1elsevier items and derived items © 2007 by saunders, an imprint of elsevier, inc. chapter 50 skin...

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 50

Skin Disorders


Learning Objectives

• Describe the structure and functions of the skin.• List the components of the nursing assessment of the

skin.Define terms used to describe the skin and skin lesions.

• Explain the tests and procedures used to diagnose skindisorders.

• Explain the nurse’s responsibilities regarding the testsand procedures for diagnosing skin disorders.

• Explain the therapeutic benefits and nursing considerationsfor patients who receive dressings, soaks and wet wraps, phototherapy, and drug therapy for skin problems.

• Describe the pathophysiology, signs and symptoms, diagnostictests, and medical treatment for selected skin disorders.

• Assist in developing a nursing care plan for the patientwith a skin disorder.


Anatomy and Physiology of the Skin


Definition

• The skin is an organ that covers the body surface • Two distinct layers


Epidermis

• Outermost layer that covers the dermis • Continually produces new cells to replace

those at the surface • Produce melanin, a dark pigment, that helps

determine the color of the skin • Strong ultraviolet light, such as in sunlight,

stimulates the production of melanin


Dermis

• Strong connective tissue that contains nerve endings, sweat glands, hair roots

• Well supplied with blood vessels, causing the skin to redden when surface vessels are dilated

• Subcutaneous tissue lies beneath the dermis


Figure 50-1


Appendages

• Hair, nails, and sebaceous glands• Hair root located in tube in dermis called a hair

follicle • Arrector muscles located around hair follicles

contract, causing hairs to stand erect and

gooseflesh skin • Sebaceous glands secrete oily substance: sebum • Sweat glands, in most parts of the skin, secrete

through skin surface water that contains salts, ammonia, amino acids, lactic acid, ascorbic acid, uric acid, and urea


Functions

• Protection • Temperature regulation • Secretions• Sensation • Synthesis of vitamin D • Blood reservoir


Age-Related Changes

• Wrinkling a result of thinning skin layers and degeneration of elastin fibers

• Sweat glands decrease, although production changes little until advanced age

• Production of sebum decreases, becoming apparent earlier in women than in men

• Dryness and pruritus are common • Skin pales because the number of cells that

produce melanin decreases


Age-Related Changes

• Skin lesions are more common• Lentigines • Senile purpura• Senile angiomas • Seborrheic keratoses • Acrochordons

• By age 50, nearly half have some gray hair • Men begin to lose hair from the scalp in their

40s; by their 80s many almost bald


Age-Related Changes

• Scalp hair thins in women as well but usually less obvious

• Increase in facial hair in both sexes • Men may have increased hair in the nares,

eyebrows, or helix of the ear • Nails flatten; become dry, brittle, and discolored


Figure 50-2


Health History

• Chief complaint and history of present illness • Discomfort, pruritus, color changes, lesions, hair

loss, or abnormal hair growth • Onset of condition/precipitating or alleviating factors

• Past medical history

• Previously diagnosed skin diseases or problems, current and recent medications, and allergies

• Diabetes mellitus, cancer, kidney failure, thyroid disease, liver disease, and anemia


Health History

• Review of systems • Change in skin color or pigmentation, change in a

mole, sores slow to heal, itching, dryness or scaliness, excessive bruising, rashes, lesions, hair loss, unusual hair growth, changes in nails

• Functional assessment • Past and present occupations, exposure to

chemicals or other irritants, skin care habits, sun exposure

• Recent changes in the work or living environment • Current stresses and sources of anxiety


Physical Assessment

• Skin color and variations in pigmentation • Document dilated blood vessels and angiomas • Nevi (moles) inspected for irregularities in

shape, pigmentation, and ulcerations or changes in surrounding skin

• If a rash, location, distribution, and characteristics. If any drainage, the color, amount, and odor are noted


Figure 50-3


Physical Assessment

• Palpate skin for temperature, moisture, texture, thickness, edema, mobility, and turgor

• Mobility and turgor • Hair color, distribution, oiliness, and texture.

