Basic Structures of the

Integumentary System
 Epidermis
 Stratum basale
 Stratus spinosum
 Stratum granulosum
 Stratum lucidum
 Stratum corneum
 Dermis
 Papillary layer: contains capillaries and receptor
sites for touch and pain
 Reticular layer: contains receptors for deep touch
as well as sweat and sebaceous glands
Subcutaneous tissue
 Appendages
 Hair
 Nails
 Glands
 Apocrine: sweat glands located in the
axilla, anus, and genital area
 Eccrine: sweat glands located on the
forehead, hands, and soles of the feet
 Sebaceous: glands located throughout
the body that secrete sebum and that
are highly influenced by increased
hormones, especially adrogens
 Basic Functions of the
Integumentary System
 Epidermis

 Dermis

 Subcutaneous tissue

 Appendages
Disorders of the Integumentary
System
Problems caused by vascularity
 Spider angioma:
 a flat, bright red spot with radiating blood
vessels at the edges
 commonly found on the upper body
 varies in size from a tiny dot up to 1.5 to 2
cm
 spider angiomas are caused by vascular
dilation of the vessels commonly seen with
high estrogen levels, pregnancy, liver
disease, and/or vitamin B deficiency
 Petechiae:
 flat red spots
 approximately 1 to 2 mm in diameter that do not
change in color when blanched;
 these are caused by tiny capillaries that have
broken, possibly caused by thinning of the
blood (anticoagulant effect), liver disease,
vitamin K deficiency, or septicemia
 Purpura:
 purple/blue-appearing patch
 varies in size and shape
 caused by a bleeding disorder or broken blood
vessels and may appear throughout the body
 Primary skin lesions
 Macule:
 nonpalpable, flat lesion that has color and
measures<1 cm
 examples: freckles, chloasma
 Papule:
 elevated palpable mass, measuring less
than 0.5 cm
 examples include warts and moles
Nodule:
an elevated firm lesion with a
circumscribed border that measures
approximately 1 to 2 cm
Vesicle:
fluid-filled,elevated mass that measures
less than 0.5 cm
if the fluid mass measures greater than 0.5
cm, the mass is termed a bulla
examples of vesicles include chickenpox,
small burns, and herpes virus lesion
BULLA
 Plaque:
 elevated group of papules that have
convalesced into one lesion measuring
greater than 0.5 cm
 examples are actinic keratosis and
psoriasis
 Pustule:
 elevated, serous (pus)-filled vesicle that
can measure any size
 examples include acne and boils
 Wheal:
 variable-sized, elevated erythemic lesion
with an irregular border that contains fluid
in the tissue of the skin
 examples include insect bites and hives
 Secondary skin lesion
 Atrophy:
 dry, thin, taut skin that appears wasted from
loss of collagen
 an example is aged skin
 hydration with fluids and keeping skin well-
moisturized with emollients such as Eucerin
TM cream are helpful for this condition
 Crusts:
 dried pus or blood on the skin surface resulting
from a vesicle that has ruptured
 examples of crusts include the final stages of
chickenpox lesions or impetigo lesions
 Erosion:
 superficial indentation of the skin that
results from a previous lesion
 an example of erosion is a scratch mark
that has not healed over time
 Fissure:
 linear break in the skin with sharp edges,
extending into the dermis
 examples include athlete`s foot or cracks
in the corner of the mouth from chapped
lips
 Scales:
 dry, dead skin that sloughs off the skin surface
and that may be dry or greasy
 examples include dandruff or psoriasis
 Scar:
 the flat connective tissue resulting from healing
over the site of previous injury, which may vary in
size, color, and shape
 examples include healed surgery incisions or
acne scars
 Ulcers:
 deep excavations in the skin; they may vary in
size and shape and extend into the dermis or
subcutaneous tissue
 examples include chancres and pressure ulcers
Chronic Dermatologic
Problems
Eczema
 Eczema
 Description:
 inflammatory response in which the skin
appears erythmic, scaly, dry and thickened
 may appear in various stages, depending on
the type (e.g., infantile eczema vs. adult
eczema)
 etiology is unknown
 eczema is characterized by
lymphohistiocytic infiltration of the vessels of
the skin
 Common form of chronic dermatitis
 Clinical manifestations:
 are generally secondary to scratching of the
skin
 dry, pruritic skin that appears thickened and
discolored
 may even cause a break in the skin in which
bleeding or oozing occurs
 lesions may appear as papules or pustules
that can lead to excoriation
 Therapeutic management
 Bath: advise the client not to use harsh
soaps; avoid frequent bathing
 Wet dressings of Burow`s solution may be
used in severe cases
 Emollients: frequent use of emollients
(EucerinTM, AquaphorTM) is
recommended
 Allergens: remove all triggers and/or
allergens; avoid skin contact with all wool
products and lanolin preparations
 Priority nursing diagnoses:
 Impaired skin integrity
 Altered comfort
 Medication therapy:
 Antihistamines such as
diphenhydramine hydrochloride
(BenadrylTM)
 severe cases may require topical or
oral steroids for brief periods
 antipruritic
 TYPES OF ECZEMA
1. Infantile eczema
- lesions begin in the cheek and
progress to the extremities and trunk
- lesions starts as vesicles, which can
result in oozing and crusting of excoriated
areas
2. Adult atopic eczema
- markedly dry skin that extremely itchy
- excoriation,lichenification and even
scarring can lead to leathery areas in the
