Assessment of Integumentary Function • Photographs may be used to document nature and extent of skin

• Changes in body function with age are part of a continuum that starts conditions and to document progress resulting from treatment
the moment life begins. Skin Appearance
• From the moment of conception, tissues and organs develop in an • Erythema
orderly manner. • Rash
• By approximately age 18, the human body reaches full anatomic and • Cyanosis
physiologic maturity • Jaundice
• The peak years of physiologic function last from the late teens • Pruritus: itching
through the thirties—the so-called PRIME OF LIFE.
• In 50s to 60’s, these physiologic changes become more apparent. Assessing Skin Lesions
• Beyond 70’s, they are significant and no longer deniable. • Vary in size, shape, cause
• Heredity, environment, and health maintenance significantly affect • Type and appearance
the timing of age-related changes. • Primary lesions – Initial lesions
• Some are quite young but appear old. The most severe cases is called – Characteristic of disease
progeria. Macule
– 8 or 9 years of age children with progeria have the physiology and Patch
appearance of 70-year-old Vesicle
Bulla
Skin Papule
• Largest organ of the body Plaque
• Functions Wheal
– Protection • Secondary lesions
– Sensation – Results from changes in primary lesions; scratching, trauma,
– Fluid balance infections, wound healing
– Temperature regulation Erosion
Scar
• Epidermis Ulcer
– outermost layer Keloid
– provides protection, keeps out chemicals and microorganisms Fissure
– body’s fluid regulation system Scales
– Regulate body temperature and eliminate waste products. Atrophy
– It has melanocytes that produce MELANIN, which provides Crust
protection from ultraviolet radiation. Litchenification

• Dermis Documenting skin lesions

– contains collagen and elastin fibers, which give strength and • Color
elasticity to the tissues. • Redness, heat, pain, swelling
– The sebaceous (oil-producing) and eccrine (sweat producing) glands • Size and location
are located in the subcutaneous tissue, as are the hair and nail follicles • Patterns of eruptions
and the sensory nerve receptors. • Distribution of lesions

• Subcutaneous tissue Consequence of Systemic Disease

– consists of areolar connective tissue, which connects the skin to the • Diabetes, diabetic dermopathy
muscles, and adipose tissue, which provides a cushion over tissue and • Stasis dermatitis
bone. • Leg and foot ulcers
– Insulation to regulate body temp. • HIV
– WBCs are available to protect from microbial invasion through the • Skin infections
skin. – Bacterial
– Blood vessels in the SQ supply the tissue with nourishment and assist – Fungal
in the process of heat exchange. – Dermatophyte

Normal Aging Changes Nails and Hair

• Thinning of skin • Nails: configuration, color, consistency
• Uneven pigmentation – Beau lines
• Wrinkling, skin folds, and decreased elasticity – Ridging, hypertrophy
• Dry skin – Pitted surface, spooning
• Diminished hair – Clubbing
• Increased fragility and increased potential for injury
• Reduced healing ability Hair: color, texture, distribution
• Albinism
Assessment of the Skin • Hair loss
• Preparation of the patient: explain purpose, provide privacy and
coverings Diagnostic Procedures
• Assessment questions • Skin biopsy
• Inspect entire body, including mucosa, scalp, hair, and nails • Patch testing
• General appearance; color, temperature, moisture, texture • Skin scrapings
• Assess any lesions; palpate and measure • Tzanck smear
• Note hair distribution • Wood light examination
Management of Patients With Dermatologic Disorders • Contagious
• Objectives of therapy are to prevent additional damage, prevent • Spread to other parts of the body or to others who touch the patient
secondary infection, reverse inflammatory processes, and relieve or use towels or combs
symptoms • Common in children living in poor hygienic conditions.
• Nursing care includes administration of topical and systemic • It often follows pediculosis capitis (head lice), scabies (itch mites),
medications, wound care and dressings, and providing for patient herpes simplex, insect bites, poison ivy, or eczema.
Hygiene
• Nursing management includes obtaining a health history, direct Folliculitis, furuncles, and carbuncles
observation, complete physical assessment and educating on self- • Folliculitis is an infection of bacterial or fungal origin that arises
Care within hair follicles.
• Commonly affects the beard area of men who shave, as well as
Nursing goals include: women’s legs.
Maintenance of skin integrity • Caused by staphylococci
Relief of discomfort • A furuncle (boil) is an acute inflammation arising deep in one or more
Promotion of restful sleep hair follicles and spreading into the surrounding dermis.
Self-acceptance • Furunculosis refers to multiple or recurrent lesions.
Knowledge about skin care • Back of the neck, axillae, buttocks.
Avoidance of complications • May start as a small, red, raised, painful pimple.
• A carbuncle is an abscess of the skin and subcutaneous tissue that
Pruritus represents an extension of a furuncle
• Most common symptom of dermatologic disorders • More likely to occur in patients with underlying systemic diseases,
• May be first indication of internal disease: diabetes, blood disorder, such as DM or hematologic malignancies, immunosuppressed pts.
cancer • More prevalent in hot climates, especially on skin beneath occlusive
clothing.
Causes:
• Medications: aspirin, antibiotics, hormones, opioids Viral Infections
• Soaps and chemicals, radiation therapy, prickly heat • Herpes zoster, also called shingles
• Psychological factors • Characterized by a painful vesicular eruption along the area of
distribution of the sensory nerves
Care for the Patient with Pruritus • After a chickenpox, the VZV responsible for the outbreak lies dormant
• Reinforce prescribed therapeutic regimen inside nerve cells near the brain and spinal cord.
• Educate on self-care • Because of declining cellular immunity, they travel by way of the
• Use tepid water for bath peripheral nerves to the skin, where the viruses multiply and create a
• Avoid rubbing vigorously with towel red rash of small, fluid-filled blisters.
• Lubricate skin after bathing
• Avoid situations that cause vasodilation Patient Education: Viral Infections
• Overly warm environment • Herpes zoster: instruction regarding prescribed antiviral medications,
• Ingestion of alcohol, hot foods, and liquids lesion care, dressings, and hand hygiene

