1

Objectives

• Describe the structure and function of the skin.

• Explain the various causes of integumentary disorders.
• Discuss important factors in the prevention of skin disease.
• Interpret laboratory and diagnostic test results for skin disorders.
• Write outcome objectives for a patient with a problem of altered
skin integrity.
• Discuss possible changes that can occur with aging that affect the
skin barrier for older adult patients.

2
 Objectives (cont.)

• Describe a focused integumentary assessment on a patient.

• Explain how to provide skin care for an older adult with dry skin.
• Describe the etiology of dermatitis.
• Describe psychosocial interventions for the patient who has
psoriasis.
• Compare and contrast the treatment of fungal skin or nail
disorders to the treatment of bacterial skin disorders.
• Describe a teaching plan for a client with scabies infection.
• Choose nursing interventions for a patient with herpes virus
infection.

3
Anatomy

• The integumentary system is composed of the skin

and its accessory structures:
oHair, nails, glands
• Integument means covering.
• The skin is divided into two principal layers:
epidermis and the dermis
• The hypodermis or subcutaneous layer is not part of
the skin but cushions, supports, nourishes,
insulates, and anchors skin.

4
5
 Functions

• Protection: • Protection:
oPhysical barrier oProtects underlying
oPrevents absorption structures
oDefends against oProtects against
chemicals excessive sun exposure
oProtections against oCushions organs
water loss or gain oProduces protective
secretions

6
Functions (cont.)

• Thermoregulation:
oControls body temperature
oAdjusts to external changes
oHelps dissipate heat during exercise
oProduces shivering to keep body warm
oCools body through evaporation

7
Functions (cont.)

• Metabolism:
oProvides insulation
oHelps produce and use vitamin D
oEliminates certain waste products
oAbsorbs medication
oStores fat

8
Functions (cont.)

• Sensation:
oPerceives stimuli
oProvides social and sexual communication
• Communication:
oCommunicates feelings and moods through
facial expression
oCommunicates cultural and sexual difference
through skin and hair color

9
The Epidermis

• The outermost protective layer of the skin

oNo nerves or blood supply (avascular)

10
The Dermis (Corium)

• The thickest skin layer, composed of live cells

oContains blood and lymph vessels, nerves, hair
follicles, sweat (sudoriforous) glands, and oil
(sebaceous) glands
oNourishes and supports the epidermis
oContains several types of connective tissue
(collagen and elastin)

11
12
 The Hypodermis (Subcutaneous)
• The layer beneath the dermis and on top of a layer of
muscle
oLoose connective tissue and fat that attaches the
epidermal and dermal layers to organs
oSpecialized in formation and storage of lipocytes for
insulation and energy
oRegulates body temperature
oCushions and protects

13
Skin Color

• A combination of 3 pigments produces normal

coloration of the skin:
oMelanin – brown-black pigment produced by
melanocytes
oCarotene – yellowish pigment in parts of the
epidermis and dermis
oHemoglobin – pigment found in red blood cells

14
Accessory Skin Structures

• Hair ® keratinized cells

• Nails
• Sebaceous or oil glands – produce sebum
sweatgland
• Sudoriferous or sweat glands Applecrine a Axillaygenital
• Ceruminal glands – produce cerumen (ear wax)

15
16
Physiology

• Protection:
oProtects body from outside elements
oPrevent invasion
oPrevents loss of body fluid
oExcretes waste products

17
Physiology (cont.)

• Thermoregulation:
oRadiation – giving off of infrared heat rays to
promote heat loss
oConvection – transfer of heat from skin to air
oEvaporation – returning water to air through
vapor
oConduction – transfer of heat by direct contact

18
Thermoregulation
• Conduction

• Convection

• Radiation

19
20
Physiology (cont.) Sunt
Cholesterol Vit D
• Vitamin D production:
oVitamin D important for growth and repair of
bones through absorption of calcium and
phosphorous
oProduced in the skin by sunlight
Vitamin D name
oChanged (via enzymes) into cacitriol or calciferol
oDeficiency causes bone loss
ra
Dz absorb
bone
21
 Physiology (cont.)
• Communication and sensory
awareness
oReceives stimuli for
hot, cold, pain, touch,
temperature
oChange in skin color
(blushing)

22
 a
ot Copyright © 2017, Elsevier Inc. All rights reserved.
case 23

of
Maintenance of Healthy Skin

• Proper nutrition
• Adequate circulation
• Regular cleansing
• Careful hand washing
• Limited exposure to sunlight
• Use of sunscreen

24
The Effects of Aging

• Loss of fat, collagen, and elasticity

• Dermis becomes thinner
• Decreased pigment formation
• Formation of brown spots
• Decreased circulation
• Thinning gray or white hair
• Less sweat glands and perspiration

25
Senile Lentigines

• Age spots, also known as liver spots.