antecubital and popliteal areas
3. Nummular eczema
- Lesions developed as coined shaped
papulovesicular patches on the arms and
legs
- excoriation and subsequent bacterial
infections can lead to lichenification
Psoriasis
 Psoriasis
 Description:
 chronic, inflammatory skin disorder
 lesions appear as whitish, scaly plaques on
the scalp, knees, and/or elbows
 no known etiology
 thought to be a multifactorial disease in
which a T-lymphocyte mediated dermal
immune response occurs
 most client with psoriasis have a family
history of the disease
 Clinical manifestations:
 dry, scaly rash that may appear a
silvery scales or plaques
 usually found on the scalp, knees, or
elbows
 Priority nursing diagnoses:
 Impaired skin integrity
 Altered comfort
 Therapeutic management:
 direct sun exposure to the skin site may be
beneficial for some clients
 emollients: frequent use of emollients and
keratolytic agents are beneficial for scalp
psoriasis
 topical steroids
 antihistamines may be used for pruritus
Seborrheic Dermatitis
 Seborrheic Dermatitis
 Description:
 common chronic skin condition occurring in
areas of active sebaceous glands, such as
the face, scalp, body folds, sternal area, and
axilla
 appears as an erythematous scaling lesion
that may appear dry or greasy
 etiology is unknown but possible causes are
believed to be hormonal influence, nutritional
deficiency, neurogenic influence, dysfunction
of the sebaceous glands, and/or fungal
infection
 Clinical manifestations:
 erythmic, scaly lesions that appear in
varying degrees (oily or flaky dry skin),
pruritic, and may cause secondary bacterial
infections
 common sites include scalp, eyebrows,
nose, ears, sternal area, and axilla
 seen more frequently in colder weather
periods, and it is thought to be caused by
decreased humidification and decreased
exposure to sunlight
 Therapeutic management:
 scalp treatment: selenium sulfide 2.5
percent suspension or coal tar
shampoos and topical steroid creams
 Priority nursing diagnoses:
 Impaired skin integrity
 Altered comfort
 Risk for infection
Malignant Neoplasms
Actinic Keratosis
 Actinic Keratosis
 Description:
 pre-malignant macules found on the skin
surface of fair skinned individuals who are
50 years of age or older, but can be seen in
high-risk individuals at any age
 development occurs because of chronic sun
exposure to the skin
 light-skin complexion are at the highest risk
 considered pre-malignant lesions
 approximately 1 percent will progress to
squamous cell carcinoma
 Clinical manifestations:
 erythematous, rough, and shiny-textured
macules
 may appear as a single macule or in groups;
 commonly seen on the face, ears, scalp,
lips, neck, and hands
 Therapeutic management
 Prophylactic treatment is recommended to
prevent development these lesions
 Protection from ultraviolet rays of the sun
with the use of clothing and sunscreens
are recommended when exposed to
sunlight
 Biopsy and removal of the lesion is
recommended if changes in the lesion
occur; these changes include the color,
border, size, and shape of the lesions
Basal Cell Carcinoma
 Basal Cell Carcinoma
 Description:
 abnormal cell growth of the basal layer of
the epidermal skin
 most common contributor to this growth is
ultraviolet rays from sunlight exposure;
 basal cells do not mature appropriately into
keratinocytes, which results in neoplastic
growth of the cells
 the surrounding tissue is also destroyed
 least aggressive type of skin cancer and
rarely metastasizes to other organs
 Clinical manifestations:
 characteristics of the five types of basal
cell carcinoma:
 Nodular basal cell carcinoma:
 small, firm papule, which appears as
pearly, white, pink, or flesh-colored,
and is commonly seen on the face,
neck, and/or head
Nodular Basal Cell Carcinoma
 Superficial basal cell carcinoma:
 this papule or plaque is the second
most common lesion and is commonly
seen on the trunk and extremities
 Pigmented basal cell carcinoma:
 this tumor is less common and usually
found on the head, neck, or face; it has
the ability to concentrate melanin,
which causes deeper pigmentation of
the center of the tumor
Superficial Basal Cell Carcinoma
Pigmented Basal Cell Carcinoma
 Morpheaform basal cell carcinoma:
 least common form
 this tumor is found on the head and neck,
appearing like a tumor with finger-like
projections (usually ivory-or flesh-colored)
and typically resembles a scar
 it has the ability to invade and destroy
adjacent tissue and structures
Morpheaform Basal Cell Carcinoma
Keratotic basal cell carcinoma:
found on the preauricular or postauricular
area
contains both basal cells and squamous cells
that keratinize
if removed, this tumor is likely to recur
high risk of metastasizing to other structures
 Therapeutic management
 Monitor progress of growth of all lesions
 lesions > 2 cm have a high reoccurrence
rate
 suspicious lesions are excised and sent for
pathological examination
Educate clients regarding importance of
monitoring lesions and early identification of
new lesions
suggest monthly assessment of the skin by
the client and periodic screening based on
symptoms by healthcare provider
Encourage protection from ultraviolet light
exposure by using sunscreen with SPF > 15
and wearing clothing such as hats and
clothing to protect the skin
 Priority nursing diagnoses:
 Impaired skin integrity
 Risk for disturbed body image
 Fear or anxiety

