Dermatologic Problems/
Integumentary System
Physical Examination
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Obtain history
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WHATS UP
Inspection
Palpation
Gloves are worn during examination
Physical Examination
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Observe for:
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Color
Temperature
Moisture
Dryness
Physical Examination
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Skin texture (rough-smooth)
Lesions
Vascularity
Mobility
Texture of hair and nails
Skin turgor
Physical Examination
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Color
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Varies from person to person
Ivory-deep brown
Pigmentations r/t
Sun exposure
 Fevers
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Sunburn, inflammationPink or
 Reddish hue
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Pallor
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Decreased skin tones
Physical Examination
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Color
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Vascularity
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Observed in
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Bluish hue
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Conjunctivae
Mucous membranes
Cyanosis = cellular hypoxia
Jaundice
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Yellow pigment
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sclera
mucous membrane
Physical Examination
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Color
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Dark skinned persons
Have reddish base and undertones
 Buccal mucosa, tongue, lips,nails normally appear
pink
 Cyanosis-skin assumes grayish cast
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Age related changes
Physical Examination
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Types of dressings
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Wet-dry dressings
Moisture-retentive dressings
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Already impregnated with moisture
Occlusive dressings
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Cover wound
Physical Examination
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Topical medications
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Lotions, suspensions
Clear solutions, liniment,
Powders, creams,
Gels, pastes,
Ointments, sprays,
Corticosteroids etc.
Wounds
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Abrasion – skin is rubbed or scraped
off
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Lacerations – torn, ragged, irregular
edges made by blunt objects
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Avulsions – the tearing away of tissue
from a body part
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Incisions – cuts made by sharp cutting
instruments
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Punctures – caused by objects that
penetrate tissue while leaving a small
surface opening
Amputations – traumatic is the
nonsurgical removal of a limb from the
body
Wound Healing
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1st intention
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2nd intention
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3rd intention
Diagnostic Tests/Treatments
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Cultures
Skin biopsy
Wood’s light examination
Skin testing (allergies)
Open wet dressing/other dressings
Therapeutic baths
Topical meds
Herpes Zoster {Shingles}
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Acute inflammatory and infectious
disorder
Painful vesicular eruption
Bright red edematous plaques along the
nerve from one or more posterior ganglia
Herpes Zoster {Shingles}
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cont’d
Eruption follows the course of the nerve
Almost always unilateral
Herpes Zoster {Shingles}
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Cause
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Varicella-zoster virus (like chicken-pox)
Incubation period 7-21 days
Vesicles appear in 3-4 days
Occur posteriorly
 Progress anteriorly & peripherally
 Along dermatome
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Duration 10 days to 5 weeks
cont’d
Herpes Zoster {Shingles}
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cont’d
Occurs most frequently in
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Elderly
Immunosuppressed
Malignancy or injury to spinal or cranial nerve
Herpes Zoster {Shingles}
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Complications
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Facial and acoustic nerve involvement
Hearing loss
 Tinnitus
 Facial paralysis
 Vertigo
 painful
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cont’d
Herpes Zoster {Shingles}
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cont’d
Complications
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Full thickness skin necrosis and scarring
Systematic infection from scratching, causing
virus to enter blood stream
Herpes Zoster {Shingles}
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Medical treatment
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Control outbreak
Reduce pain and discomfort
Prevent complications
Acyclovir (Zovirax) IV, PO, topically
Corticosteroids
Antihistamines
Antibiotics
cont’d
Herpes Zoster {Shingles}
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cont’d
Nursing Care
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Cool compresses two-three times per day
Help cleanse and dry lesions
Measures to decrease itching
Medication
Parasitic Skin Infections (PSI)
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Higher risk situations?