The scalp is inspected for scaliness, infestations, and lesions

• Shape/contour of the fingernails and toenails • Color of the nail bed• Capillary refill checked by applying pressure to

the nail to cause blanching and then releasing


Figure 50-4


Diagnostic Tests and Procedures

• Microscopic examination of skin specimens• Potassium hydroxide (KOH) examination • Tzanck smear • Scabies scraping

• Wood’s light examination • Patch testing for allergy• Biopsy

• Shave biopsy • Punch biopsy • Surgical excision


Therapeutic Measures

• Dressings• Protect wounds; retain surface moisture • Types: wet, dry, absorptive, and occlusive

• Negative pressure wound therapy• Reduce healing time of traumatic wounds, dehisced

surgical wounds, pressure and chronic ulcers

• Soaks and wet wraps• Soothe, soften, and remove crusts, debris, and

necrotic tissue


Therapeutic Measures

• Phototherapy• Ultraviolet light in combination with photosensitive

drugs promotes shedding of the epidermis

• Drug therapy• Topical drugs: keratolytics, antipruritics, emollients,

lubricants, sunscreens, tars, anti-infectives, glucocorticoids, antimetabolites, antihistamines, antiseborrheic agents, and vitamin A derivatives


Disorders of the Skin


Pruritus

• Etiology and risk factors • Triggered by touch, temperature changes,

emotional stress, and chemical, mechanical, and electrical stimuli

• Prominent symptom of psoriasis, dermatitis, eczema, insect bites


Pruritus

• Medical treatment • Stress management and avoidance of known

irritants, sudden temperature changes, and alcohol, tea, and coffee

• Lubricants in the bathwater and emollients applied after bathing also may help

• Medications include corticosteroids, antihistamines, and local anesthetics


Pruritus

• Assessment• Collect data about symptoms that may help

determine the cause • The history of the current illness is important

because pruritus may be just one symptom of a condition that requires attention


Pruritus

• Interventions• Lubricants/emollients; adding oils to bathwater• Advise to avoid bathing in very hot water • Administer medications or instruct patient in their

use • Inspect skin daily to determine effects of treatment • Explain possible causes of pruritus and encourage

the patient to avoid them


Atopic Dermatitis (Eczema)

• Pathophysiology• Acute stage: red, oozing, crusty rash and intense

pruritus • Subacute stage: redness, excoriations, and scaling

plaques or pustules. Fine scales may give skin a silvery appearance

• Chronic stage: the skin becomes dry, thickened, scaly, and brownish gray



• Etiology and risk factors• Personal or family history of asthma, hay fever,

eczema, or food allergies • People with atopic dermatitis have an immune

dysfunction, but it is not known whether that dysfunction is a cause or an effect of the disorder


Figure 50-6



• Medical diagnosis • Health history and physical examination• Skin biopsy, serum immunoglobulin E levels, and

cultures; allergy tests

• Medical treatment • Topical corticosteroids; systemic antihistamines



• Assessment• Allergies, bathing practices, and current medications

• Interventions• Impaired Skin Integrity • Risk for Infection • Disturbed Body Image


Seborrheic Dermatitis

• Pathophysiology• Chronic inflammatory disease of the skin • Affects scalp, eyebrows, eyelids, lips, ears, sternal

area, axillae, umbilicus, groin, gluteal crease, and under the breasts

• Areas affected by this condition may have fine, powdery scales, thick crusts, or oily patches

• Scales may be white, yellowish, or reddish • Pruritus is common



• Etiology and risk factors • The cause is unknown • May be an inflammatory reaction to infection with

the yeast Malassezia



• Medical diagnosis • Health history and physical examination

• Medical treatment • Topical ketoconazole (Nizoral), sometimes with

topical corticosteroids • Shampoos that contain selenium sulfide (Selsun),

ketoconazole, tar, zinc pyrithionate, salicylic acid, or resorcin



• Assessment• Inspect and describe the affected areas

• Interventions• Explain the condition and reinforce the physician’s

instructions for treatment


Psoriasis

• Pathophysiology • Abnormal proliferation of skin cells • Classic sign: bright red lesions that may be covered