 Medication therapy: none

Kaposi`s Sarcoma
 Kaposi`s Sarcoma
 Description:
 skin cancer of the endothelial lining of the
small blood vessels, seen most commonly
on the face, nose, and ears
 etiology is unknown
 a cancer speculated to be related to an
infective agent such as a retrovirus, such as
the virus that causes acquired
immunodeficiency syndrome (AIDS)
 Clinical manifestations
 Vascular lesions (macules, papules,
nodules) that can affect the skin and viscera
 Over time the lesions enlarge and become
confluent, forming large masses
 as these masses enlarge, the tissue below
the mass becomes involved and the tumor
then invades the lymphatic tissue, which
may then result in varying degrees of
lymphoedema, primarily affecting the
genitalia and lower extremities
 As the disease progresses, this tumor
may interfere with internal organ
function
 may cause bleeding to the point of
hemorrhage (commonly seen as a late
sign)
 Initially Kaposi`s sarcoma may be
symptom-free
 pain maybe experienced in the later
stage
 Therapeutic management:
 isolated lesions may be removed by excision
cryotherapy, and/or local radiation for comfort
and/or cosmetic treatment
 Priority nursing diagnose:
 Impaired skin integrity
 Fear or anxiety
 Risk for disturbed body image
 Medication therapy:
 chemotherapy treatment can be used as a
single agent or a combination treatment
Nonmelanoma: Squamous Cell
Carcinoma
Nonmelanoma: Squamous Cell
Carcinoma
 Description
 The most common type of skin cancer
 fair-skinned males tend to have a higher
incidence
 majority occurring from 30 to 60 years of age
 occurs on areas of the skin that are frequently
exposed to ultraviolet light, such as the face,
ears, nose, lips, and hands;
 grows quicker , more aggressive, and is more
likely to metastasize than basal cell carcinoma
 Etiology and pathophysiology
 The etiology multifactoral
 Environmental causes include ultraviolet
radiation, chemicals, physical trauma, and
pollution
 With exposure of ultraviolet light to the
skin, the rays penetrate the tissue and
alter normal DNA and suppress the
body`s T-cell and B-cell immunity,
producing tumors of the squamous
epithelial or mucous membranes
 As the tumor grows, the cells increase in
size and an irregular shape is formed
 Tumors may proliferate and invade the
dermal layer of the skin
 may also present from preexisting skin
lesions, such as old scars
 these tumors may proliferate into the
dermal structure and can cause
metastasis by the lymphatic tissue
 Clinical manifestations
 Squamous cell carcinoma mat present as
a small fleshy colored papule that is firm
to touch
 As the tumor grows, the color may change
and appear erythemic, sore, and/or even
bleed if touched
 Therapeutic management
 Recommended management is removal
of the tumors by:
 cryotherapy
 surgical excision
 electrodesiccation
 radiotherapy
 The cure rate is approximately 90 percent
 recommended to remove these tumors as
soon as identified to prevent the person`s
risk of metastasis
 Nursing management
 teaching methods to prevent further tumors
from arising
 minimizing sun exposure
 wear protective clothing
 wear sunscreen with a SPF of 15 or
greater
 avoid tanning booths
 Priority nursing diagnoses:
 Impaired skin integrity
 Ineffective health maintenance
 Fear or anxiety
 Risk for disturbed body image
 Medication therapy: none
Bacterial infection
 Bacterial Infections (Pyodermas)
 Itincludes a variety of acquired skin
lesions characterized by erythema and
pustules

 Mostcommon causative organisms are

gram-positive staphylococci and beta-
hemolytic streptococci
Impetigo
 Impetigo
 Description:
 A superficial skin infection that initially
appears as an erythemic vesicle and later
changes to a honey-colored crusted lesion
 most commonly seen in children but
occasionally affects adults
 An alteration in skin integrity occurs, and
bacteria invade the epidermis and cause an
infection
 most common organisms are Staphylococcus
aureas and group-A beta-hemolytic
streptococcus
 Clinical manifestation
 lesions are commonly found on the
face, arms, legs, and buttocks
 appear as thin erythemic vesicles,
which then becomes honey-colored
crusts or erosions
 may occur as a single lesion or several
lesions that have convalesced and
appear as a group of lesions
 Therapeutic management:

 encourage good hand washing with hot

soapy water to prevent spreading the
bacteria to others

 for recurrent lesions, a culture of the site is

obtained to isolate the pathogens
Priority nursing diagnosis:
Ineffective health maintenance
Medication therapy:
topicalantibiotics
For severe cases, systemic antibiotics
are recommended
Cellulitis
 Cellulitis
 Description
 A bacterial infection of the dermal and
subcutaneous tissues with lesions
appearing in various stages, ranging
from vesicles, bullae, abscesses, and
plaques
most commonly seen in adults
group-A beta-hemolytic Streptococcus
pyogenes and Staphylococcus aureus
being the most frequent organisms
involved
occurs because of a break in the
integrity of the skin (abrasion, laceration,
etc.)
may also occur secondary to a skin
lesion
 Clinical manifestations:
 cellulites is characterized by an erythemic,
swollen, tender-to-touch area of the skin at
the site of entry of the bacteria;
 associated symptoms include
 fever, chills, malaise, and anorexia with
associated regional lymphadenopathy
 Therapeutic management:
 rest, elevation of the extremity, moist
heat to the site for comfort
 consider culture and sensitivity of
tissue site for severe cases
 for necrotic tissue, surgical excision
and debridement are recommended
along with antibiotic therapy
Priority nursing diagnosis:
Impaired skin integrity

Medication therapy:
antibiotic therapy
 Folliculitis
 Staphylococcal infection in one or more hair
follicles

 Appears in pustule formation; inflammation

occurs resulting in erythema

 It
is commonly seen in the beard area of men
who shave and on women’s leg
 Furuncle (boils)
 Itis an acute inflammation arising deep in one
or more hair follicles and spreading into the
surrounding dermis

 Manifest a deep, coin sized erythematous

pustule, lesions are painful and usually
develops a cellulitis with a white center on the
skin surface
 Carbuncle
 Itrefers to the group of infected hair
follicles

A subcutaneous infection develops into

red, painful mass which can spread and
cause septicemia

 It
occurs most commonly at the back and
upper neck
 Stye/ Hordeolum
 Itmanifest as a pink, swollen area in the
eyelid
 Nursing Management
 Administer medications
 Prevent infection and infection transmission
- Instruct the client not to squeeze a boil or
pimple
 Instruct the client to bathe at least daily with
bactericidal soap
 Isolate drainage in severe cases of folliculitis,
furuncles or carbuncles
 Promote comfort measures
- supportive treatments
- apply warm, moist compresses
 Provide client and family teaching
Viral infection
Herpes simplex virus
(Type 1, Type 2)
 Herpes simplex virus
(Type 1, Type 2)
 Description
 manifested by vesicles on the oral mucosa-
mouth or lips, which is HSV Type 1, or in the
genital mucosa (HSV Type II)
 Herpes simplex virus (HSV) can occur at any
age
 The virus is spread by direct contact of
contaminated body fluids
 incubation period range of 2 to 14 days
 The virus occurs in three stages
 Primary – blisters occur on the mucosa or
lips; malaise and fever are also common
symptoms
 Recurrent infections – outbreaks may
occur at any time and are commonly
precipitated by stress and illness; symptoms
are usually milder than the primary;
commonly present with a prodrome of
tingling, itching, or a burning sensation at the
site prior to the outbreak of lesions
 Latency period – the virus remains dormant
in the body
 Clinical manifestations
 The primary symptoms include:
 malaise, fever, and vesicles appearing
on the mucosa
 Secondary symptoms include:
 prodrome of tingling, burning sensation
prior to the outbreak of vesicles on the
mucosa
 latency period is asymptomatic
 Therapeutic management:
 advise rest
 encourage good handwashing
technique to prevent spreading the
virus
 comfort measures such as petroleum
jelly or lip balm may be used for oral
lesions
 to prevent spreading the virus, avoid close
contact with others while lesions are present
 to prevent HSV Type 2, advise the use of
latex condoms to prevent spreading genital
lesions