26
Question

Which physiologic change(s) associated with aging predispose(s) older

adults to skin breakdown? (Select all that apply.)
1. Decreased melanocytes
2. Loss of collagen
3. Increased elastic fibers
4. Decreased adipose tissues
5. Reduced sebaceous gland activity

27
Answer

Which physiologic change(s) associated with aging

predispose(s) older adults to skin breakdown? (Select all that
apply.)
1. Decreased melanocytes
2. Loss of collagen
3. Increased elastic fibers
4. Decreased adipose tissues
5. Reduced sebaceous gland activity

28
 Assessment

Integumentary System

29
Types of Skin Lesions

• Macule

• Papule

• Vesicle

• Plaque

• Wheal

• Pustule

30
Keloid Scar

31
Assessment (Data Collection)

• Older adult considerations

• Skin breakdown

• Skin lesion documentation

• Observation while bathing

32
Health History and
Clinical Manifestations
• During the health history interview, the nurse asks
about any family or personal history of:
oSkin allergies
oAllergic reactions to food, medications, and
chemicals
oPrevious skin problems
oSkin cancer
oAny change in hygiene products
33
Health History and
Clinical Manifestations (cont.)
• Contains specific information about the problem:
oOnset
oSigns and symptoms
oLocation
oPain
oItching
oRash or other discomfort

34
Physical Assessment

• Involves the entire skin area, including:

oScalp
oHair
oNails
• The skin is a reflection of a person’s overall health.
• Alterations commonly correspond to disease in
other organ systems.

35
Physical Assessment (cont.)

• Inspection and palpation are techniques commonly

used in examining the skin.
• Use well lighted and warm room.
• A penlight may be used to high-light lesions.
• The client completely disrobes and is adequately
draped.
• Gloves are worn during skin examination.

36
Assessing General Appearance

• Assessed by observation:
oColor, temperature, texture (rough or smooth)
oMoisture or dryness
oLesions and vascularity
oMobility, and condition of the hair and nails
• Assessed by palpation:
oSkin turgor, possible edema, and elasticity

37
Assessing Skin Color

• Skin color varies from person to person and ranges

from ivory to deep brown to almost pure black.
• The skin of exposed portions of the body tend to be
more pigmented.
• The vasodilation that occurs with fever, sunburn,
and inflammation produces a pink or reddish hue.

38
Assessing Skin Color (cont.)

• Pallor is an absence of or a decrease in normal skin

color and vascularity.
oBest observed in the conjunctiva or around the mouth
• Jaundice is a yellowing of the skin, directly related
to elevations in serum bilirubin.
oOften first observed in the sclera and in the mucous
membranes

39
Assessing Oral Mucous Membranes

pali tillon test

40
Pallor of the Conjunctiva

Jaundice of the Eyes

yellow
Jaundice

ybillirubin
41
Assessing Skin Color

• Erythema is redness of the skin caused by

congestion of capillaries.
• In light skinned people, it is easily observed at any
location.
• Dark skin assumes a purple-gray cast during
inflammation.
• The skin is palpated for increased warmth indicating
inflammation.
• The skin is palpated for smoothness or hardness
indicating edema.
42
 skin
on
Redness
Erythema, Inflammation, Edema

43
Rash

• In instances of pruritus (itching) the client is asked

to indicate which areas of the body are involved.
• The skin is stretched gently to decrease the reddish
tone and make the rash more visible.
• Pointing a penlight laterally across the skin may
highlight the rash, making it easier to observe.

44
 Rash
caused
by mold

Rubella Rash
Candida diaper rash
45
Cyanosis

• Cyanosis is the bluish discoloration that results from a lack of oxygen

in the blood.
• In people with light skin, it manifests as a bluish hue to the lips,
fingertips, and nail beds.
• In a person with dark skin, the skin usually assumes a grayish cast.
• Areas around the mouth and lips and over the cheekbones and
earlobes should be assessed.

46
Nail Bed Cyanosis and Clubbing

47
Color Changes

• Almost every process that occurs on the skin causes

some color change.
• Hypopigmentation may be caused by a fungal
infection, eczema, or vitiligo.
• Hyperpigmentation can occur after sun injury or as
a result of aging.