with silvery scales

• Etiology and risk factors • Caused by rapid proliferation of epidermal cells • Usually chronic with cycles of exacerbations and

remissions


Psoriasis

• Medical diagnosis • Health history and physical examination

• Medical treatment • No cure; usually treated with topical medications:

corticosteroids, tazarotene, Estar (coal tar), and vitamin D derivatives


Figure 50-7


Psoriasis

• Assessment• Describe symptoms and treatments• Inspect affected areas for lesions and scales • Document joint pain or stiffness because the

condition may cause arthritis

• Interventions• Ineffective Therapeutic Regimen Management • Disturbed Body Image • Social Isolation


Intertrigo

• Pathophysiology • Inflammation where two skin surfaces touch: axillae,

abdominal skinfolds, and under the breasts • The affected area is usually red and “weeping” with

clear margins; may be surrounded by vesicles and pustules

• Etiology and risk factors • Results from heat, friction, and moisture between

touching surfaces


Intertrigo

• Medical diagnosis and treatment • Based on site/appearance of inflamed skin• If the skin not broken, wash with water twice daily;

rinse and pat dry; soft gauze used to separate layer of tissue and absorb moisture

• For severe inflammation or fungal infection: topical corticosteroid or antifungal agent


Intertrigo

• Assessment• Complaints of pain, irritation, or redness in body

folds • Inspect susceptible areas daily


Intertrigo

• Interventions• Areas where skin surfaces are in contact must be kept clean

and dry • Apply topical medications as ordered • Report increasing redness and tenderness, fever, and broken

skin to the physician • Encourage women with pendulous breasts to wear a soft,

supportive bra • If incontinence has contributed to perineal intertrigo, position

patient with legs apart to allow moisture to evaporate


Fungal Infections

• Pathophysiology • Tinea pedis (athlete’s foot)• Tinea manus (hand)• Tinea cruris (groin)• Tinea capitis (scalp)• Tinea corporis (body)• Tinea barbae (beard)• Candidiasis: affects skin, mouth, vagina,

gastrointestinal tract, and lungs


Fungal Infections

• Etiology and risk factors • Spread through direct contact or by inanimate objects • Lesions may be scaly patches with raised borders • Pruritus common symptom

• Medical diagnosis • Confirmed by microscopic examination of skin

scrapings• Medical treatment

• Fungal: treated with antifungal powders and creams • Oral candidiasis: treated with clotrimazole troches, nystatin

mouthwash or lozenges, oral amphotericin B


Figure 50-8


Fungal Infections

• Assessment• Conditions that might make a person susceptible to

fungal infections• Inspect the skin and mucous membranes for lesions

• Interventions• Disturbed Body Image • Altered Oral Mucous Membrane • Risk for Injury


Acne

• Pathophysiology • Affects the hair follicles and sebaceous glands • Comedones (whiteheads, blackheads), pustules, cysts • Often develop on the face, neck, and upper trunk

• Etiology and risk factors • Androgenic hormones cause increased sebum production;

bacteria proliferate, causing sebaceous follicles to become blocked and inflamed

• Medical diagnosis • Health history and physical examination findings


Acne

• Medical treatment • Topical medications: antibiotics, keratolytics such as

benzoyl peroxide, topical vitamin A preparations• Oral antibiotics given over several months • Nonpharmacologic treatment: comedo extraction or

cryotherapy • Dermabrasion to reduce scarring


Acne

• Assessment• Document any treatments being used

• Inspect skin to determine extent and severity

• Interventions• Disturbed Body Image • Ineffective Therapeutic Regimen Management


Herpes Simplex

• Etiology and risk factors • Viral infection begins with itching and burning and progresses

to vesicles that rupture and form crusts• Nose, lips, cheeks, ears, genitalia most often affected • Oral lesions called cold sores or fever blisters• Infections on the face and upper body usually caused by HSV-