Priority nursing diagnosis:

Impaired tissue integrity
Altered comfort
 Medication therapy:
 acetaminophen (Tylenol) or
camphophenique may be used for
comfort as needed
 antiviral medications such as acyclovir
(Zovirax), famciclovir (Famvir), or
valacyclovir (Valtrex) may be used to
check further replication of the virus
and diminish symptoms if started
within 24 to 48 hours after initial onset
of lesions
Herpes Zoster
 Herpes Zoster
 Description
 A viral infection manifested by vesicles on the
skin
 commonly seen in older adults and the elderly
 it is estimated to occur in approximately 20
percent of the U.S. population
 Herpes zoster is a reactivation of the varicella
virus, which has been dormant for many
years, in the dorsal root ganglia
 Clinical manifestations:
 vesicular rash on the skin that usually
follows one dermatome
 clusters of vesicles are common along with
symptoms of tingling, itching, burning, and
even pain at the site of the lesions
 the client may experience fatigue, malaise,
fever, and headache in addition to the local
discomfort of the rash
 Therapeutic management:
 comfort measures include wet dressings or
soaks (Burow`s solution) at the lesion sites
two to three times a day
 oatmeal baths (Aveeno TM) are soothing
and help to dry up lesions
 rest is recommended
 the virus may be transmitted to others;
therefore care should be taken to avoid
persons at risk
 lesions should be monitored for secondary
bacterial infections
 Priority nursing diagnoses:
 Impaired skin integrity
 Altered comfort
 Medication therapy:
 antiviral medications may be used if therapy
is started within 24 to 48 hours after the
outbreak of vesicles
 current medications include acyclovir
(Zovirax), famciclovir (Famvir), and
valacyclovir (Valtrex)
 acetaminophen (Tylenol) and ibuprofen
(Motrin) may be used for discomfort
Fungal infections
Candidiasis
 Candidiasis
 Description
 Infection caused by candida albicans, a
yeast-like fungus that most often
causes superficial cutaneous infections
 Symptomatic infections occur on moist
cutaneous sites and mucosal surfaces
if local immunity is disturbed
 can affect all ages
 diaper rash in infants
 summertime inframammary rash in women
 vaginitis in premenopausal women
 oral candidiasis in immunocompromised clients
 buttocks and perineal rash in incontinent clients
 Risk factors
 moist, warm, or altered skin integrity
 systemic antibiotics
 pregnancy, birth control use
 poor nutrition
 diabetes, or chronic illnesses
 immunosuppression
 Clinical manifestations:
 lesions are bright red, smooth macules
with a macerated appearance and a
scaling elevated border
 characteristic “satellite” lesions are small,
similar-appearing macules outside the
main lesion
 Oral candidiasis - known as thrush and is
characterized by white, milky removable
plaques on the oral mucosa
 associated symptoms may include a
burning sensation or decreased taste
 Vulovaginitis - found on the vaginal mucosa
and can spread to the pertineum and groin;
satellite lesions are usually present
 other signs and symptoms include
excessive itching and a thick, white, curd-
like vaginal discharge
 Perineal/diaper and skin-fold rash - occurs
on the perigenital and perianal areas and can
extend to the inner thighs and buttocks
 other areas affected include axilla, umbilical
area, and under the breasts
 erythema, papules, pustules, and a scaling
border are characteristic
 Balanitis - inflammation of the glans and the
prepuce of the penis that typically present as
flattened pustules with edema, scaling,
erosion, burning, and tenderness
 Paronychial infection - erythema, edema,
and tenderness of the nail folds
 a creamy, purulent discharge may be
expressed with pressure on the nail
 the nails usually become discolored and
have ridging