48
Hypopigmentation Hyperpigmentation

49
Assessing Skin Lesions

• Skin lesions are the most prominent

characteristics of dermatological conditions.
• They vary in size, shape, and cause.
• They are classified according to their appearance
and origin.
• They can be described as primary or secondary:
oPrimary – initial lesions of the disease
oSecondary – external causes

50
Skin Lesions: Macule, Patch

• Flat, nonpalpable skin color change.

• Macule < 1 cm, circumscribed border.
• Patch > 1 cm, may have irregular border.
• Examples:
oFreckles, flat moles, petechiae, rubella, vitiligo,
port wine stains, ecchymosis

51
 Mark
birth
Freckles Port Wine
stain

Petecchiae Mole

52
Skin Lesions: Vesicle, Bulla

• Circumscribed, elevated, palpable mass containing

serous fluid.
oVesicle < 1 cm
oBulla > 1 cm
• Examples:
oVesicles – herpes simplex/zoster, chickenpox,
poison ivy, burns
oBulla – pemphigus, contact dermatitis, large
blisters, poison ivy

53
Chickenpox Pemphigoid bulla

Deep partial thickness burns 54

Skin Lesions: Papule, Plaque

• Elevated, palpable, solid mass with circumscribed

border.
• Plaque may be coalesced papules with flat top.
oPapule < 1 cm
oPlaque > 1 cm
• Examples:
oPapules – elevated nevi, warts
oPlaques – psoriasis
55
Papules

Psoriasis
plaques

Lichen Planus
Warts

56
Skin Lesions: Wheal

• Elevated mass with transient borders.

• Often irregular.
• Size and color vary.
• Caused by movement of serous fluid into dermis.
• No free fluid like vesicles.
• Examples:
oUrticaria (hives), insect bites

57
Urticaria

Insect bite

Urticaria
58
Skin Lesions: Pustule

• Pus filled vesicle or bulla

• Examples:
oAcne
oImpetigo
oCarbuncles
oFuruncles

59
 Pustules

Carbuncles (boils)

Impetigo
down to dermis 60

Impetigo
contagouse
Skin Lesions: Nodule, Tumor

• Elevated, palpable, solid mass.

• Extends deeper into the dermis than a papule.
oNodule 0.5-2.0 cm, circumscribed
oTumor 1-2 cm, may not be circumscribed
• Examples:
oNodules – lipoma, squamous cell carcinoma
oTumors – larger lipoma, carcinoma,
neurofibromas

61
Skin Lesions: Cyst

• Encapsulated fluid filled or semisolid mass.

• In the subcutaneous tissue or dermis.
• Examples:
oSebaceous cyst
oEpidermoid cysts

62
 Sebaceous cyst

Epidermoid cyst

Ruptured
Sebaceous
cyst

Comedone (blackhead)
cyst
63
Assessing Vascularity and Hydration

• After evaluating color and inspecting lesions ®

assess of vascular changes of the skin.
• A description of vascular changes includes location,
distribution, color, size, and the presence of
pulsation.
• Examples: petechiae, ecchymosis, telangiectasia,
angiomas

64
 Cherry Angioma

Angioma

Petechiae

Ecchymosis Telangiectasia

65
Assessing Vascularity and Hydration

• Assessing the skin by palpation:

oMoisture
oTemperature
oTexture
• Skin turgor (elasticity) may be a factor in assessing
the hydration status of a client.
• Skin turgor decreases in normal aging.

66
Assessing the Nails and Hair

• Nail inspection includes observation of:

oConfiguration
oColor
oConsistency
• Many alterations in nail or nail bed reflect local or
systemic abnormalities in progress or resulting from
past events.
• Nail base is usually firm.

67
Beau’s Lines: may reflect Clubbing:
severe illness or local trauma peripheral
tissue
hypoxia

Paronychia:
inflammation
of the skin
around the
nail 68
Assessing the Nails and Hair

• Inspection and palpation.

• Wear gloves.
• Examination room should be well lighted.
• Separating the hair.
• Assess color, texture, and distribution of the hair.
• Assess for lesions, itching, inflammation, scaling, or
infestation.

69
Tinea Capitis: scalp
ringworm

Head lice (infestation)

Flaking and Dandruff 70

Assessing Hair Color and Texture

• Natural hair color ranges from white to black.

