lisa m. dunn msn/ed, rn, ccrn, cne. exemplar: xerosis (dryness) a common problem among older...
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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
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
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.
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
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
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
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
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
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
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.