 Candida organisms may also be a causative

agent in otitis externa and scalp disorders
 Therapeutic management:
 diagnosis is made by culture of scrapings
or by microscopic examination of scaling
with potassium hydrochloride (KOH)
preparation
 Avoid sharing linens or personal items
 Use clean towel and washcloth daily
 Dry all skin folds, avoid frequent
immersion of hands in water
 Wear clean cotton underwear daily
 For vaginal candida, avoid tight clothing
and pantyhose, bathe more frequently
and dry genital area thoroughly
 may need to treat sexual partner at the
same time to avoid reinfection or have
the partner use condoms until resolved
 avoid douching and change perineal
pads frequently
 For vaginal candida, avoid tight clothing
and pantyhose, bathe more frequently
and dry genital area thoroughly
 may need to treat sexual partner at the
same time to avoid reinfection or have
the partner use condoms until resolved
 avoid douching and change perineal
pads frequently
 Priority nursing diagnosis:
 Impaired tissue integrity
 Acute pain
 Medication therapy
 Oral candidiasis: nystatin, clotrimazole,
and in recurrent cases, ketoconazole,
fluconazole, or itraconazole; liver function
tests must be monitored because of risk
of hepatotoxicity
 Perineal: topical treatment with nystatin
ointments BID
 Balantitis: topical treatment with
imidazole cream or nystatin powder BID
 Paronychial :
 topical imidazole cream or application of
2 percent gentian violet;
 for nonresponsive cases, systemic
ketoconazole or fluconazole;
 systemic medications require monitoring
of liver function tests because of risk of
hepatotoxicity
 Hair/scalp: antifungal shampoo
 Vulvovaginitis: vaginal creams/suppositories
or treatment with DiflucanTM
Infestations
Pediculosis
 Pediculosis
 Description
 An infestation of the skin or hair by the
species of blood- sucking lice capable of
living as external parasites on the human
host
 Pediculosis capitis is the head louse, the
size of a sesame seed, clear in color
when hatched but becomes grayish-white
to red/brown after maturing
 Head lice infestation is very common
among school age children of all
socioeconomic backgrounds and
spread by sharing combs, hats, and
scarves
 Pediculosis pubis, also known as
“crabs”, infests the genital area and is
one of the most common sexually
transmitted diseases
Pubic lice can spread by sexual
contact
Nits/eggs attach to the hair shaft
by a cement-like/cocoon-like
structure and are difficult to
remove
Lice live up to 30 days and a
female can lay up to 100 eggs
 Clinical manifestations
 Intensive pruritis is the most common
symptom that may result in excoriations
 Head lice may resemble dandruff
flakes; however, they are not easily
brushed off
 Papular urticaria may be found at the
neck or pubic area
 Therapeutic management
 Nits must be mechanically removed
 50/50 white vinegar-water solution
may loosen the nits
 olive oil may also be used
 nit comb is used to remove nits from
the hair shafts
lice may also be removed by
fingers or tweezers; nits remove
more easily by back-combing the
hair
To treat eyelashes apply
petrolatum to lashes b.i.d. for 10
days; lice will either suffocate or
slide off
 Educate children and parents about
mode of transmission (person to
person) and preventative measures,
such as not sharing combs, brushes,
hats, scarves, helmets, headphones,
bedding, or sleeping bags
 Coats and hats should be hang
separately and not touching each
other
Sleeping material should be labeled and kept
separately in plastic bags
All family members need to be examined and
treated at the same time
Soak personal hair items in 2 percent Lysol or
pediculocide for 1 hour
Shaving hair is not found to be helpful
Machine-wash all washable clothing used in the last
48 hours and dry in the dryer for at least 20 minutes
 Place unwashable items in airtight plastic
bags for a period of 1 week to kill lice
 Upholstered furniture or pillows may be
ironed with a hot iron
 Clean any item in contact with hair with 2
percent Lysol or pediculocide
 Vacuum mattresses, rugs, upholstered
furniture, and stuffed animals regularly
Medication therapy
 For pediculosis capitis: permethrin
(Nix), pyrethrin shampoo (Rid), or
lindane (Kwell) shampoo left on 5 to 10
minutes and then washed off; lindane
can be repeated in 1 week; due to
neurotoxicity of lindane, it should not be
used by children, nursing or pregnant
women, individuals with known seizure
disorders, or on open skin
 For pediculosis pubis: treatment
includes lindane, pyrethrin (Rid) or
permethrin (Nix) as a shampoo left on
for 10 minutes or as a lotion left on for
several hour Co-trimoxazole (Bactrim
DS): b.i.d. for 3 days has been shown to
be effective; a second therapy 10 days
later may be necessary to kill emerging
nits before they reproduce
Scabies
 Scabies
 Description
 A contagious disease caused by
infestation of the skin by the mite
Sarcoptes scabiei var hominis;
 the impregnated mite burrows into the
skin and remains there for life
(approximately 30 days), laying 2 to 3
eggs per day; the eggs hatch in 3 to 4
days and reach maturity in 4 days,
migrate to the skin surface, mate, and
repeat the cycle
 more common in people who don`t have
bathing facilities or access to clothes-
washing facilities
 mite can live in clothing fibers and can be
transmitted by contact of infected clothing
or bed linens
 Pathological findings by skin biopsy of a
nodule will reveal portions of the mite-
although rarely performed
 diagnosis is usually made by clinical
presentation of burrows, vesicles, and
nodules
 Clinical manifestations
 Presents as a generalized pruritic rash
particularly of the hands, wrists,
elbows, axillary areas, breasts,
abdomen, or genitals
 Itching may become intense
 increased warmth of the skin and
nocturnal itching is a classic symptom,
since mites tend to have increased
movement at night
 Lesions may be erythematous, crusted
papules, or purplish nodules, which may be
accompanied by flesh-colored, raised
burrows (threadlike linear ridges a few
millimeters in length with a minute black dot
at one end)
 clients develop itch approximately 10 to 14
days after exposure
 exposure to hot water or steam also
can increase pruritis
 Therapeutic management
 Close family members and personal
contacts must be treated as well, even
if there are no apparent signs or
symptoms
 All bed clothing, linens, unwashed
worn clothing, and stuff animals
should be washed and dried in a hot
dryer because the dryer kills the mite
Mites and eggs may be killed by placing
items in airtight plastic bags for 7 days
since the mite cannot live off the host
more than 3 days; mites can live 24 to 36
hours in room conditions and longer in
humid environments
Relief from itching may not occur for 3 to
6 weeks after treatment because of
hypersensitivity of the skin to debris left in
the burrow
  Lotions/creams should be applied
from the neck down, using a
toothbrush to get under
fingernails and toenails; the lotion
