanical ventilation, tracheostomy, hyperbaric
oxygen treatment
• IV analgesics, tetanus immunization
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Burn Injury Wound Management
• Infection prevention measures; debris removal
• Open Method: exposes burned areas to air; used
only for areas where it is difficult to apply dressings
(face, perineum)

Isolation, sterile environment, escharotomy
• Closed Method: current, preferred method

Use of dressings: nonadherent; absorbent;
occlusive, semiocclusive; dressing changes
• Antimicrobial Therapy: silver sulfadiazine,
mafenide, silver nitrate, Acticoat
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
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
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Burns
• 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
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
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Autograft
Homograft (allograft)
Heterograft
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Burn Injury Surgical Management
• Surgical Management: debridement
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


Removal of necrotic tissue
Four ways: naturally, mechanically, enzymes,
surgery
Disadvantage: bleeding
Covering of healthy tissue: skin graft, temporary skin
substitute, cultured skin
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Surgical Management: Skin
Grafting
• Purpose: lessen infection, minimize fluid loss,
hasten recovery, reduce scarring, prevent loss of
function
• Keratinocytes regenerate epidermis.
• Used for deep partial-thickness and full-thickness
burns
• Unassisted healing: granulation tissue,
contractures, chronic open wounds
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Surgical Management: Skin
Grafting—(cont.)
• Sources for Skin Grafts



Autograft: client’s own skin
Allograft: human skin from cadaver
Heterograft: animal skin
• Types of Autografts


Split-thickness; full-thickness; slit
Disadvantages; pressure garments; sunscreen
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Surgical Management: Skin
Grafting—(cont.)
• Skin Substitutes



Cover wound; promote healing
Direct interaction with body tissues
Applied soon after skin is healed and débrided
• Cultured Skin


Culture client’s skin; collagen
Disadvantage: pigmentation mismatch
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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
Signs and symptoms of complications
Exercises
Clothing and ADLs
Social skills
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
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Burn Injury Nursing Management
• Assessment



Wound; client’s status
Calculation and infusion—fluid replacement
requirements
Treatment of shock; pain relief
• Wound care: antimicrobials, dressings, monitoring for
infection, emotional support

Client teaching: exercise, pressure garments, skin care
measures
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Nursing Process
• Nursing diagnoses
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Anxiety
Pain
Knowledge, deficient related to disease
Infection, risk of
Trauma, risk for
Social interaction, impaired
Self-esteem, risk for situational low
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
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