Management of Patients with
Dermatologic Disorders
NURS 125
Care of
Integumentary Diseases
By the end of this session, the learner will be able to:
1. Assess and diagnose normal and abnormal findings of skin in adult and
geriatric clients.
2. Describe common dermatological terms, diagnostics, medical therapies and
surgical interventions for dermatological problems.
3. Explain the pathophysiology, clinical manifestations, complications and
nursing management of infectious skin diseases (i.e., Bacterial, Viral, Fungal,
Parasitic, Bites).
4. Explain the pathophysiology, clinical manifestations, complications and
nursing management of dermatological problems (i.e., Eczema, Psoriasis,
Steven's-Johnson Syndrome, Toxic Epidermal Necrolysis).
5. Explain the pathophysiology, clinical manifestations, complications and
nursing management of dermatological lesions (i.e., Basal Cell, Squamous
Cell, Melanoma).
Skin
• Largest and heaviest single organ
– 16% body weight
• Layers
– Epidermis – Thin layer, devoid of blood vessels
• Outer horny layer of dead keratinized cells, avascular
• Inner cellular layer where both melanin and keratin are formed
• Migration of the inner layer to outer layer takes ~1 mos
– Dermis – Middle layer well supplied with blood
• Connective tissue, elastin, collagens, sebaceous glands, sweat
glands, hair follicles
– Subcutaneous – Fat layer
Skin Color
• Pigments
– Melanin
• Brownish pigment, genetically determined increased by
sunlight
– Carotene
• Golden yellow in subcutaneous fat, heavily keratinized areas
like palms and soles
– Oxyhemoblobin
• Bright red pigment, arteries and capillaries
– Deoxyhemoglobin
• Darker bluish pigment, “bluish cast” = cyanosis
Cyanosis
• Central cyanosis
– Oxygen level in arterial blood is low
– Lips, oral mucosa, tongue, nails, hands, feet
– Lips may turn blue in cold
• Peripheral cyanosis
– Cutaneous blood flow decreases and slows
– Nail beds, hands, feet
– Anxiety and cold
Pigmentation & Color
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Café-Au-Lait Spot
Tinea Versicolor
Vitiligo
Cyanosis
Jaundice
Carotenemia
Erythema
Heliotrope
Patterns & Shapes
• Linear
– Herpes Zoster Virus
• Clustered
– Herpes Simplex Virus
• Annular, Arciform
– Tinea faciale
• Geographic
– Mycosis fungoides
• Serpiginous
– Tinea corporis
Types of Lesions
• Macule
– Small flat lesion with different color, up to 1 cm
• Patch
– Larger flat lesion with different color, > 1 cm
• Plaque
– Elevated superficial lesion > 1 cm
• Papule
– Small elevated lesion, up to 1 cm
• Nodule
– Marble-like elevated lesion > 0.5 cm
Types of Lesions
• Wheal
– Irregular and transient localized skin edema
• Welt
– Elevated ridge or lump usually due to trauma
• Urticaria or Hives
– Elevated edematous erythematous patches of skin
or mucous membranes
Types of Lesions
• Cyst
– Nodule filled with liquid or semisolid
• Vesicle
– Small blister fluid filled elevation of epidermis, up to 1 cm
• Bulla
– Large blister fluid filled elevation of epidermis, > 1.0 cm
filled with serous fluid
• Pustule
– Circumscribed elevation of the skin filled with pus and
having an inflamed base
Types of Lesions
• Scale
– Thin flake of dead exfoliated shedding skin
• Crust
– Dried residue from discharge (e.g., serum, cellular debris,
bacteria)
• Lichenification
– Visible and palpable thickening of the epidermis and
roughening of the skin
• Keloid
– Hypertropic scarring
Types of Lesions
• Abrasion
– Rubbing or scraping of cells or tissue from skin or
mucous membranes
• Erosion
– Loss of superficial epidermis (no bleeding)
• Excoriation
– Loss of dermis, scratching (bleeding)
• Fissure
– Linear crack in epidermis (dryness)
Skin Wounds
• Laceration
– Caused by tissue tearing apart
• Incision
– Caused by a sharp instrument