is showered off 8 to 12 hours later
 Priority nursing diagnoses:
 Impaired skin integrity
 Altered comfort
 Medication therapy
 Permethrin 5% cream (Elimite) is
the treatment of choice; a second
application in 48 hours is
sometimes recommended
 Crotamiton 10% (Eurax) is less
toxic but is also slightly less
effective therefore application for 2
nights is advised
 Lindane 1% cream or lotion (Kwell) is the
least expensive but has the potential for
neurotoxicity and should not be used by
children, nursing or pregnant women,
people with a known seizure disorder, or
any widespread excoriations/open skin;
treatment after 1 week
 Systemic antipruritics
 May require emollients and midpotency
corticosteroids after using scabicide to
suppress hyperreactivity caused by the
mites
Allergic reactions
Contact Dermatitis
 Contact Dermatitis
 Description
 An eruption of the skin related
to contact with an irritating
substance or allergen
 primary irritant dermatitis affects
individuals exposed to specific
irritants and produces
discomfort immediately
 Common irritants include chemicals, dyes,
metals, and latex gloves
 allergic contact dermatitis affects only
individuals previously sensitized to the
contactant
 it represents a delayed hypersensitivity
reaction
 most common are poison ivy, sumac, and
oak
 Contact dermatitis an inflammation caused
by an external irritant or allergic reaction
mediated by IgE
 the epidermal reaction is caused by T-
lymphocytes
 the location of the rash helps provide clues
to the offending antigen
 there is no specific age or sex affected, but
black skin is less susceptible
 Clinical manifestations
 Acute: papules, vesicles, bullae with
surrounding erythema; crusting, oozing,
and pruritis may be present
 Chronic: erythematous base, thickening
with lichenification, scaling, and fissuring
 Drainage of large vesicles may be
necessary without removing tops
  Aveeno (oatmeal) baths are helpful to
decrease itching
 Antihistamines of choice may be used to
decrease itching and edema
 Use calamine lotion to aid drying
 Priority nursing diagnoses:
 Impaired skin integrity
 Altered comfort
 Apply wet dressings to oozing, pruritic
lesions to aid in drying and debridement;
cool tap water, Burrow`s solution 1 to 40,
saline 1 tsp/pint water and silver intrate
solution can be used
 Suppress inflammation with antibacterial
solution
 May use topical steroid creams but do not
use on the face
 Medication therapy
 Midpotency topical corticosteroids
 High- potency topical corticosteroids
such as amcinonide (Cyclocort) 0.1%
or dexamethasone (Decaderm) 0.25%
 Systemic medications including
prednisone, antibiotics, and
antihistamines
Urticaria
 Urticaria
 Description
 An itchy rash, single or multiple superficial
raised pale macules with red halo;
 subsides rapidly, no scars or change in
pigmentation
 may be recurrent
 Acute urticaria is a response to many
stimuli
 IgE-mediated histamine release
from mast cells is sometimes seen
in response to drug exposure and
subsides over several hours
Chronic urticaria persists over 6
weeks; it is not mediated by IgE; it
is also associated with fever, chills,
arthralgia, myalgia, and headache
 Urticaria is a response to massive release
from mast cells in the superficial dermis;
 this can be caused by multiple agents
such as drug reaction, food or food
additive allergy, inhalant, contact or
ingestion allergy, transfusion reaction,
insect bite or sting, bacterial, viral, fungal
or helminthic infection, collagen vascular
disease, lupus, heat, cold, sunlight, or
emotional stress
 True urticarial lesions do not remain in
the same area of the skin longer than
24 hours
 lesions that are present 72 hours or
longer suggest cutaneous vasculitis as
a possible cause
 Clinical manifestations
 Single or multiple raised, blanched,
central wheals surrounded by red
flare that is intensely pruritic
 May occur anywhere on the body
 Variable size of 1 to 2 mm to 15 to20
cm or larger
 Resolves spontaneously in less than
48 hours
 Therapeutic management
 Cool moist compresses help to control
itching
 Avoidance of etiology is known
 Antihistamine if accidentally reexposed
 Instruct client that there is risk of life-
threatening reaction on reexposure
 Priority nursing diagnoses:
 Impaired skin integrity
 Risk for injury
 Altered comfort
 Medication therapy
 Subcutaneous administration of
epinephrine 1:1000 for intense itching
 Antihistamines
 Histamine (H2) receptor antagonists
may enhance effectiveness of
conventional antihistamines
 Cyprohepadine (Periactin) 4 mg every 6
hours for cold urticaria
 Corticosteroids for pressure urticaria
 Topical sunscreens and hydroxyzine
(Vistaril) for solar urticaria
Benign Conditions
Lentigo
 Lentigo
 Description
 A brown macule resembling a freckle except
that the border is usually irregular
 Benign lentigo resembles a freckle
 lentigo maligna (pre-melanoma) is a brown or
black mottled, irregularly outlined, slowly
enlarging lesion in which there are an
increased number of scattered atypical
melanocytes; it usually occurs on the face;
one-third progress to melanoma but transition
may take 10 to 15 years
 Senile lentigo (liver spots) occurs on exposed
skin of older white individuals
 Clinical manifestations
 Benign lentigo: freckle, pigmented, flat, or
slightly elevated macule
 Lentigo maligna: brown/black uneven
macule with irregular border which slowly
extends
 Senile lentigo: pigmented flat areas
usually on sun-exposed areas
 Therapeutic management
 Instruct on ABCD of skin lesions:
asymmetry, border, color, and diameter
 Teach to inspect skin routinely and
seek professional advice for any noted
changes
 Instruct clients to use sunscreens, hats,
or caps when out in the sun to avoid
overexposure
 Priority nursing diagnoses:
 Risk for ineffective health maintenance
 Medication therapy
 No medication needed for lentigo
 Lentigo maligna: follow-up by a
dermatologist is recommended
Seborrheic Keratosis
 Seborrheic Keratosis
 Description
 Benign plaques, beige to brown or even
black in color, ranging in size from 3 to 20
mm in diameter with a velvety or warty
surface
 The pathophysiology of this condition
involves the proliferation of immature
keratinocytes and melanocytes totally
within the dermis
 it affects mainly males 30 years and older
 Clinical manifestations
 “Stuck-on” brown spots over the trunk
which may bleed when irritated by
clothing or picked
 Size varies from 1 to 3 cm
 May be skin-colored, tan, brown, or black
and are usually oval-shaped with a warty,
greasy feel
 Usually present on the face, neck, scalp,
back, and upper chest
 Therapeutic management
 Sunscreens, decrease sun exposure,
and avoid tanning
 Wear hats when outdoors
 Teach the ABCD of skin lesions that
indicate need for evaluation by a
healthcare provider
 Medication therapy
 No medications indicated for seborrheic
keratosis
 May be removed by electrocautery or
frozen with liquid nitrogen
 the area may be hypopigmented after
removal
Vitiligo
 Vitiligo
 Description