• Hair begins to turn gray with age, initially during the
third decade of life.
• Albinism has white hair from birth.
• Hair dyes, bleaches, curling or relaxing products
alter natural state of the hair.
• Texture ranges from fine to coarse, silky to brittle,
oily to dry, and shiny to dull.

71
Assessing the Hair

• Body hair distribution varies with location.

• Hair over most of the body is fine, except in the
axillae and pubic areas which it is coarse.
• Facial differences in hair are expected.
• Men tend to have more body and facial hair than
women.
• Loss of hair (alopecia) can occur over the entire
body or confined to specific area.

72
Hair Loss

• Most common cause of hair loss is male pattern

baldness.
male
• Androgen is necessary for male pattern baldness to
develop.
• Begins with receding of the hairline in the frontal-
temporal area and progresses to gradual thinning
and complete loss of hair over top of scalp and
crown.

testorone a hair grow

73
Other Changes

• Male pattern hair distribution may be seen in some

women at the time of menopause, when the
hormone estrogen is no longer produced by the
ovaries.
• In women with hirsutism, excessive hair may grow
on the face, chest, shoulders, and pubic area.
• Clients with skin conditions may be viewed
negatively by others.
• Skin conditions can lead to disfigurement, isolation,
job loss, and economic hardship.
74
Question

The patient presents with a rash of unknown origin. Which

assessment question(s) would help determine the cause?
(Select all that apply.)
1. “When did the rash or lesion first appear?” y
2. “Can you think of any event or different food you ate or
substance you were using just before the rash appeared?”
3. “Which drugs are you taking? Do you take any over-the-
counter preparations?”
4. “Have you ever had radiation therapy?”
5. “Do you have a history of any skin disorders in your
family?”

75
Answer

The patient presents with a rash of unknown origin. Which

assessment question(s) would help determine the cause?
(Select all that apply.)
1. “When did the rash or lesion first appear?”
2. “Can you think of any event or different food you ate or
substance you were using just before the rash appeared?”
3. “Which drugs are you taking? Do you take any over-the-
counter preparations?”
4. “Have you ever had radiation therapy?”
5. “Do you have a history of any skin disorders in your
family?”

76
The Integumentary system

Diagnostics
77
Diagnostic Tests and Procedures

• Skin biopsy

• Culture and sensitivity tests

• Microscopic tests

• Special light inspection

• Diascopy

• Skin patch testing

Epinephrine
Allergy 78
Wood’s Light Examination

˜Use of a high pressure mercury lamp that produces long wave

ultraviolet rays which result in characteristic dark purple
fluorescence.
˜Lesions that contain melanin disappear, lesions without melanin
increase whiteness.
˜Diagnoses pigmentary abnormalities.
˜Detects superficial fungal and bacterial infections.

Vessell picture
79

Angeogram
Wood’s Light Examination

80
Tzanck Smear

• Secretions from a suspected lesion are applied to a glass slide,

stained, and examined under microscopy.

81
 Biopsy

• Biopsy is the removal of a sample of tissue by

excision or needle aspiration for cytological
(histological) examination.
• Biopsy for skin lesions can be a punch biopsy, shave
biopsy, or excisional biopsy.
• Biopsy confirms or rules out malignancy.ñÉnw

F
• Skin biopsies are performed under local anesthesia.

py Belt ptt
Wafarin Heparin
82
Culture and Sensitivity Tests
• Skin/wound cultures:
o A small skin culture sample is obtained with a sterile applicator and the
appropriate type of culture tube (e.g., bacterial or viral)
o A nasal swab is also commonly done to determine previous exposure to
certain types of bacteria

• Post-procedure intervention:
o Viral culture is placed immediately on ice
o Sample is sent to laboratory to identify an existing organism

83
Scalpel Excision Biopsy

84
Punch Biopsy

85
Skin Scrapings
• Tissue samples are scraped from suspected lesions with a scalpel
blade moistened with oil so that the scraped skin adheres to the
blade.
• Scraped material is transferred to glass slide and examined
microscopically.
• Used to identify the spores and hyphae of fungal lesions, as well as
infestations such as scabies.

86
Potassium hydroxide (KOH) Test

• Confirms a fungal skin lesion.

• A microscopic examination of the scales scraped off
a lesion is mixed with potassium hydroxide (KOH).
• Positive for fungus if →presence of fungal hyphae
(threadlike filaments).