Gerontologic Considerations Types of Herpes Simplex

• Pruritus occurs frequently in elderly as a result of dry skin. 1. Orolabial Herpes
• Elderly people are also more likely to have a systemic illness that • AKA Fever blisters or cold sores,
triggers pruritus • Erythematous grouped vesicles on the lips
• Higher risk for occult malignancy, and are more likely to be taking • Tingling or burning with pain
multiple medications than younger people. • Sunlight exposure or increased stress
• More often in children and young adults
Infectious Diseases of the Skin 2. Genital Herpes
• Grouped vesicles on an erythematous base initially involving the
Bacterial infections vagina, rectum, or penis.
• Impetigo • New lesions can continue to appear for 7 to 14 days.
• Folliculitis, furuncles, and carbuncles • Begin with a prodrome of burning, tingling, or itching about 24 hours
Viral infections before the vesicles appear.
• Herpes zoster Patient Education: Viral Infections
• Herpes simplex: orolabial, genital • Herpes simplex: instruction regarding prescribed antiviral
Fungal infections medications and prophylactic medication use, instruction regarding
• tinea pedis, tinea corporis, tinea capitis, tinea cruris, tinea unguium spread of herpes, and measures to reduce contagion of partner or of
neonates born to mothers with genital herpes
Bacterial infections
• AKA pyodermas, pus-forming bacterial infections of the skin Fungal infections
• Staphylococcus aureus, group A streptococci • Most common fungal skin infection is tinea, which is also called
• Impetigo RINGWORM because of its characteristic appearance of a ring or
• Folliculitis - furuncles or carbuncle rounded tunnel under the skin
• Affect the head, body, groin, feet, and nails.
IMPETIGO tinea Capitis (head)
• Superficial infection of the skin caused by staphylococci, streptococci, Tinea Corporis (body
or multiple bacteria. Tinea Ungum (toenails)
• Bullous impetigo Tinea cruris (groin; “jock itch”
• more deep-seated infection of the skin caused Tinea pedis (foot; “athlete’s foot”)
• formation of bullae (large, fluid-filled blisters)
Patient Education: Nursing Process: The Care of the Patient With Psoriasis—Assessment
Fungal Infections • Appearance of the skin
• Medications, use of oral and topical agents, and shampoos - Classic plaque-type lesions
• Use clean towels and washcloths every day • Assess nail and scalp involvement
• Do not share towels • Coping of the patient with condition
• Keep skin folds and feet dry • Note impact of the disease on patient activities and interactions
• Wear clean, dry, cotton clothing (underwear & socks)
• No synthetic underwear, tight-fitting garments, wet bathing suits, and Nursing Process: The Care of the Patient With Psoriasis—Diagnoses
plastic shoes • Deficient knowledge
• Avoid excessive heat and humidity • Impaired skin integrity
• Hair loss associated with tinea capitis is temporary • Disturbed body image