• Contusion
– Caused by a blow from a blunt object
• Puncture wound
– Caused by skin penetration with a sharp object
• Penetrating wound
– Caused by skin penetration of a bullet or metal fragment
Vascular Lesions
• Spider angioma
– Fiery red, < 2 cm
• Spider vein
– Bluish, up to several inches
• Cherry angioma
– Bright red or brown, 1-3 mm
• Petechia
– Deep red or purple, 1-3 mm
• Purpura
– Deep red or purple, > 3 mm
• Ecchymosis
– Purple or blue, fades to green, yellow, brown, > 3 mm
Skin Tumors
• Benign Nevus
– Round, well defined, uniform color, diameter < 6 mm
• Actinic Keratosis
– Superficial, flattened papules covered by dry scale
• Seborrheic Keratosis
– Yellow to brown raised lesions, greasy
• Basal Cell Carcinoma (BCCA)
– Slow growing, usually > age 40
• Squamous Cell Carcinoma (SCCA)
– Sun exposed skin, usually > age 60
• Melanoma
– Sun exposed skin, ABCDE
Basal Cell Carcinoma (BCCA)
• CAUSE
– Slow-growing destructive skin tumor
– Originates when undifferentiated basal cells become carcinomatous
instead or differentiating into sweat glands, sebum, and hair
– Prolonged sun exposure 90% on exposed body areas
– Radiation exposure, arsenic ingestion, burns, immunosuppression
and rarely vaccinations
• RISK FACTORS
– Most common malignancy in Caucasians
– Light-skin, blond or red-hair, blue or green eyes
– Over age > 40
Basal Cell Carcinoma (BCCA)
MANIFESTATIONS
– Noduloulcerative
• central crater, elevated borders with pigmented plaques
– Superficial
• pearly or waxy, white or light pink, flesh-colored or brown
DIAGNOSTICS & TESTS
– Incisional or excisional biopsy and histologic study
CONSEQUENCES
– Skin destruction
MANAGEMENT
– Curettage, electro desiccation, chemotherapy, irradiation or
chemosurgery, cryotherapy
Malignant Melanoma
CAUSE
– Increased sun exposure or decrease in the ozone layer
– Arises from melanocytes (synthesize the pigment melanin)
possible abnormal or absent organelle called a melanosome
– 70% of malignant melanomas arise from a preexisting nevus
– Familial p16 gene
RISK FACTORS
– Sun exposure, increased nevi, burn or freckle in sun,
hormonal factors, family history
– Common sites are the head and neck in men, legs in women
ABCDE
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A = Asymmetry
B = Borders irregular
C = Color variation
D = Diameter > 6 mm
E = Evolving in appearance
including enlargement or elevation
Malignant Melanoma
MANIFESTATIONS
• Asymmetry, Border, Color, Diameter, Evolution
DIAGNOSTICS & TESTS
– Excisional biopsy, Punch biopsy
CONSEQUENCES
– Metastasis via the lymphatic and vascular systems
– Regional lymph nodesskinliverlungsCNS
MANAGEMENT
– Chemotherapy, Immunotherapy, Radiation therapy, Gene
therapy
Diagnostics & Treatments
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Skin Scraping
Electrodessication or Electrocoagulation
Curettage
Punch Biopsy
Cryosurgery
Excision
Phototherapy
Radiation
Laser Technology
Drug Therapy
Wound Assessment
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Anatomical location
Size
Wound bed tissue
Exudate
Type of Odor
Margins
Periwound
Anatomical Location
• Head 12:00 o’clock
– occipital, frontal, temporal, parietal
• Body
– anterior, posterior, medial, lateral
• Pelvis
– coccyx, sacrum, ischium
• Foot 6:00 o’clock
– plantar surface is the only exception
– Toes 12:00 o’clock, Heal 6:00 o’clock
Size
• Measure L x W x D / H each time the wound is assessed
– Length x Width x Depth and/or Height in centimeters
• Measure the longest length Head 12:00 to Toe 6:00
• Measure the widest width side to side, perpendicular 90˚
from the length
• Depth and/or Height is the distance from visible surface to
the deepest or highest area
– Use a cotton applicator and grasp by thumb and forefinger,
