Interventions for

Clients with Skin

Problems

April Joy R. Alis, RN

 XEROSIS (DRYNESS)
A common problem among older
clients.
Aka Xerosis Cutis. Xeros comes from
the Greek and means dry.
Fine flaking of the stratum corneum.
The condition of dehydrated skin with
redness of the skin (erythema), intense
itching, fine cracking of the skin and
dry scaling.
 Collaborative
Management
Nursing interventions aim to
rehydrate the skin and relieve
itching.
Bathing with moisturizing soaps, oils,
and lotions may reduce dryness.
Water softens the outer skin layers;
creams and lotions seal in the
moisture provided by water.
 GENERAL PRURITUS
Pruritus is caused by stimulation of
itch-specific nerve fibers at the
dermal-epidermal junction.
Itching is a subjective symptom
similar to pain.
Itching as the most common
symptoms which results to rash or
lesions.
Rapid onset, severe and interferes
ADLs.
May be the first indication of a
systemic internal disease such as
DM, blood disorders or cancer.
Caused by oral medications,
hormones, opioids, certain soap or
chemicals.
 Pathophysiology
Scratching inflamed cells and
nerve endings to release histamine
produces more pruritus
excoriation, redness and raised areas
infections.
 B =Blood disease
L =Liver disease
I =Infection,immunological or
autoimmune
disease
N =Neoplastic disease,neurological
disease
K =Kidney disease
E =Endocrine disease
D =Drug
 Nursing Management
Instruct patient to use tepid (not hot) water
and blot excess water with special attention
on body folds.
Avoid exposure to overly warm environments.
Avoid alcohols, hot foods and liquids
Use humidifier if environment air is dry.
Avoid activities that result to perspiration
Advice wearing cotton clothing.
Cool sleeping environment is helpful.
Trimmed nails to prevent skin damage and
infections when scratching.
 Collaborative
Management
Balneotherapy is a therapeutic bath
using colloidal oatmeal.
Therapy:
Antihistamines
Topical steroids
 SUNBURN
First-degree,
superficial burn
Cool baths
Soothing lotions
Antibiotic
ointments for
blistering and
infected skin
Topical
corticosteroids for
pain
 URTICARIA
AKA hives
Urticaria: presence of white or red
edematous papules or plaques of
varying sizes
Allergic reactions
Acute vs. Chronic urticaria
 URTICARIA
Removal of triggering substances
Antihistamines helpful
Avoidance of overexertion, alcohol
consumption, and warm
environments, which can worsen
symptoms
URTICARIA
 BACTERIAL INFECTIONS
Folliculitis: superficial infection
involving only the upper portion of the
follicle
Furuncles/Boils: much deeper infection
in the follicle
Cellulitis: generalized infection with
either Staphylococcus or
Streptococcus involving deeper
connective tissue
 ECZEMA
Atopic dermatitis is a superficial
inflammatory process involving the
epidermis.
Associated with family history, IgE level
elevations, allergies and excessive water
exposure as in frequent hand washing.
Goal of treatment relieve pruritus,
lubricate the skin, reduce inflammation
and prevent/control secondary
infections.
 Forms of Eczema
Infantile begins at 2-6 months and
decreases with aging, spontaneous
remission may occur by age 3.
Childhood follow infantile form and
occurs at 2-3 years of age
Preadolescent and adolescent
begins at 12 yrs of age and may
continue until early adult or indefinitely.
Classifications
contact dermatitis
drug related
photoeczematous dermatitis
primary irritants
Assessment
Redness
Scaliness
Weeping, oozing and crusting
lesions
Itching and minute papules
Adolescent and early adult forms
commonly occur in antecubital and
politeal areas.
Assess if regional lymph nodes are
swollen and irritability may be
present.
Interventions
Avoid exposure to skin irritants such as
soaps, detergents, fabric softeners, diaper
wipers and powder.
Avoid excessive bathing and washing of
affected areas; lubricate skin.
Medication may include cetaphil
Intermittently apply cool, wet compresses
for short periods to soothe the skin, pat dry
between cooling treatments.