87
Patch Testing

• Performed to identify substances to which the client has

developed an allergy.
• Involves applying the suspected allergens to normal skin
under occlusive patches.
• Weak reaction: redness, elevation, or pruritus
• Moderate reaction: fine blisters, papules, and severe
itching
• Strong reaction: blisters, pain and ulcers

88
Patch Testing

89
Intradermal Skin Testing

• Performed to identify substances to which the client has

developed an allergy.
• Involves injecting the suspected allergens under the
skin.
• Weak reaction: redness, elevation, or pruritus
• Moderate reaction: fine blisters, papules, and severe
itching
• Strong reaction: blisters, pain and ulcers

90
91
Diascopy

• Technique allows clearer inspection of lesions by eliminating the

erythema caused by increased blood flow to the area.

• A glass slide is pressed over the lesion, causing blanching and

revealing the lesion more clearly.

Tornoronninuwaw
Twain 00 1800
8 Mr
96000800

92
 Disorders
The Integumentary System

93
Disorders

• Causes
• Prevention
o Cleanliness
o Diet
o Age
o Environment
• Older adult considerations

94
Environment

• Healthy People 2020 objectives to reduce occupational skin diseases

or disorders among full-time workers.

• Sun-exposure precautions.

• Ultraviolet radiation protection.

95
Planning

• Restore the skin to normal.

• Decrease pain and itching.

• Protect the skin from further damage.

• Prevent infection.

• Prevent scarring as much as possible.

96
Implementation
˜ Giving medicated baths.

˜ Laundry requirements.
˜ Application of wet compresses or dressings.

˜ Application of topical therapy.

97
Guidelines for Applying Topical Medications

˜ Powders

˜ Ointment

˜ Gels

˜ Lotions

make skim thinner

Hydro cortisol

98
Protecting the Skin

• Bathing a client with skin problems:

oUse mild or soap substitute
oRinse and blot dry
• Special care is necessary when changing dressings.
• Solutions such as sterile saline are used to loosen
crusts, remove exudate, or free adherent dry
dressings.

99
Preventing Secondary Infection

• Proper precautions should be observed for all

potentially infectious skin lesions.
• Most lesions with purulent drainage contain
infectious material.
• Standard precautions and the use of gloves when
inspecting the skin and changing dressings.
• Proper disposal of contaminated dressings.

100
Reversing the Inflammatory Process

• The type of skin lesion determines the type of

medication or treatment prescribed.
• If skin is acutely inflamed and oozing wet dressings
and soothing lotions are used.
• Chronic conditions with dry or scaly skin require
water soluble emulsions, creams, ointments, and
pastes.
• Therapy is modified according to skin response.

101
Pruritus

• Itching is often a symptom of skin disease but may

also be a symptom of a systemic problem.
oLiver disease, iron deficiency, cancer, diabetes, or
thyroid disturbance
• Client may scratch which may lead to skin breaks
which can become infected and cause scarring.

102
103
Pathophysiology of Pruritus

• Scratching causes inflamed cells and nerve endings

to release histamine à increased pruritus à itch-
scratch cycle.
• Skin integrity may be altered à excoriation,
erythema, wheals, infection, or changes in
pigmentation.
• Pruritus usually is more severe at night and less
reported during waking hours.

104
Medical and Pharmacologic Management of
Pruritus
• Avoid washing with soap and hot water.
• Bath oils containing a surfactant that makes oil mix
with bath water may be sufficient for cleaning
(Alpha-Keri).
• Application of a bland emollient to moisten the
skin.
• Application of cold compresses to constrict blood
vessels.

105
Medical and Pharmacologic Management of
Pruritus
• Topical corticosteroids decrease itching due to their
anti-inflammatory action.
oHydrocortisone cream
• Oral antihistamines block release of histamine from
damaged cells.
oBenadryl (diphenhydramine), Atarax
(hydroxyzine)
• If pruritus continues, further investigation may be
done to determine a possible systemic problem.

106
Nursing Management of Pruritus

• Remind client to use tepid water, not hot.

• Avoid rubbing vigorously.
• Avoid situations that cause vasodilation, may
increase itching: warm environment, alcohol use
• After bathing, lubricate skin with emollient to trap
moisture.
• Cool, humidified room.
• Cotton clothing rather than synthetic.
107
Urticaria
• Characterized by sudden appearance of edematous, raised
pink areas called wheals that itch and burn.