1; genital infections by HSV-2

• Medical diagnosis • Laboratory studies of exudate from a lesion and blood studies

to detect specific antibodies


Figure 50-9


Herpes Simplex

• Assessment• Describe the development of the herpetic lesions • Sexual contacts documented so that they can be advised of

the need for medical evaluation • Inspect the lesions

• Interventions• Acute Pain • Ineffective Coping • Ineffective Therapeutic Regimen Management


Herpes Zoster

• Etiology and risk factors• Commonly called shingles • Varicella-zoster virus; also causes chickenpox • Symptoms: pain, itching, and heightened sensitivity along a

nerve pathway, followed by the formation of vesicles in the area

• When the skin is affected, crusts form • Older adults especially susceptible to complications• Immunosuppressed at greater risk for herpes zoster infections;

may have serious systemic complications


Figure 50-10


Herpes Zoster

• Medical diagnosis • Health history and physical examination findings • Tzanck smear or viral culture of material from a lesion

• Medical treatment • Antiviral agents: acyclovir, famciclovir, valacyclovir, and

foscarnet • Wet dressings soaked in Burow’s solution • Pain may be treated with analgesics and sedatives


Herpes Zoster

• Assessment• Conditions or treatments that might cause the

patient to have a reduced immune response • Distribution and appearance of the lesions

• Interventions• Impaired Skin Integrity • Acute Pain • Ineffective Coping


Necrotizing Fasciitis

• Infection of deep fascial structures under the skin • Aerobic and anaerobic organisms: Streptococcus,

Staphylococcus, Peptostreptococcus, Bacteroides, and Clostridium species

• Organisms excrete enzymes that destroy blood vessels that supply the affected area

• Deprived of blood flow, tissue necrosis occurs • Treatment involves extensive débridement, intravenous

and topical antibiotics, and eventual skin grafting


Infestations

• Lice• Scabies


Figure 50-12


Pemphigus

• Chronic autoimmune condition: bullae (blisters) develop on the face, back, chest, groin, and umbilicus

• Blisters rupture easily, releasing a foul-smelling drainage • Potassium permanganate baths, Domeboro solution, and oatmeal

products soothe the affected areas, reduce odor, and decrease the risk of infection

• Treatments: corticosteroids, other immunosuppressants, and oral or topical antibiotics

• Patients with extensive skin loss require the same care as burn patients


Actinic Keratosis

• Precancerous lesions most often found on the face, neck, forearms, and backs of the hands—all areas exposed to sunlight

• May become malignant if not treated • Most common among older white adults • Appear as papules or plaques of irregular shape

• The hard scale on the lesion may shed and reappear

• Treatments include drug therapy, cryotherapy, electrodesiccation, and surgical excision


Nonmelanoma Skin Cancer

• Basal cell carcinoma • Painless, nodular lesions; pearly appearance • Related to sun exposure • Grow slowly and rarely metastasize • Treated with surgical excision, Mohs’ micrographic

excision, electrodesiccation and curettage, cryotherapy, radiation, or drugs that are applied topically or injected into the lesion


Nonmelanoma Skin Cancer

• Squamous cell carcinoma • Scaly ulcers or raised lesions • Develop on sun-exposed areas including the lips,

and in the mouth • Caused by overuse of tobacco and alcohol • Grow rapidly and metastasize • Treatment may include surgical excision,

cryotherapy, and radiation therapy


Figure 50-13A-C


Melanoma

• Arises from pigment-producing cells in the skin • Most serious form of skin cancer; fatal if it

metastasizes • Found anywhere on the body • Irregular borders and uneven coloration; many are

dark, but some are light. Begin as tan macule that enlarges

• Removed surgically; a wide area around a melanoma is usually excised

• Chemotherapy and immunotherapy also may be employed


Figure 50-13D


Cutaneous T-Cell Lymphoma

• Migration of malignant T cells to the skin • Mycosis fungoides and Sézary syndrome • May resemble eczema, with macular lesions appearing

on areas protected from the sun • Tumors form, enlarge, spread to distant sites • When confined to the skin, this type of lymphoma can

be cured with topical chemotherapy, systemic psoralens with UVA, and/or superficial radiotherapy