Administer antihistamines and topical
corticosteroids as prescribed.
Administer prescribed antibiotics if
secondary infections occur.
Prevent or minimize scratching; keep nail
short and clean and place gloves or cotton
 Eliminate conditions that increase
itching such as wet diapers, excessive
bathing, ambient heat, woolen clothes
and proximity to rough fabrics or
furry stuffed animals
Instruct the parents to wash clothing
in a mild detergent and rinse
thoroughly.
Instruct the parents about measures
to prevent skin infections.
Instruct the parents to monitor the
lesions for signs of infection (honey-
colored crusts with surrounding
erythema and to seek immediate
 IMPETIGO
Highly contagious bacterial infections of the
skin caused by beta A - hemolytic streptococci/
staphylococci or even both.
Affect people of all ages.
Can occur because of poor hygiene or at the
injured site as secondary infections and/or
caused by exposure to poison ivy, tropical
climates and improper sanitations.
Most common sites of infection are face,
around the mouth and then hands, neck and
extremities.
Serious complication glomerulonephritis
 Lesions begin as vesicles or pustules
surrounded by edema and redness.
(Pustules are similar to a vesicle
except its fluid content is purulent).
Lesion progress to an exudative and
crusting stage, vesicular fluid becomes
cloudy and vesicles rupture, leaving
honey-colored crust covering ulcerated
bases.
Assessment
Lesions
Erythema
Pruritus
Burning
Secondary lymph node involvement
Interventions
Contact isolation; use standard precautions
and implement agency- specific isolation
procedures for the hospitalized child.
Strict hygiene practices are important
because it is a highly contagious condition.
Allow lesions to dry by air exposure
 Assist the child with daily bathing
with antibacterial (hexachlorophene)
soap as prescribed.
Apply warm saline or other
prescribed compresses to the lesions
2 0r 3 times daily, followed by soap
and water to remove crusts and allow
for healing.
Apply topical antibiotic (bacitracin/
muporicin) ointments and instruct
parents in their use, infection is still
communicable for 48 hours beyond
initiation of antibiotic treatment.
Apply and instruct the parents in the
 Adherence to prescribed antibiotic is
extremely important because
secondary infections such as
glomerulonephritis may occur.
Instruct the parents in the methods
to prevent the spread of infections
such as hand washing.
Inform parents that the child needs to
use separate towels, linens and
dishes.
Inform parents that linens and
clothing should be washed with
 ACNE VULGARIS
Is a disorder of the skin with eruption of
papules or pustules primarily due to
increased production of sebum from the
sebaceous glands.
Affects adolescents and young adult
between 12 to 35 yrs of age.
Non-inflammatory composed of whiteheads
and blackheads in the follicular duct.
Inflammatory result from action of certain
bacteria (propionibacterium acnes) that live
in the hair follicles and breakdown the
triglyceride of the sebum into free fatty acids
and glycerine.
 ACNE
Red pustular eruption affecting the
sebaceous glands of the skin
Progressive disorder that manifests
as non-inflammatory comedones,
inflammatory papules, pustules, and
cysts
Topical agents
Systemic antibiotics and possibly
isotretinoin (Accutane) possibly
helpful
 Characterized by comedones (primary
acne lesion), both close and open and by
papules, pustules, nodules and cysts.
Affected by hormone level (androgen)
which block the secretions with
subsequent blackheads accumulation of
lipid, bacterial and epithelial debris.
Pathophysiology
Androgens stimulate the sebaceous gland
enlarge and secrete natural oil, sebum
rises to the top of the hair follicle flows
out on the skin surface accumulated
materials forms comedones.
Treatment options
Oral contraceptives reduce sebum
production
Desquamation preparations which free the
flow of sebum.
Accutane specifically for severe acne.
Contraindicated for pregnancy, monitor for