withdraw applicator while maintaining position of thumb and
forefinger, measure from tip of applicator to position against
centimeter ruler
Wound Bed Tissue
• Granulation
– Beefy red shiny moist fragile granular tissue with network of
new capillaries
• Slough
– Yellow stringy substance attached to the wound bed tissue
• Eschar
– Black or brown tissue layer of dried plasma proteins and dead
cells which must be removed before healing can proceed
• Necrosis
– Black dead cells
Color of Tissue
• RED wounds are in the proliferative phase and
reflect the color of healing
PROTECT granulation
• YELLOW wounds are characterized by oozing from
the tissue
CLEANSE then reassess
• BLACK wounds reflect dead tissue which must be
removed before the wound can heal
DEBRIDE then reassess
Exudate
• Serous
– Clear straw-colored serum
• Sanguineous
– Thick with RBCs
• Serosanguineous
– Serum and a few RBCs
• Purulent
– Pus-like white or yellow, green or blue color
– Suppuration is the process of pus formation
– Bacteria which cause pus are called pyrogenic
• Fibrinous
• Others: Bilious, Fecal, Lymphatic
Types of Odor
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Musty
Foul
Sour
Sweet
Fecal
Urine
Wound Closure
• Healing by Intention
– Primary
• Surgical repair, approximated edges, lowers risk of infection,
involves little tissue loss, heals with minimal scarring
– Secondary
• Chronic wounds, edges not approximated, greater tissue loss,
higher risk if infection, longer healing times
– Tertiary (delayed primary intention)
• Surgical wounds left open for 3-5 days to provide time for
decreasing edema of infection, closed with sutures, staples,
adhesives later
Wound Closure
• Approximation
– Describes degree of closure
• Dehiscence
– Wound edges have opened
• Evisceration
– Viscera, organ or bowel is spilling out of wound
Periwound
Surrounding Area
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Normal
Erythema (Redness)
Indurated (Swollen, edematous)
Macerated (Wrinkled by moisture)
Skin Strips (Epidermis removed by adhesive)
Dermatitis (Candida albicans)
Hemosiderin stain (Purplish discoloration)
Temperature (Hot, Warm, Cool)
Margins
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Irregular wound shape
Undermining
Tunneling
Sinus tract
Fistulas
Epibole
Hyperkeratotic
Skin Ulcers
• Ulcer
– Loss of tissue
• Pressure injury
– Localized injury to the skin or underlying tissue usually over a bony
prominence as a result of pressure or pressure in combination with
shear or friction (ONLY STAGE THIS TYPE OF ULCER)
• Diabetic ulcer
• Vascular ulcer
– Arterial
– Venous
• Terminal ulcer
Pressure Injury
CAUSE
• Pressure
– Sustained compression and pressure obliterates arteriolar and
capillary blood flow to the skin
• Friction
– A force acting parallel to the skin surface
• Shearing Forces
– A combination of pressure and friction
– Created by bodily movements
• Patient slides down in bed
• Dragged across sheets
Pressure Injury
RISK FACTORS
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Decreased mobility
Decreased sensation
Sustained compression
Shearing forces or fractured skin
Moisture (fecal or urinary incontinence)
Poor nutritional status or low albumin
Pressure Injury
TYPES
• Stage I
– Skin intact, redness does not blanch
• Stage II
– Partial thickness skin loss
• Stage III
– Full thickness skin loss to subcutaneous
• Stage IV
– Full thickness skin loss to muscle or bone
• Unstageable
– Base of wound is covered with slough or eschar
Pressure Injury
NURSING DIAGNOSIS
• Ineffective tissue perfusion related to…
• Impaired skin integrity related to…
• Impaired physical mobility related to…
• Imbalanced nutrition: Less than body requirements
related to…
• Disturbed body image related to…