 Are totally white macules with an absence
of melanocytes
 An acquired, slowly progressive
depigmentation in small or large areas of
the skin caused by a decrease in active
melanocytes
 Type A: nondermatomal and widespread
involved in 75 percent of cases
 Type B: dermatomal and segmental; 50
percent of cases begins between ages
10 to 30
 Clinical manifestations
 Loss of pigment with increased
sunburning of areas
 more often occurs around the eyes,
mouth, and anus
 May be pruritic and associated with
premature graying
Therapeutic management
Avoid sun exposure, which may
increase differentiation between normal
and abnormal skin
Skin dyes/cosmetics for blending
purposes
 Priority nursing diagnoses:
 Risk for disturbed body image
 Medication therapy
 Localized with midpotency steroids
 Oral systemic steroids are effective in
arresting disease progression
 Depigmenting of normal skin with
hydroquinone cream (Melanex)
Pressure Ulcers
 Pressure Ulcers
 Description
 Ischemic lesions of the skin and
underlying tissue caused by external
pressure that impairs the flow of blood
and lymph
 also known as bedsores and decubitus
ulcers
Pressure ulcers are a common and serious
complication affecting the frail, disabled,
acutely ill, or immobile client, usually in long-
term care and rehabilitation settings
Most common sites are over bony
prominences, such as elbows, hips, heels,
outer ankles, and base of spine
over 95 percent of ulcers develop on the
lower part of the body
 Causes include an uneven application of
pressure over a bony hard site
 high pressure applied for 2 hours
(produces irreversible tissue ischemia
and necrosis), shearing forces that
develop when a seated person slides
toward the floor or foot of the bed if
supine, frictional forces that develop
when pulling a client across a bed sheet,
and moisture from incontinence or
perspiration
 Clinical manifestations:
 pressure ulcers are staged according to
their characteristics
 Assessment:
 risk factors:
 immobility, malnutrition, and low body
weight, hypoalbuminemia, fecal and/or
urinary incontinence, bone fracture,
vitaminC deficiency, low diastolic blood
pressure, age-related skin changes such
as diminished pain perception, thinning
of epidermis,
loss of epidermal vessels, altered
barrier properties, reduced immunity
and slowed wound healing, anemia,
infections, peripheral vascular
insufficiency, dementia,
malignancies, diabetes, CVA, dry
skin, and edema
 Diagnostic and laboratory test findings:
 culture of the wound
 WBC with differential and sedimentation rate
to determine presence of primary or
secondary infection
 if no progression of ulcer, albumin levels
may be obtained to determine dietary needs
 Therapeutic management
 Evaluate risk factors
 Improve overall nutritional status – adequate
protein intake
 Clean wound each time dressing is changed
to remove dead tissue, excess fluid and
debris
 Main body temperature and acidic pH
 Never use antiseptics and harsh skin
cleaners that may harm tissue
 Employ pressure reduction via specialized
beds
 Reposition client every 2 hours
 Use support devices such as padding (gel
pads), floatation pads, mattress overlays
and specialize (such as air-fluidized,
oscillating, or kinetic) beds
 Avoid agents that delay wound healing
such as topical corticosteroids, hydrogen
peroxide, iodine, and hypochlorite
 Control fecal and urine incontinence
 Avoid massage over bony prominences
 Use moisture barrier
 Assess site every 8 to 12 hours; carefully
document healing, e.g., state there is a
“healing Stage III ulcer, rather than “Stage
II ulcer” if ulcer was Stage III and exhibits
healing
 Use absorption dressing if wound has
large amounts of exudates and change
frequently
 Priority nursing diagnoses:
 Impaired skin integrity
 Disturbed body image
 Risk for infection
 Pain
 Risk for imbalanced nutrition: less than body
requirements
 Risk for ineffective thermoregulation
 Impaired tissue perfusion
 Risk for impaired physical mobility
 Anxiety
 Planning and implementation
 Provide relief of pressure on wound
 perform passive range of motion and
encourage active range of motion exercises
 Encourage oral high-calorie and high-protein
supplements
 Encourage oral zinc, vitamins A and C, and
iron to aid in tissue healing
 Conduct systemic skin inspection at least
once daily
 Monitor weight and nutrition intake
 Clean skin at time of soiling and routine
intervals
 Keep skin well-hydrated and lubricated
 Avoid exposure to cold, dry environments
 Document all risk factors and implement
strategies
 Ensure that proper positioning schedules
are followed every 2 hours
 Use pressure reduction aids
 Medication therapy
 Clindamycin (Cleocin) or gentamycin
(Garamycin) may be ordered for
complications such as cellulites,
osteomyelitis, or sepsis
 Vitamin C 500 mg b.i.d. and zinc sulfate
supplements aid healing
 Antibiotic prophylaxis will eradicate
bacterial component
 A 2-week trial of topical antimicrobials
should be used only for a clean superficial
ulcer that is either not healing or producing a
moderate amount of exudates – cultures are
necessary to determine whether antifungal
or specific antibacterial agents are indicated
 Enzymatic debriding agents such as
collagenase (Santyl, Granulex),
fibinolysin-desoxyribonuclease (Elase),
papin (Panafil), or sutilains (Travase) are
used with a moisture barrier to protect
surrounding tissue
 Recommended dressings include
polyurethane films (Op-SiteTM,
TegadermTM), absorbent hydrocolloid
dressings (DuodermTM)
 Client education
 Need for frequent evaluation of all clients with a
history of pressure sores, especially if they have
limited mobility
 Nutritional requirements and meal planning
 Early identification of skin redness to prevent
breakdowns
 Skin cleansing routine
 Underpads to absorb moisture
 Repositioning techniques and frequency
 Need to evaluate and ensure continence and
facilities
 Use of mattress overlays, seat cushions or
special mattresses Ways to avoid injuries
Burn Injury
 Description:
 an alteration in skin integrity resulting in
tissue loss or injury caused by heat,
chemicals, electricity, or radiation
 There are several types of burn injury:
 thermal
 chemical
 electrical
 radiation
 Thermal:
 results from dry heat (flames) or moist heat
(steam or hot liquids)
 most common type
 causes cellular destruction that results in
vascular, bony, muscle, or nerve
complications
 can also lead to inhalation injury if the head
and neck area is affected
 Chemical burns
 are caused by direct contact with either
acidic or alkaline agents
 they alter tissue perfusion leading to
necrosis
 Electric burns:
 severity depends on type and duration of
current and amount of voltage
 it follows the path of least resistance
(muscles, bone, blood vessels, and nerves)
 sources of electrical injury include direct
current, alternating current, and lightning
 Radiation burns:
 are usually associated with sunburn or
radiation treatment for cancer
 usually superficial
 extensive exposure to radiation may lead to