 Retin-A (tretinoin) a topical cream to reduce
scarring from acne.
Benzyl peroxide produce rapid and
sustained reduction of inflammatory lesions.
Mechanical removal by an extractor.
Complete cleansing with regular or
Neutrogena soap and clean towels.
Mild facial erythema via sunlight or lamp.
Topical antibiotics (tetracycline,
clindamycine and erythromycin) suppress
growth of P. acnes.
Systemic oral tetracycline, doxycycline and
minocycline for moderate to severe cases.
Dermabrasion for selected cases, to reduce
scarring.
 Implementations
Teach good skin and scalp hygiene.
Avoid squeezing, rubbing and picking
Avoid greasy cleansing creams and
cosmetics.
Support a high protein and low fat diet and
eliminate seaweed products which aggravate
condition.
Avoid food such as chocolate, cola, fried
foods or milk products.
Adequate rest and sunshine
Provide emotional support for body image and
relationship problems.
 Interventions
Teach good skin and scalp hygiene.
Avoid squeezing, rubbing and picking
Avoid greasy cleansing creams and
cosmetics.
Support a high protein and low fat
diet and eliminate seaweed products
Avoid food such as chocolate, cola,
fried foods or milk products.
Adequate rest and sunshine
Provide emotional support
 FUNGAL INFECTIONS
Dermatophyte infections can differ in
lesion appearance, anatomic location,
and species of the infecting organism.
The term tinea describes
dermatophytoses.
a. Tinea capitis d. Tinea barbae
b. Tinea pedis e. Tinea manus
c. Tinea cruris f. Tinea corporis
 Skin Care
Meticulous skin care and prevention
of spread of infection.
Frequent proper hand washing to
reduce the spread of pathogenic
organisms.
Frequent proper hand washing
Sunscreen
Elevate extremities
 Drug Therapy for Skin
Disorders
Antibacterial drugs
Antifungal drugs
Anti-inflammatory drugs
 PEDICULOSIS
Pediculosis -
infestation by human
lice
Head lice:
Pediculosis capitis
Body lice:
Pediculosis corporis
Pubic or crab lice:
Pediculosis pubis
 Pediculosis
Pruritus most common symptom
Drugs such as Bio-Well, Kwell,
Kwellada, Ovide, or Prioderm
Laundering of clothing and bed linen
 SCABIES
Sarcoptes scabiei
Scabies is derived from the Latin word
scabere, which means to scratch
Scabies is a contagious skin disease
caused by mite infestations.
Scabies is transmitted by close and
prolonged contact or infested bedding.
Examine skin between fingers and on the
palms.
Infestation is confirmed by an
examination of a scraping of a lesion
under a microscope.
 Assessment
Pruritic popular rash
Burrows on the skin (fine grayish-fine
lines that may be difficult to see).
Itching is more intense than with
pediculosis and becomes unbearable
at night.
Hypersensitivity to mite results in
excoriated erythemathous papules,
pustules and crusted lesions on the
elbows, nipples, lower abdomen,
buttocks, thighs and axillary fold.
 Intervention
Topical application of a scabicide such
as lindane (Kwell) or permethrin.
Lindane should not be used in
children younger than 2 years
because of the risk of neurotoxicity
and seizures.
If skin have infected scratch marks or
pustules on it, treat the infection first
before treating itch itself.
 Instruct the parents in application of
the scabicide
Household members and contacts
of the infected child need to be
treated the same.
Instruct the parents about the
importance of frequent hand
washing.
 Instruct the parents that all clothing,
bedding and pillow cases used by
the child need to be changed daily,
wash in hot water, dried in hot dryer
and ironed before reuse.
Instruct the parents that non-
washable toys and other items
should be sealed in plastic bags.
If skin still feels irritated, take starch
baths for half an hour once or twice
a day.
 Scabies (Continued)
Scabicides include Kwell, Kwellada,
or topical sulfur preparations.
Launder clothes and personal items.
 COMMON
INFLAMMATIONS
Contact dermatitis is a term for askin
reaction resulting from exposure to
allergens(allergic contact dermatitis)
orirritants (irritant contact dermatitis).