• Signs/Symptoms – pruritus, edema, burning pain, dyspnea

(anaphylaxis)

• Diagnosis – History, allergy test, IgE antibodies

• Treatment – antihistamines, epinephrine

• Nursing Interventions – therapeutic baths, teach s/s of

anaphylaxis, teach avoidance of allergen

108
Pathophysiology of Urticaria

• Body encounters an antigen which body defenses

recognize as foreign.
• Lymphocytes respond to antigen and produce
antibodies against the antigen.
• Mast cells release histamine à vasodilation à
localized erythema, edema, and pruritus.
• Capillary inflammation à increased permeability à
fluid leakage and edema.
• Other factors can à bronchoconstriction (dyspnea)
and nerve stimulation (pain).

109
Urticaria (Hives or Wheals)

110
Angioedema

• Form of urticaria in subcutaneous tissue

• Signs/Symptoms – burning, pruritus, acute pain,
respiratory distress
• Diagnosis – History, inspection

• Treatment – antihistamines, epinephrine,

corticosteroids
• Nursing Interventions – cold packs and cold compresses,
teach medic alert bracelet, avoid allergen

111
Pathophysiology of Angioedema

• Angioedema and urticaria are varying

manifestations of the same pathologic process.
• Angioedema involves vascular leakage beneath the
dermis and subcutaneous tissue.
• Histamine and other substances à dilation of the
arterioles à fluid leakage à edema.

112
Angioedema

113
Psoriasis

• Chronic, noninfectious skin inflammation occurring with remissions

and exacerbations, involving keratin synthesis that results in psoriatic
patches; may lead to an infection in the affected area.
• Possible causes: stress, trauma, infection, hormonal changes, obesity,
an autoimmune reaction, and climate changes, genetic
predisposition.

114
Psoriasis
• Signs/Symptoms – pruritus, erythematous, silvery, scaling
plaques on scalp, elbows, chin and trunk, pitted and
discolored nails; Yellow discoloration, pitting, and
thickening of the nails are noted if they are affected
• Diagnosis – observation
• Treatment – topical steroids, keratolytics,
photochemotherapy, methotrexate, vitamin D, Tazorac for
severe form.
• Nursing Interventions – disease is chronic and incurable, focus
on well being, goal is to slow proliferation

115
Pathophysiology of Psoriasis

• Primary cause unknown but thought to be a

combination of genetics and environmental stimuli.
• Epidermal cells proliferate faster than normal à
profuse scales or plaques.

116
Psoriasis Lesion on the Hand

117
Psoriasis

118
119
Stevens-Johnson Syndrome

• A medication-induced skin reaction/immunological response

(common medications → antibiotics, anti-seizure, NSAIDS).
• May be mild or severe, with vesicles, erosions, and crusts on
the skin; if severe, systemic reactions occur.
• Most common in clients with impaired immune systems.
• Treatment includes immediate discontinuation of the
medication causing the syndrome; antibiotics,
corticosteroids, and supportive therapy may be necessary.

120
Dermatitis

• Etiology, pathophysiology, signs, and symptoms

o Contact dermatitis
o Atopic dermatitis
o Stasis dermatitis
• Diagnosis and treatment
• Nursing management

121
Contact Dermatitis

• Hypersensitive, inflammatory reaction due to

contact with environmental agent.
• Signs/Symptoms – burning, pain, pruritus, edema,
vesicles and papules
• Diagnosis – History, ID testing, IgE, eosinophils
• Treatment – identify cause, corticosteroids,
antihistamines
• Nursing Interventions – rinse area with Burrow's
solution (antiseptic), cool environment, cold
compresses, daily baths with oil, keep nails short,
loose light clothing

122
Types of Dermatitis

• Dermatitis Venenata – contact with certain plants.

oPoison Ivy, poison oak
• Exfoliative Dermatitis – infestation by certain heavy
metals, or by antibiotics, aspirin, codeine, gold or
iodine.
oArsenic or mercury
• Dermatitis Medicamentosa – drug allergies
oPenicillin, codeine, and iron
123
Dermatitis
• Signs/Symptoms – mild to severe erythema and vesicular
lesions, respiratory distress
• Diagnosis – patient history, elevated IgE, eosinophilia
• Treatment – therapeutic baths, corticosteroids
• Nursing Interventions:
o Dermatitis venenata – rinse affected area
o Cool wet compresses, colloid baths, antipruritic lotions, dressing

124
Warts (Verruca)

• Small, flesh colored, brown or yellow papules

caused by the human papillomavirus (HPV).
• Signs/Symptoms – rough, nipple like growths most
often on hands
• Diagnosis – inspection and history

• Treatment –Cryosurgery, laser, keratolytic agents

• Nursing Interventions – teach prevention

125
Pathophysiology of Warts

• Benign epidermal lesions caused by human

papillomavirus infection.
• Over 100 subtypes of human papillomavirus.
• Spread by autoinoculation.
• Trauma and maceration facilitate introduction of
virus into the skin à generalized lesions that
proliferate.