tissue damage and multisystem injury
 Emergent phase of burn management:
 the emergent/resuscitative stage lasts from
the onset of injury through successful fluid
resuscitation
 during this stage, it is determined whether
the client is to be transported to a burn
center for complex intervention depending
on onset of injury, identification of burn
source, and complicating factors
 Classification of burn depth:
 done according to the depth of
damaged tissue
 Superficial thickness (formerly
first-degree):
 involves the epidermis only and is
recognized by characteristics of
erythema, absence of blisters for 24
hours, local pain; healing occurs
spontaneously in 3 to 5 days with no
scar formation
Superficial thickness
(formerly first-degree)
 Superficial partial thickness (formerly
second-degree):
 involves the epidermis and dermis,
characterized by moist areas that are red to
ivory whit in color, blisters form immediately;
area is painful because touch and pain
receptors are intact; area heals with greater
or lesser amounts of scarring within 21 to 28
days
 Deep partial thickness (formerly second-
degree):
 involves possibly the entire layer of the
dermis, and is more severe than a
superficial partial thickness burn
 skin appendages are left intact
 area has a dry waxy whitish appearance and
may be difficult to differentiate initially from
full-thickness burns
 may heal spontaneously in about 1 month
although skin grafting is often done to close
the wound, accelerate healing, reduce
scarring, and reduce risk of infection
Superficial partial thickness
(formerly second-degree)
 Full thickness (formerly third-degree):
 involves destruction of all skin elements
with coagulation of subdermal plexus
 muscle and tendons may be involved
 Full thickness
(formerly third-degree)
 An estimate of the burn size is calculated
using the “Rule of Nines” or the Lund and
Browder method
 each chart accounts for 100 percent of the
total body surface area (TBSA) although the
Lund and Browder method takes into
account the client`s age when estimating
body surface area
 Severity of burn is classified using the
American Burn, and major burn; these
categories help determine treatment
 Nursing assessment:
 history of injury, estimate burn extent
and depth, obtain past medical history
and medication history including date of
last tetanus prophylaxis
 assess for other concurrent injuries
 Diagnostic and lab test findings:
 may have elevated hematocrit and
decreased hemoglobin caused by
fluid shift
 decreased sodium and increased
potassium caused by damage to
capillary and cell membranes
 elevated BUN and creatinine caused by
dehydration
 myoglobin in urinalysis
 possible deterioration of arterial blood
gases
 oxygen saturation readings depending on
respiratory status
 Priority nursing diagnoses:
 Risk for deficient fluid volume
 Risk for infection
 Impaired physical mobility
 Imbalanced nutrition; less than body
requirements
 Ineffective breathing pattern
 Impaired tissue perfusion
 Risk for impaired gas exchange
 Anxiety
 Risk for ineffective thermoregulation
 Pain
 Impaired skin integrity
 Therapeutic management
 First aid:
 douse flames with water or smother them
with a blanket, coat, or other similar
object
 cool a scald burn with use of cool water
 flush chemical burns copiously with
water or other appropriate irrigant after
dusting away any dry powder if present
 remove client from contact with an
electrical source only after current has
been shut off
 Priority care is on ABCs:
 airway, breathing, and circulation;
 assess for smoke inhalation injury (singed
nares, eyebrows or lashes; burns on the
face or neck; stridor, increasing dyspnea)
 give oxygen (up to 100 percent as
prescribed), being prepared for possible
intubation and mechanical ventilation if
severe inhalation injury or carbon monoxide
inhalation has occurred
 assess for signs of shock caused by fluid
shifts (increase pulse, falling BP and urine
output, pallor, cool clammy skin,
deteriorating level of consciousness)
 Fluid resuscitation:
 Brooke formula uses 2 ml/kg/% TBSA
burned (3/4 crystalloid plus ¼ colloid) plus
maintenance fluid of 2,000 mL D5W per 24
hours
 Parkland (Baxter) formula uses 4 mL/kg/%
TBSA burned per 24 hours (crystalloid only
– lactated Ringer`s)
 both formulas give half of 24 hour total in the
first 8 hours, and the second half over the
next 16 hours
 Other considerations:
 remove all rings and jewelry to avoid
tourniquet effect caused by swelling/edema
of burn site
 provide cardiac monitoring for the first 24
hours after an electrical burn
 Medication therapy:
 pain therapy,
 tetanus prophylaxis,
 topical antimicrobial as well as
systemic antibiotics
 Client education:
 focuses in this phase on brief
explanations about the injury,
treatments, and ongoing nursing care
Acute phase of burn management:
this phase begins with the start of
diuresis (usually 48 to 72 hours
post-burn) and ends with closure of
the burn wound
 Clinical manifestations:
 vary depending on cause, depth and TBSA
of burn
 associated symptoms arising from other
organ systems may include nausea and
vomiting, pain, skin redness, chills,
respiratory distress, and hypovolemia
 Therapeutic management:
 wound care management (debridement,
dressing changes, hydrotherapy, possible
escharotomy, wound grafting)
 nutritional therapies (high-calorie, high-
protein diet with vitamins and minerals)
 infection control
 pain management
 psychosocial support
 physical therapy
 maintain fluid/hydration status
 maintain heated environment
 Medication therapy:
 topical and/or systemic antibiotic
therapy
 pain control with opioid analgesics
is usually required
Rehabilitative phase of burn management:
this phase begins with wound
closure
and ends when the client returns to
the highest level of health restoration
 Clinical manifestations:
 depend on cause, body surface area
affected and depth
 may have immobility or restriction of
mobility of affected area
 scarring is possible
 Therapeutic management:
 obtain psychosocial evaluation
 provide support and management
 arrange counseling if necessary
 prevent immobility contractures with
exercises or ongoing physical therapy
 assist in returning to work, family and social
life
 use preventative measures for scar
formation (such as burn garments)
 assess home environment for needs and
accessibility
 assess pain management needs
 Medication therapy:
 ongoing pain management
 antibiotic therapy as necessary
 Client education
 Environmental safety
 use low temperature setting for hot
water heater ensure access to and
adequate number of electrical
cords/outlets,
 isolate household chemicals
 avoid smoking in bed
 Use of household smoke detectors with
emphasis on maintenance
 Proper storage and use of flammable
substances
 Evacuation plan for family
 Care of burn at home
 Signs and symptoms of infection
 How to identify risk of skin changes
 Use of sunscreen to protect healing
tissue and other protective skin care
measures