Clinical Manifestations: red rash, blisters or
wheals, itchy, burning skin.
Interventions
Elevate affected area to reduce edema
Apply cool, wet dressings and tepid
sponge bath as prescribed.
Maintain a cool environment.
 Protect affected area from trauma.
Prevent scratching and rubbing of
the affected area.
Instruct client to avoid contact with
the identified allergen.
Instruct client to avoid harsh soaps.
Instruct the client to avoid using
heating pads or blankets.
Administer antibiotic, antipruritic or
antihistamine, and/or corticosteroid
 Atopic dermatitis (Eczema)
Forms of Eczema: Infantile, Childhood
Assessment : triad of conditions that
includes asthma, inhalant allergies (hay
fever), and a chronic dermatitis (eczema).
extremely itchy and inflamed, causing
redness, swelling, vesicle formation
(minute blisters), cracking, weeping,
crusting, and scaling, drying of skin
Interventions
Avoid exposure to skin irritants
Avoid excessive bathing and washing of
affected areas; lubricate skin.
 Intermittently apply cool, wet compresses
for short periods to soothe the skin, pat
dry between cooling treatments
Administer antihistamines and topical
corticosteroids as prescribed.
Administer prescribed antibiotics if
secondary infections occur.
Prevent or minimize scratching
Eliminate conditions that increase itching
Instruct the parents to wash clothing in a
mild detergent and rinse thoroughly.
Instruct the parents to monitor the lesions
for signs of infection
 PSORIASIS
Lifelong disorder
with exacerbations
and remissions
Scaling disorder
with underlying
dermal
inflammation;
possibly an
autoimmune
reaction
 Psoriasis
Psoriasis vulgaris most often seen
Exfoliative psoriasisan explosively
eruptive and inflammatory form of the
disease
Five types of psoriasis: plaque, guttate,
inverse, pustular, and erythrodermic.
Diagnostic Studies
Based on appearance
Skin biopsy or scraping
 Treatment of Psoriasis
Bath solutions andmoisturizers,mineral oil,
andpetroleum jelly
Topical steroids: corticosteriods
Tar preparations
Ultraviolet light therapy, vitamin D, sunlight
Systemic therapy
Cytotoxic agents
Immunosuppressants
Biologic agents
Emotional support
WOUND
CLASSIFICATION OF
WOUNDS
1.Mechanism of injury
a) Incision- open wound;
painful;deep;shallow
b) Contusion-closed wound, skin appears
ecchymotic (bruised).
c) Abrasion-open wound involving the
skin; painful
d) Puncture-open wound which penetrates
the skin and underlying tissues.
e) laceration-made by object that tears
tissues
f) Penetrating wounds-open wound
that penetrates the skin and the
underlying tissues.
2. According to depth
a) Partial thickness- confined to the
skin
b) Full-thickness- involving the dermis,
epidermis, subcutaneous tissues
and possibly muscle and bone.
Decubitus ulcer
Gunshot wound
Stab wound
Lacerating wound
3. Degree of contamination
a) Clean -an aseptically made wound, that
does
not enter the alimentary, respiratory or
genito-urinary tracts.
b) Clean contaminated -are surgical wounds
in which the alimentary, respiratory and
genitals or urinary tract has been entered.
c) Contaminated - wounds exposed to
excessive amounts of bacteria
d) Dirty or infected -wounds containing
dead tissues and with evidence of clinical
infection (purulent discharged).
 TYPES OF WOUND
DRAINAGE
1. Serous-clean, watery
2. Purulent- thick, yellow, green, tan or
brown.
3. Serosanguineous-pale, red, watery
mixture of serous and sanguineous.
4. Sanguineous- bright red, indicative
of active bleeding.
 PHASES OF WOUND
HEALING
1. INFLAMMATORY PHASE-starts
immediately after injury and lasts 3-6
days or 4-6 days.
2 major processes occur during this
phase
HEMOSTATIS AND PHAGOCYTOSIS
Hemostatis- blood vessels constrict,
platelets aggregates and bleeding
stops, scabs forms, preventing entry
of infectious organisms.
 Inflammation-increase blood flow, to
wound resulting localized redness
and edema, attracts WBC and wound
growth factors.
WBC arrive-clear debris from wound.
2. PROLIFERATIVE PHASE-extends
from day 3 to about day 21 post
injury.