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Poor hygiene
Living in close quarters
Pediculosis- Lice (PSI)
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Infestation by human lice
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Pediculosis capitis-head
Pediculosis corporis-body
Pediculosis pubis- pubic or crab
Pediculosis (PSI)
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Parasite
Approximately 2-4 mm
Female lays eggs-hundreds-nits
Deposit on hair shaft base
Pediculosis (PSI)
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Symptoms
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Pruritus
Excoriation
Vectors of other diseases
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Typhus
Recurrent fever
Pediculosis Capitis (PSI)
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More common in women
Sides and back of scalp
Assess for
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Visible white flecks (nits)
Matting and crusting of scalp
Foul odor
Pediculosis Capitis (PSI)
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Treatment
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Pediculicides
Hand pick or comb nits out
Launder bed linens & vacuum
Seal items in plastic bags for 14 days
Repeat above in 10-14 days
Pediculosis Corporis (PSI)
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Lice live and lay eggs in clothing
Itching
Assess for
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Excoriation on
Trunks
 Abdomen
 Extremities
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Pediculosis Pubis (PSI)
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Intense pruritis
Vulvar region
Peri-rectal
More compact
Crab-like appearance
Pediculosis Pubis (PSI)
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Contracted from
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Infested bed linens
Sexual intercourse
May also infest
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Axilla
Eyelashes
Chest
Pediculosis (PSI)
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Treatment
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Chemical killing
Clean linens with hot water and soap
Dry-clean
Fine-tooth comb
Treat social contacts
Scabies (PSI)
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Contagious skin disease
Mite infestation
Transmitted by
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Close-prolonged contact with
Infested companion
 Infested bedding
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Scabies (PSI)
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Characterized by
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Epidermal curved or linear ridges
Follicular papules
Pruritus Palms
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More intense and unbearable at night
White visible epidermal ridges by
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Mite burrowing into outer layers of skin
Scabies (PSI)
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Hypersensitivity reaction
Excoriated erythematous papules
Pustules, crusted lesions
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Elbows
Axillary folds
Lower abdomen
Buttocks, thighs
Between fingers
Genitalia
Scabies (PSI)
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Treatment
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Topical sulfur preparations
One-two applications daily
Launder personal items
No disinfectant
Ringworm (PSI)
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Ringworm - an infection caused by a
fungus
Jock itch – form of ringworm on
groin area
Athlete’s foot – fungal infection of
foot (feet)
Fungus
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live and spread on the top layer of
the skin and on the hair
grow best in warm, moist areas,
contagious via skin-to-skin contact
with a person or animal that has it or
when you share things like towels,
clothing, or sports gear.
You can also get ringworm by
touching an infected dog or cat,
although this form of ringworm is not
common.
Psoriasis
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Lifelong disorder
Exacerbations
Remissions
Cannot be cured
Psoriasis
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Pathophysiology
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Scaling disorder
Underlying dermal inflammation
Abnormality in proliferation of epidermal cells
in outer skin layers
Normal – 28 days to shed cells
Psoriasis Cells shed every 4-5 days
Psoriasis
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Cause-unknown
Genetic predisposition
Environmental factors
May appear after skin trauma
Sunburn
Surgery
Psoriasis
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Improves in warmer climates
Aggravated by
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Infections
Streptococcal throat infection
 Candida infections
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Hormonal changes
Psychological stress
Psoriasis
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Assessment
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History
Family history
Age at onset
Disease progression
Pattern of recurrences
Gradual or sudden
Psoriasis Vulgaris
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{Ordinary/Common}
Most common
Thick erythematous papules or plaques
Surrounded by silvery white scales
Psoriasis Vulgaris
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{Ordinary/Common}
Common sites
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Scalp
Elbows
Trunk
Knees
Sacrum
Extensor surfaces of limbs
Skin Cancers
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Overexposure to sunlight
Common skin cancers
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Squamous cell carcinoma
Basal cell carcinoma
Melanoma
Actinic Keratosis
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Pre-malignant lesions
Cells of epidermis
Chronically sun-damaged skin
Can lead to squamous cell carcinoma
Squamous Cell Carcinoma
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Malignant neoplasms of epidermis
Invade locally
Potentially metastic
Ear
Lip
External genitalia
Cause
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Repeated irritation or injury
Basal Cell Carcinoma
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Basal cell layer of epidermis
Lesions go unnoticed
Metastasis rare
Underlying tissue destruction progresses
to underlying vital structure
Melanomas
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Pigmented malignant lesions
Originate in melanin-producing cells of
epidermis
Melanomas
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Risk factors
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Genetic predisposition
Excessive exposure to UV light
Precursor lesions resembling unusual
moles
Highly metastatic
Survival depends on early diagnosis and
treatment
Skin Cancers
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Incidence/Prevalence
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Light skinned persons
Outside work
Higher altitudes
Chemical carcinogens
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Type I - Often burns, rarely tans. Tends to have freckles, red or fair hair,
and blue or green eyes.