Parasitic Skin Infestations Interventions

• Pediculosis (lice): pediculosis capitis, pediculosis corporis, Phthirus
pubis
• Scabies (mites): Sarcoptes scabiei
Patient Education: Pediculosis Capitis
• Head lice may infest anyone and are not a sign of uncleanliness
• Shampoo (lindane [Kwell] or pyrethrin [RID]) and combing of hair
with fine-tooth comb dipped in vinegar to remove all nits
• Clothing and bedding must be disinfected, washed in hot water, or
dry cleaned. Furniture and floors should be frequently vacuumed
• Do not share combs, hats, and so on
• All family members and close contacts must be treated
Patient Education: Pediculosis Corporis and Pubis
• Related to poor hygiene
• Pediculosis pubis is chiefly by sexual contact
• All clothing and bedding must be washed in hot water or dry cleaned
• Patient and partner should also be scheduled for checkup
Patient Education: Scabies
• Mites frequently involve fingers, and hand contact may spread
infection.
• Health care personnel should wear gloves
• Take a warm, soapy bath; allow skin to cool; and apply prescription
scabicide lindane, crotamiton, or 5% permethrin to entire body, not
including the face or scalp. Leave on for 12 to 24 hours
• Wash clothing and bedding in hot water and dry in a hot dryer
• Treat all contacts at the same time
• Repeat the treatment in 1 week to prevent reinfestation
• Pruritus may continue for several weeks and does not mean
retreatment is required
NONINFECTIOUS INFLAMMATORY DERMATOSES
• Pt education regarding the disease, skin care, and treatment regimen
• Measures to prevent skin injury: avoid picking or scratching
• Measures to prevent skin dryness: use of emollients, avoid excessive
washing, and use warm (not hot) water, pat dry
• Use of the therapeutic relationship for support and to aid coping
Exfoliative dermatitis
• Serious condition & inflammation w/ generalized erythema and
scaling
• Associated with chills, fever, prostration, severe toxicity, and a
pruritic scaling of the skin.
• Because of widespread dilation of cutaneous vessels, large amounts of
body heat are lost
• Preexisting skin disorders hat have been implicated include psoriasis,
atopic dermatitis, and contact dermatitis, severe reaction to many
medications.
Management
• Maintain fluid and electrolyte balance and to prevent infection.
• Comfortable room temperature should be maintained because the
patient does not have normal thermoregulatory control as a result of
temperature fluctuations caused by vasodilation and evaporative water
loss.
• Fluid and electrolyte balance must be maintained because there is
considerable water and protein loss from the skin surface.
• Administration of plasma volume expanders may be indicated
Blistering Diseases
• Bacterial, fungal, viral infections
• Allergic contact reactions
• Burns
• Metabolic disorders
• IgG autoimmune reactions
- Pemphigus vulgaris
- Pemphigus foliaceus
- Paraneoplastic pemphigus

Psoriasis Pemphigus
• A chronic, autoimmune, inflammatory disease of the skin in which • Group of serious diseases of the skin characterized by the
epidermal cells are produced at an abnormally rapid rate appearance of bullae (blisters) of various sizes.
• Periods of remission and exacerbation throughout life • An autoimmune disease involving IgG.
• May be aggravated by stress, trauma, seasonal and hormonal changes • Genetic factors
• Treatment: baths to remove scales and medications • Medication Reaction
Assessment
Medical Management • Appearance of the skin
• Goals: slow rapid turn over of epidermis, promote resolution of • Monitor VS and assess for s/s of infection
psoriatic lesions, control disease cycle • Pain, pruritus, and discomfort
• Remove scales during bath using soft brush, apply emollient • Coping of the patient with condition
creams after, maintain routine • Note impact of the disease on patient activities and interactions
• Pharmacologic therapy
• Topical Nursing Diagnoses
• Phototherapy • Acute pain: skin and oral cavity
• Systemic • Impaired skin integrity
• There is no known cure! • Disturbed body image
• Risk for infection
• Deficient fluid volume due to loss of tissue fluids
Interventions
• Meticulous oral hygiene
• Avoid commercial mouthwashes
• Keep lips moist with lip balm, petroleum, or lanolin
• Cool mist humidified air
• Cool, wet dressing or baths; hygiene measures
• Apply powder liberally to keep skin from adhering to sheets
• Monitor for and prevent hypothermia
• Skin care may be similar to that of the patient with extensive burns
• Measures to prevent secondary infections
• Encourage adequate fluid and nutritional intake

Goal
• Prevent loss of serum and the development of secondary infection
• Corticosteroids
• Immunosuppressive agents
• Plasmapheresis
• plasma, is separated from the blood cells. Typically, the plasma is
replaced with another solution such as saline or albumin, or the plasma
is treated and then returned to your body.

Toxic Epidermal Necrolysis (TEN) & Stevens-Johnson Syndrome (SJS)

• Potentially fatal skin disorders and the most severe forms of erythema
multiforme.
• Mortality rate from TEN is 30% to 35%. TEN and SJS are triggered by
a reaction to medications.
• Occur in all ages and both genders.
• SJS and TEN are clinically similar except for their distribution.
• Changes affect < 10% of body surface area in SJS and > 30% of body
surface area in TEN
• People who are immunosuppressed, including those with HIV
infection and acquired immunodeficiency syndrome (AIDS), have a
high risk of TEN and SJS.
Assessment
• Skin, oral cavity inspection
• VS
• Fatigue, pain levels
• Urine volume, specific gravity, and color monitored
• Local s/s infection at IV site
• Daily weight
• Evaluate for anxiety and coping mechanisms

Nursing Diagnoses
• Impaired tissue integrity (i.e., oral, eye, and skin) related to epidermal
shedding
• Deficient fluid volume and electrolyte losses related to loss of fluids
from denuded skin
• Risk for imbalanced body temperature (i.e., hypothermia) related to
heat loss secondary to skin loss
• Acute pain related to denuded skin, oral lesions, and possible
infection
• Anxiety related to the physical appearance of the skin and prognosis

Interventions
• Maintaining skin and mucous membrane integrity
• Attaining fluid balance
• Preventing hypothermia
• Relieving pain
• Prevent infection, consider reverse isolation
• Reducing anxiety
• Monitoring and managing potential complications
• Promoting home and community-based care