collagen synthesis establishment

of new capillaries creation of
granulation tissue wound
contraction epitheliazation.
3. REMODELLING OR MATURATION
PHASE
-final healing stage may continue for I
year or more.

Remodeling of scar tissue to provide

wound strength.
TYPES OF WOUND HEALING
FIRST INTENTION HEALING-partial
thickness wounds.
- a clean incision is made with primary
closure, minimal scarring.
-expected when the edges of clean
surgical incisions are sutured together,
tissue loss is minimal or absent if the
wound is not contaminated with
microorganism.
-e.g.-abrasion or skin tear.
 SECOND INTENTION HEALING-
granulation
-accompanies traumatic open wounds
with tissues loss or wounds with a high
microorganisms count.
-go though a process involving scar
tissue formation a heal slowly because
of the volume of tissue needed to fill
the defect.
-e.g.-contaminated surgical wound,
pressure ulcer.
 FACTORS AFFECTING WOUND
HEALING
Developmental considerations
(healthy children and adults)
Nutrition
Lifestyle
Medications
Contamination and infection
 COMPLICATIONS OF WOUND
HEALING
1. HEMORRRHAGE
-risk of hemorrhage is greatest during
the 1st 48 hours after surgery.
-emergency - should apply pressure
dressing to the wound and monitor
vital signs.
2. INFECTION
-surgical infection is apparently 2-11
days post operatively.
- watched for presence of changed in
wound color, pain or drainage-
culturing of the wound.
3. DEHISCENCE WITH POSSIBLE
EVISCERATION
-may occur 4-5 days postoperatively.
-involves an abdominal wound in which
the layers below the skin separates.
- an increase in flow of serosanguinous
drainage into the dressing can indicate
 impending dehiscence.
- If occurs should be quickly
supported by sterile dressing soaked
in sterile normal saline.
-position? Client in bed with knees
bentwhy? To decrease pull on the
incision. and? Notify physician
Wound evisceration from
stab wound
Wound dehiscence
Infected wound dehiscence
WOUND ASSESSMENT PARAMETERS
Etiology
Location of the wound
Stage of wound/extent of tissue loss
Phase of healing
Wound size
Presence of undermining, sinus tracts or
tunnels
Condition of the wound bed
Volume of exudates
Condition of periwound skin
Presence of pain
 WOUND MANAGEMENT
1. DRESSINGS - material applied to
wound with or without medication, to
give protection and assist in healing.
-what are the purposes?
a)To protect the wound from mechanical
injury
b)Splint or immobilized the wound.
c)Absorbs dressing
d)Prevent contamination from bloody
discharges
e.) Promote homeostasis (pressure
dressing)
f.) Debride the wound
g.) to kill or inhibit microorganism
h.) provide a physiologic
environment conducive to healing
i.) provide mental and physical
comfort for the patient.
Pressure dressing
What are the types of dressings?
a. DRY TO DRY DRESSINGS
-used primarily for wounds closing
by primary intention.
>adv-offers good protection,
absorption & provide pressure
>dadv-they adhere to the wound
surface when drainage dries.
- when remove can cause pain
and disruption of granulation
tissue.
 b. WET TO DRY DRESSINGS
-used for untidy or infected wounds
that must be debrided and closed
by secondary intention.
>how can it be done?
-gauze saturated with sterile saline
or antimicrobial soln. is packed
into the wound, the wet dressing
are then covered by dry dressings
>when to changed?
-when it becomes dry
 Indication
The objective of the wet-to-dry dressing
technique is to clean a wound or to
prevent build-up of exudate. It is called
a wet-to-dry dressing because you
place a moist dressing on the wound
and allow it to dry. When the dressing is
removed, it takes with it the exudate,
debris, and nonviable tissue that have
become stuck to the gauze. Wet-to-dry
dressings are indicated for wounds that
are dirty or infected.
 Technique
Moisten a gauze dressing with solution, and
squeeze out the excess fluid. The gauze
should be damp, not soaking wet.
Completely open the gauze (it usually comes
folded), and place it on the wound. You do
not need many layers. Then cover with a
thin layer of dry gauze. When changing the
dressing, pour a few mlof saline (or water)
on the bottom layer of gauze if it has
completely dried out. This technique
prevents the removal of healthy new tissue
from the surface of the wound. Remove the
dressing gently to avoid causing pain.
 How Often?
Optimally, a wet-to-dry dressing
should be changed 34 times/day,
depending on how much
debridement is needed. The dressing
should be changed more frequently
for a dirty wound than for a clean
wound. Gradually the wound will
become cleaner and heal.
 b. WET TO WET DRESSINGS
-used on clean open wounds or on
granulating surfaces.
>adv-provide a more physiologic
environment (warmth moisture)
which can enhance the local healing
processes and assure greater patient
comfort.
>dadv-surrounding tissues can
become ulcerated. high risk for
infection.
 Indication
A wet-to-wet dressing does not
debride the wound, which remains as
it is. The dressing remains wet so
that when the gauze is removed, the
top layers of the healing wound are
not removed with it. This dressing
should be used on clean, granulating
wounds with no overlying exudate in
need of removal.
 Technique
Moisten the gauze dressing with
solution. It should not be soaking
wet, but it should be a little wetter
than damp. Unfold the gauze, place it
over the wound, and then cover with
dry gauze. The dressing should still
be wet or damp when it is changed.
If the bottom layer of gauze has
dried out, saturate the gauze with
saline or water before removal.
 How Often?
The wet-to-wet dressing should be
changed at least twice a day to
prevent drying.
 2. DRAINS- device or a tube used to
draw fluids from an internal body
cavity to the surface.
-what are the purposes?
a)placed in the wounds only when
abdominal fluid collections are present.
b)placed near the incision site
> wound drainage-drains placed within
the wounds are attached to a portable
suction with a collection container.
e.g. hemovac, jackson-pratt, penrose
drain.
 3. BINDERS AND BANDAGES
-what are the purposes?
a)Creates pressure over the body
parts
b)Immobilize body parts
c)Reduce or prevent edema
d)Secure a splints
e)Secure dressing
UNEXPECTED OUTCOMES &
RELATED INTERVENTIONS
1. Inflamed and tender wounds which
evidence of drainage and foul odor.
N@ a. Monitor clients for signs of infection