Kaposi’s Sarcoma

• Malignancy of the blood vessels • Red, blue, purple macules with pain, itching, swelling • Lesions appear first on the legs and then on the upper body, face,

and mouth • Enlarge to form large plaques that may drain• In patients with HIV but not confined to this group • Local lesions excised or injected with intralesional chemotherapy • Systemic lesions are treated with chemotherapy, immune therapy,

and radiotherapy


Disorders of the Nails


Infections

• Usually indicated by redness, swelling, and pain around the margin of the nail

• Treated with warm soaks and topical or systemic anti-infectives

• Incision and drainage may be necessary


Ingrown Toenail

• Painful inflammation at distal corner of nail • Caused by trimming nail too short at the

corners or wearing shoes that are too tight • Ingrown nail should be protected from pressure

as it grows out • Warm soaks may be soothing • Surgical excision of ingrown portion of nail


Care of the Patient with a Nail Disorder

• Assessment• Health history should document the diagnoses of

diabetes mellitus or peripheral vascular disease • In the physical examination, inspect the nails for

redness, swelling, or pain • Inspect extremities for lesions and abnormal color,

and palpate for warmth and peripheral pulses


Care of the Patient with a Nail Disorder

• Interventions• Teach patients how to trim their nails correctly and

the importance of properly fitting shoes • Toenails should be cut straight across and even

with the end of the toe • If patient cannot care for the feet adequately, refer

to a podiatrist


Burns


Definition of Burns

• Tissue injuries caused by heat • Depending on source of injury, burn is

described as thermal (flame, flash, scalding liquids, hot objects), chemical, electrical, radiation, or inhalation

• Leading cause of accidental death despite improved survival rates attributed to advances in the care of burn patients


Classification

• Burn size • Rule of nines• Lund and Browder method

• Burn depth • Superficial burn (first degree)

• Affect only the epidermis

• Superficial or deep partial-thickness burn (second degree)• Affects the epidermis and the dermis

• Full-thickness burns (third degree, fourth degree)• Extend into even deeper tissue layers


Figure 50-15


Figure 50-16


Figure 50-17


Burn Severity

• American Burn Association criteria• Burn size: 25% or more body surface area for

people younger than 40 years; 20% or more body surface area for older than 40 years

• Disfiguring or disabling injuries to the face, eyes, ears, hands, feet, or perineum

• High-voltage electrical burn injury• Inhalation injury• Major trauma in addition to the burn


Pathophysiology of Burn Injury

• Local effects • Tissue releases chemicals that cause increased capillary

permeability, which permits plasma to leak into the tissues • Injury to cell membranes permits excess sodium to enter cell and

potassium to escape into the extracellular compartment • These shifts cause local edema and decrease in cardiac output • Fluid evaporates through the wound surface, further contributing to

the declining blood volume • 18 to 36 hours after a burn injury, capillary permeability begins to

normalize and reabsorption of edema fluid begins • Cardiac output returns to normal and then increases to meet

increased metabolic demands


Pathophysiology of Burn Injury

• Systemic effects

• Fluid balance • Gastrointestinal function • Immune system • Respiratory system • Myocardial depression • Psychological effects


Stages of Burn Injury

• Emergent: begins with the injury and ends when fluid shifts have stabilized

• Acute: begins with fluid stabilization and ends when all but 10% of burn wounds are closed or when all wounds are closed

• Rehabilitation: lasts as long as efforts continue to promote improvement


Medical Treatment: Emergent Stage

• Assess airway, breathing, and circulation and then determine whether the patient has injuries in addition to the burn

• If inhalation injury, oxygen therapy is started • May require intubation if airway is compromised • IV lines established to begin fluid resuscitation and to

provide emergency vascular access



• Indwelling urinary catheter and a nasogastric tube usually inserted

• Blood drawn for baseline lab studies• Tetanus prophylaxis may be administered • Pain assessed and analgesics are ordered• Wound is cleaned, débrided, and inspected



• Patient with serious burns is transferred to a burn specialty care unit or a critical care unit