126
127
Bacterial Skin Infections

• Furuncle (boil) – inflammation in the hair follicle

(folliculitis) spreading to surrounding skin.
• Carbuncle – group of furuncles (boils).
• Felons – soft tissue under and around an area
becomes infected most often seen on the fingers

128
 Pathophysiology of Folliculitis, Furuncles,
Carbuncles and Felons
• Inoculation of the skin in hair bearing areas with
bacteria à inflammation with tenderness, pain, and
surrounding cellulitis as the body attempts to keep
infection localized.
• Bacteria may produce necrosis of the invaded tissue
à formation of furuncle (boil) with leukocytosis,
fever, and pain.

129
Folliculitis

• Staphylococcal infection starting around the hair follicle

caused by prolonged moisture, trauma and poor hygiene.
• Signs/Symptoms – white pustules or follicular nodules
• Diagnosis – inspection and history
• Treatment – topical hygiene, topical and systemic antibiotics
• Nursing Interventions – teach hygiene, hand washing

130
Folliculitis

131
Furuncle

132
Carbuncle

133
Felon

134
Skin Infections

• Signs/Symptoms – associated with folliculitis, furuncles,

carbuncles and felons: erythema, edema, pain, and
pruritus
• Diagnosis – physical exam, health Hx, inspection,
culture
• Treatment – draining the lesion and applying local
antibiotics
• Nursing Interventions – warm soaks to speed the
process of suppuration (production of purulent
drainage), isolation for drainage and secretions,
dressing changes

135
Cellulitis
• Infection of the skin caused by Staphylococcus
aureus, Streptococcus, or Haemophilus influenza
type B.
• Signs/Symptoms – erythema, edema, tenderness,
warmth, vesicles, bullae
• Diagnosis – appearance, signs/symptoms, culture,
CBC
• Treatment – antibiotics
• Nursing Interventions – antibiotics, warm moist
dressing changes, analgesics, bed rest

136
Pathophysiology of Cellulitis

• Is a diffuse inflammation of connective tissue with

severe inflammation of dermal and subcutaneous
layers of the skin.
• Normal skin bacteria enter break in skin à infection
and inflammation à release of histamine and other
factors à erythema, edema, heat, and pain.
• Systemic response includes fever, swollen glands.

137
138
Cellulitis

139
Herpes Simplex

• Herpes simplex virus type 2 (HSV-2) is most often associated with

genital herpes.
• Herpes simplex virus type 1 (HSV-1) lesions are primarily non-genital.
• Preventing spread of herpes virus.
• Lemon balm for cold sores.

140
Pathophysiology of Herpes Simplex Virus

• Resides in dormant form in the nerves of the body.

• In their dormant state they do not cause any genital
herpes infection.
• When activated the virus à skin surface à rapid
multiplication à painful, vesicular lesions that
rupture and crust (shedding).

141
Herpes Simplex Type I

142
Herpes Simplex (cont.)

143
Herpes Simplex (cont.)

• Etiology and pathophysiology

• Signs and symptoms
• Diagnosis

oHistory and physical examination

• Treatment
• Nursing management

oGood personal hygiene

144
Herpes Simplex Type II

145
146
Herpes Zoster (Shingles)

• Etiology and pathophysiology:

o Dormant and can be reactivated by trauma, malignancy, or local radiation
o High risk: immunocompromised individuals
o Vaccine
• Signs and Symptoms:
o Aching or discomfort along the nerve pathway
• Danger of herpes zoster transmission

147
Herpes Zoster (Shingles) (cont.)

148
Herpes Zoster (Shingles)

• Caused by herpes varicella (chickenpox) virus.

• Signs/Symptoms – unilateral vesicular rash along nerve

fibers, preceded by pain, pruritus

• Diagnosis – culture, inspection, and Hx

• Treatment – Acyclovir, analgesics, steroids, antipruritic

lotions

• Nursing Interventions – control pain, give meds, wet

dressings, prevent spread, prevent secondary infection,
proper diet, and vitamin C

149
Pathophysiology of Herpes Zoster

• Continuation or extension of a previous chickenpox

(Varicella) infection.
• Dormant virus lives in the nerve cell bodies an in
cells of the dorsal root, cranial nerve, or autonomic
ganglion
• Immunosuppression à virus release from the cells
à travel down nerve axons à viral infection of the
skin in the region of the nerve

150
Herpes Zoster (Shingles)

151
Fungal Infections

• Tinea capitis – round, scaly, pustular, erythematous,

pruritic, painful lesions around the edges of the scalp.