(fever, increase in WBC count).

b. notify physician
c. obtain wound culture as ordered.
2. Increase wound drainage
N@ a. changed dressing frequently
b. notify physician
3. Wound bleeds during dressing change
 PRESSURE ULCER
Tissue damage caused when the skin and
underlying soft tissue are compressed
between a bony prominence and an
external surface for an extended period.
Pressure ulcers may be caused by
inadequate blood supply and resulting
reperfusion injury when blood re-enters
tissue
Mechanical forces that create ulcers:
Pressure, Friction, Shear
PRESSURE ULCER
 Identification of High-
Risk Clients
Activity/mobility
Nutritional status
Incontinence
Mental status/decreased sensory
perceptionclient at risk for pressure
ulcers
Diminished Sensation
Excessive Body Heat
Advanced Age
Smoking
 Bedbound patients are most at risk of
developing bed sores on their:
Ankles
Back of the head
Breasts (female patients)
Elbows
Genitals (male patients)
Heels
Knees
Rims of the ears
Shoulder blades
Shoulders
Toes
 Wound Assessment
Stage I:A reddened area on the skin that,
when pressed, does not turn white. This is a
sign that a pressure ulcer is starting to develop.
Stage II:The skin blisters or forms an open
sore. The area around the sore may be red and
irritated.
Stage III:The skinnow develops an open,
sunken hole called a crater. There is damage to
the tissue below the skin.
Stage IV:The pressure ulcer has become so
deep that there is damage to the muscle and
bone, and sometimes to tendons and joints.
Pressure Ulcer
 Impaired Skin Integrity
Interventions include:
Individual client needs
Nonsurgical management:
dressings, physical therapy, drug
therapy, diet therapy, new
technologies, electrical stimulation,
vacuum-assisted wound closure,
and hyperbaric oxygen therapy
 Turning and repositioning the patient
remains the cornerstone of
prevention and treatment through
pressure relief.
Nutritional status should be
evaluated and optimized to ensure
adequate intake of calories, proteins,
and vitamins.
 DO NOT!
Massage the skin near or on the
ulcer. It can cause more skin
damage.
Use a donut-shaped or ring-shaped
cushions. They interfere with blood
flow to that area and cause
complications.

Elsevier items and derived items 2006 by Elsevier Inc.

 Surgical Management
Preoperative care
Operative procedures
Postoperative care
Do not disturb dressing.
Ensure complete rest of grafted
area.
Ensure care of pedicle flap.
Provide postoperative care of
donor sites.
Ensure correct client positioning.
 Debridement
Necrotic tissue should be removed in
most pressure ulcers.
Necrotic tissue is an ideal area for
bacterial growth, it has the ability to
greatly compromise wound healing.
There are at five ways to remove necrotic tissue.
1. Autolytic debridement is the use of
moist dressings to promote autolysis with the
body's own enzymes and white blood cells. It
is a slow process, but mostly painless and is
most effective in patients with good immune
systems.
2. Biological debridement, or maggot
debridement therapy, is the use of medical
maggots to feed on necrotic tissue and
therefore clean the wound of excess bacteria.
Although this fell out of favour for many years,
in January 2004, the FDA approved maggots as
a live medical device
 3. Chemical debridement, or
enzymatic debridement, is the use of
prescribed enzymes that promote the
removal of necrotic tissue.
4. Mechanical debridement, is the
use of debriding dressings, whirlpool or
ultrasound for slough in a stable wound
5. Surgical debridement or Sharp
Debridement is the most fastest
method, as it allows a surgeon to
quickly remove dead tissue.
 Risk for Infection and Wound
Extension
Interventions:
Monitor the ulcers progress.
Provide timely treatment with
topical and systemic antibiotics.
Take steps to reduce
introduction of pathogenic
organisms to the ulcer through
direct contact.
 Prevention of Infection and
Wound Extension
Interventions:
Report the following to the primary
health care provider:
Sudden deterioration of the ulcer,
increase in size or depth of the
lesion
Changes in color or texture of the
granulation tissue
 Complications:
Sepsis
Cancer
Cellulitis
Bone and joint infections
 OVERVIEW
Herpes simplex virus (HSV). There
are two types of HSV, HSV-1 and
HSV-2, both of which belong to a
wider group calledHerpes viridae.
Another well-known virus in this
group is varicella zoster virus, which
causes chicken-pox and shingles.