• IV essential during the first few days of burn treatment • Volume based on patient’s weight and extent of injury • First 24 hours, IV fluids may consist of various combinations of

electrolyte, colloid, and dextrose solutions • Second 24 hours, volume decreased based on urine output• Fluids then different combinations of electrolyte, colloid, and dextrose

solutions • Some formulas omit electrolyte solutions in the second 24 hours

• Antibiotic therapy and surgical procedures


Wound Care

• Open method: topical antimicrobials but no dressings

• Closed care: topical medications covered by dressings

• Topical medications: silver sulfadiazine (Silvadene) and mafenide acetate (Sulfamylon)

• Tetanus booster given if patient has not been immunized within the past 5 years


Wound Care

• For clean partial-thickness wounds that will heal without grafting, temporary wound coverings• Amniotic membranes, grafts from cadavers or pigs,

and a number of synthetic materials

• Graft sites also treated with negative pressure wound therapy

• Donor sites treated with fine-mesh gauze and synthetic and biosynthetic products


Wound Care

• Débridement• Removal of debris and necrotic tissue from a wound • By scissors, forceps, surgical excision, or enzymes

• Skin grafting • Autograft: the patient’s own skin • Split-thickness or a full-thickness graft

• Scarring • Can be reduced with pressure dressings in the early stages of

care, followed by custom-fitted garments that apply continuous pressure


Figure 50-18


Care of the Patient with Burn Injury

• Health history• Circumstances surrounding the burn injury • Chronic diseases, surgeries, or hospitalizations • Medications and allergies • Family history even though not specific to burn injuries; it may

alert the staff to other problems • Review of systems detects current problems • Habits and lifestyle, roles and responsibilities, stressors, and

coping strategies



• Physical examination • Vital signs• Inspect for burn wounds and other lesions • Wound color and the presence of eschar • Palpate intact skin for temperature and turgor • Chest expansion observed, and the lungs auscultated for

wheezing, stridor, or atelectasis • Apical pulse be auscultated for rate and rhythm • Abdomen assessed: active bowel sounds/distention • Extremities are inspected for injury and deformity • ROM assessment is delayed if extremity immobilized



• Interventions• Decreased Cardiac Output • Fluid Volume Excess • Acute Pain• Risk for Infection • Hypothermia • Risk for Imbalanced Nutrition: Less Than Body Requirements • Impaired Physical Mobility • Ineffective Coping • Ineffective Family Coping


Conditions Treated with Plastic Surgery


Aesthetic Surgery

• Alters a body feature that is structurally normal but perceived by the patient as unattractive

• Examples: rhytidectomy, blepharoplasty, chin implants, rhinoplasty, abdominoplasty, breast augmentation, and breast reduction


Reconstructive Surgery

• Repair disfiguring scars, restore body contours after radical surgery like mastectomy, eliminate benign lesions such as birthmarks, restore features damaged by trauma or disease, and correct developmental defects


Preoperative Nursing Care

• Assessment: health history• Patient’s description of plastic surgery and what he or she

expects the procedure to accomplish. Past medical history may elicit conditions that might affect wound healing

• Review of systems: surgical area receives special attention

• Functional assessment: patient’s lifestyle and usual activities

• Interventions• Anxiety • Deficient Knowledge


Postoperative Nursing Care

• Assessment• Vital signs and level of consciousness • Inspect dressings for drainage or bleeding, but do

not remove them without specific orders • Observe flaps and grafts for color and evidence of

fluid accumulation, and palpate for warmth • Inspect and measure drain contents each shift • Fluid should lighten from sanguineous (red) to

serosanguineous (pink) to serous (pale yellow)• Patient’s comfort level


Postoperative Nursing Care

• Acute Pain • Risk for Infection • Risk for Injury • Risk for Deficient Fluid Volume • Disturbed Body Image • Ineffective Therapeutic Regimen Management

1elsevier items and derived items © 2007 by saunders, an imprint of elsevier, inc. chapter 50 skin...

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elsevier items

derived items

imprint of elsevier

skin slide

skin problems

skin lesions

skin surface water

selected skin disorders