Type II - Usually burns, sometimes tans. Tends to have light hair, and
blue or brown eyes.
Type III - Sometimes burns, usually tans. Tends to have brown hair and
eyes.
Type IV - Rarely burns, often tans. Tends to have dark brown eyes and
hair.
Type V - Naturally black-brown skin. Often has dark brown eyes and hair.
Type VI - Naturally black-brown skin. Usually has black-brown eyes and
hair.
Skin Cancers
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Prevention
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Avoid exposure to sunlight
Use of sunscreen SPF30 or greater
Skin Cancers
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Assessment
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Age
Race
Family history
Removal of skin growths
Skin Cancers
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Assessment
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Change in
Size, Color, Sensation
 Of any
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Mole, Birthmark, Wart, Scar
Hair-bearing areas of body
Skin Cancers
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Interventions: Radiation therapy
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Elderly
Large, deeply invasive basal cell tumors
Poor risk for surgery
Malignant melanoma resistant
May be used in combination with systemic
chemotherapy
Skin Cancers
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Interventions: Surgery
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Cryosurgery
Local application of liquid nitrogen
 Cell death
 Tissue destruction
 Hemorrhagic blister formation x 1-2 days
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Nursing Care
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Clean site with hydrogen peroxide
Topical antibiotic may be ordered
Skin Cancers
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Interventions: Plastic or reconstructive
surgery
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Wound flaps
Pressure wounds
Skin Flap vs. Skin Graft
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Skin Flap
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Segment of tissue
attached on one end
while other end is
moved to new site
Nursing Care
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Assess for infection
Assess circulation of
tissue
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Skin Graft
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Section of skin
detached &
transferred
Nursing Care
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Keep affected part
immobilized
Inspect dressing
After 2-3 weeks,
massage with oil
No heating pads or
sun exposure
Pressure Ulcers
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Etiology
Pressure Ulcers
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Etiology
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Immobility
Impaired sensory perception or cognition
Decreased tissue perfusion
Decreased nutritional status
Friction and shear
Increased moisture
Pressure Ulcers
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Stages
Pressure Ulcers
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Stages
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Stage I
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Non-blanchable erythema
Tissue swelling
C/O discomfort
Stage II
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Break in skin
Epidermis
Dermis
Necrosis
Pressure Ulcers
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Stages
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Stage III
Subcutaneous tissue
 Deep crater
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With undermining
Without undermining
Stage IV
Underlying structures
 May have large undermined area
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Pressure Ulcers
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Nursing Care
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Relieve pressure
Proper positioning
Improve mobility
Improve sensory perception
Improve tissue perfusion
Improve nutritional status
Reduce friction and shear
Minimize moisture
Burns
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1st degree – partialthickness (superficial)
2nd degree – partialthickness (deep)
3rd degree – fullthickness
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Chemical burns
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Electrical burns
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Thermal burns
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Sunburn
Burns
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Extent of burn injury
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Rule of nines
Stages of care
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I – Emergent
II – Acute
III - Rehabilitation
Burns
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Tests
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Wound cultures
CBC, BUN, glucose, electrolytes, urine studies
Interventions
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IV fluid replacement
Antibiotic/antimicrobial agents
Analgesics
Burns
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Treatment
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Debridement & cleaning
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Dressing
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Mechanical, chemical, surgical
Escharotomy
Open, closed, biological, synthetic
Skin grafts
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Autograft
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Split-thickness
Full-thickness
Burn Care
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Impaired gas exchange
Impaired skin integrity
Deficient fluid volume
Pain
Ineffective peripheral tissue perfusion
Risk for sepsis
QUESTIONS?