• Risk for infection related to…
• Pain related to…
Pressure Injury
CONSEQUENCES
• Long-term wound healing
• Increased cost of care
Pressure Injury
MANAGEMENT
• Oxygenation & Circulation
– Capillaries deliver O2 required by cells use oxygen
• Temperature
– Cells and enzymes function at body temperature (Around
37˚C not Room Air 21˚C) cover wound
• Nutrition
– Calories & Fluid Hydration, Albumin (protein), Vitamin A, B,
C, D, & K, Zinc and Fatty Acids proper client nutrition
Management of Patients with
Burn Injury
NURS 125
Objectives
By the end of this session, the learner will be able to:
1. Identify the levels of burns
2. Understand classifications of Total Body Surface
Area (TBSA)
3. Explain nursing interventions (i.e., special for
inhalation)
4. Identify which type of shock can occur
5. Review complications of burns
Superficial Burn
• Example sunburn or first degree
– Limited to redness (erythema)
• Bright pink to red
– Blanches briskly
– A shinny white plaque forms
– Minor to moderate pain at the site of injury
– Involves only the epidermis
– Healing in 3 to 5 days
– No scar
Deep Partial Thickness
• Example scalding water or second-degree
– Erythema with superficial blistering
– Pain depends on the level of nerve involvement
– Epidermis and 1/3 of the dermis
– Involves the superficial (papillary) dermis
– May involve part of the deep (reticular) dermis
– Heals in 7 to 10 days
Partial Thickness
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Mottled red/white color
Injury to the dermis
Painful
Slow epithelialization
Changes in appearance
Probability of deepening (conversion)
Dense scarring
Full Thickness
• Example fire or third-degree
– White, brown, black or dark red
– Firm to leathery texture
– Epidermis and dermis is lost
– No residual epidermal cells to repopulate
– Damage to the subcutaneous tissue
– Hard eschar will be present
– Results in scarring, loss of hair shafts, keratin
– Burns may require grafting
Full Thickness
• Characteristics
– Fixed hemoglobin
– Thrombosed vessels
– Insensate (lack of pain)
– Loss of distal pulses or cap refill
• Shock
• Constriction (circumferential)
– May require emergency escharotomy or
fasciotomy
Full Thickness
• Chemical accelerant or fourth-degree
– Damage to muscle, tendon, and ligament
tissue
– Damage of the hypodermis
– If hypodermis is destroyed in a condition
called compartment syndrome results
– Grafting is required
– Highest degree of fatality
Classifications
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Superficial burns do not count
Lund & Browder Chart
Rule of Nines
1% Palm Rule
Total Body Surface Area (TBSA)
Nursing Interventions
• Stop Burning
– Remove clothing and jewelry
• Airway
– 80% of deaths from inhalation
• Breathing
– 100% NRB Mask
• Circulation
Inhalation Injury
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Soot on face, tongue, teeth
Soot staining in oropharynx
Singed scalp, nasal and facial hair
Vocal quality
Work of breathing, wheezing, stridor
Decreased PaO2, Increased CO2
Intubate immediately if suspected
Burn Shock
• Hypovolemic Shock
– Capillary leak
– Decreased plasma volume
– Decreased cardiac output
– Decreased organ perfusion
– Metabolic acidosis
– MODS
Parkland Formula
Lactated Ringers (LR) 2 - 4 mL x Kg x TBSA
– First 24-hours post injury
– ½ 24-hour total to be given in the first 8-hours
– ½ 24-hour total to be given in the remaining
16-hours
Example
Patient: 70 Kg with 50% TBSA burn
4 mL LR x 70 Kg x 50% TBSA burn =
14 Liters (14,000 mL)
• 7 L to be given in the first 8-hours
– 7,000 mL/8 = 875 mL/hr.
• 7 L to be given in the remaining 16-hours
– 7,000 mL/16 = 438 mL/hr.
Burn Complications
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Sepsis
Pneumonia
Renal Failure
Pulmonary Edema
ARDS