• Tinea corporis (ringworm) – flat, erythematous, pruritic,

circular lesions with clear centers.

• Tinea cruris (jock itch) – brown to red pruritic lesions

extending outward in the groin and perineal area.

• Tinea pedis (athlete’s foot) – fissures and vesicles between

the toes.

152
Pathophysiology of Tinea Infections

• Transmission may occur from direct contact with

infected animals, infected humans, or contaminated
fomites such as furniture and clothing.
• Dermatophytoses (fungi) come in contact with skin
à lesions that range from sharply demarcated with
erythematous margins and dry scaling to papulo-
vesicular lesions.

153
Tinea Capitis and Tinea Corporis

154
Tinea Cruris and Tinea Pedis

155
Fungal Infections

• Diagnosis – visual inspection, Wood’s light or lamp for

tinea capitis, health history
• Treatment – antifungal drugs

• Nursing Interventions – protect area from trauma and

irritation by keeping feet clean and dry, apply
antifungal medications, warm compresses, warm
soaks with Burow’s solution, encourage cotton
socks, sandals, or going barefoot

156
Question

In managing dermatitis, the nurse provides which instruction(s)?

(Select all that apply.)
1. Avoid the irritant or allergen.
2. Provide adequate skin lubrication.
3. Wash skin frequently with germicidal soaps.
4. Maintain skin moisture.
5. Apply steroid-based preparations.

157
Answer

In managing dermatitis, the nurse provides which instruction(s)?

(Select all that apply.)
1. Avoid the irritant or allergen.
2. Provide adequate skin lubrication.
3. Wash skin frequently with germicidal soaps.
4. Maintain skin moisture.
5. Apply steroid-based preparations.

158
Fungal Infections

• Fungi that are truly pathogenic to humans.

• Opportunistic infections and altered immune system.
• Tinea pedis (athlete’s foot or dermatophytosis), tinea cruris (jock
itch), tinea of the scalp (ringworm), and tinea barbae (barber’s itch).

159
Fungal Infections (cont.)

• Moniliasis (thrush) attacks the mucous membranes of the mouth,

rectum, and vagina (candidiasis).

• Older adults and onychomycosis.

160
Fungal Infections (cont.)

• Diagnosis:
o Microscopic examination of skin scrapings that have been treated with
potassium hydroxide (KOH) solution
• Preventing recurrent fungal infection
• Complementary and alternative treatment of nail fungus

161
Onychomycosis (Nail Fungus)

162
Tinea Pedis

• Etiology, pathophysiology, signs, and symptoms

• Diagnosis
• Treatment
• Nursing management

163
Scabies
• Parasitic infestation with the female itch mite Sarcoptes
scabei.

• Prolonged contact with infected person, crowded living

conditions, poverty, sexual behaviors, world travel.

• Signs/Symptoms – brown wavy, threadlike lines on body,

severe pruritis, excoriation

• Treatment – Kwell, Rid, Eurax, Sulfur in petrolatum

• Nursing Interventions – prevention, contact isolation

164
Sarcoptes Scabei (Itch mite)

165
Question
The nurse who observes evidence of severe itching on the
scalp of a school-aged girl with pediculosis should give which
important instruction(s)? (Select all that apply.)
1. “Machine wash clothes and bedding using the coldest
cycle.”
2. “Share combs and hair brushes.”
3. “Soak all combs and brushes in very hot water for more
than 5 minutes.”
4. “Seal items that cannot be washed in air-expelled plastic
bags for 14 days.”
5. “Instruct all family members about the infestation and
ways to prevent re-infestation.”

166
Answer
The nurse who observes evidence of severe itching on the
scalp of a school-aged girl with pediculosis should give which
important instruction(s)? (Select all that apply.)
1. “Machine wash clothes and bedding using the coldest
cycle.”
2. “Share combs and hair brushes.”
3. “Soak all combs and brushes in very hot water for more
than 5 minutes.”
4. “Seal items that cannot be washed in air-expelled plastic
bags for 14 days.”
5. “Instruct all family members about the infestation and
ways to prevent re-infestation.”

167
QUESTIONS?

168