Elsevier items and derived items 2006 by Elsevier Inc.

HERPES SIMPLEX VIRUS
Type 1 herpes simplex virus:
orally, classic recurring cold sore
Type 2 herpes simplex virus:
sexual contact, genital area,
genital herpes
After first infection, virus dormant
in a nerve ganglia; no symptoms
Autoinoculation or transfer from
one part of the body to another
 Herpes Simplex Virus
(Continued)
Herpetic whitlowa form of
herpes simplex infection
occurring on the fingertips of
medical personnel who have
come in contact with viral
secretions
 Signs and Symptoms
If symptoms do occur, they will usually appear 2
to 7 days after exposure and last 2 to 4 weeks.
Itching or tingling sensations in the genital or
anal area;
small fluid-filled blisters that burst leaving small
painful sores
pain when passing urine over the open sores
(especially in women);
headaches;
backache;
flu-like symptoms, including swollen glands or
fever.
 TREATMENT
There is no cure for the herpes
simplex virus and treatment is not
essential, as an outbreak of genital
herpes will usually clear up by itself.
Prescribe a course of antiviral tablets
to reduce the severity of an outbreak.
The antiviral tablets work by
preventing the herpes simplex virus
from multiplying.
 PEMPHIGUS VULGARIS
Rare, chronic blistering disease with high
morbidity and mortality.
Caused by autoimmune (IgG) disorder
that occurs most often during middle and
old age.
Occurs in both men and women and
usually begin after the age 40.
Associated with penicillins and captopril
and with myasthenia gravis.
 Pathophysiology
Initial lesions occur on the oral mucosa

Chewing and swallowing spread of
disease with becomes difficult
appearance of new lesions on
the face and skin fold areas

Starvation occurs later lesions
(fragile, flaccid bullae) form in
the trunk

malnutrition breaking the bullae

leaves partial thickness
wounds that bleeds, weep and
form crust
 Clinical manifestation
Lesions are painful, bleeds easily and
heal slowly.
Enlarge bullae, rupture and leave large,
painful eroded areas accompanied by
crusting and oozing.
Offensive odor and bacterial super
infection is common.
Complications susceptible to secondary
bacterial infections, fluid and electrolyte
imbalance with hypoalbuminemia for
extended areas.
 Interventions
Early recognition and treatment.
Consult physician on first appearance of
lesion.
Oatmeal or starch bath make patient
more comfortable.
Compresses of 1:5000 solution of
potassium permanganate may soothe
the involved areas.
Systemic steroids and cytotoxic agents
are used to bring about remission.
Topical antibiotic creams are used to
 TOXIC EPIDERMAL NECROLYSIS AND
STEVENS-JOHNSON SYNDROME
Are potentially fatal skin disorders and
most severe forms of erythema
multiforme.
Mortality rate for TEN is 30-35%
Triggered by reaction to medications
most especially sulfonamides,
antiseizure and NSAIDs.
Occurs in all ages and both genders but
increase with older people.
2-3 cases per 1 million
 Clinical Manifestations
Conjunctival burning / itching
Cutenous tenderness
Fever, cough, sorethroat, headache,
extreme malaise and myalgias.
Mucosal involvement may damage
larynx, bronchi and esophagus.
Flaccid bullae develop; large sheets of
epidermis are shed including
finger/toenails, eyebrows and eye lashes,
total body weeping resembling partial-
thickness burn thus referred to as
scalded skin syndrome.
Diagnostic findings
Histologic studies of frozen skin cells
from fresh lesion.
History of use of medication

Medical Management
Control of fluid and electrolyte balance,
prevention of sepsis and ophthalmic
complications.
Supportive care
All medication are discontinued
temporarily.
Surgical debridement/ hydrotherapy
Corticosteroids, IVIG within 48 hrs
Temporary biologic dressing (pig skin,
Interventions
Maintain skin integrity place client on a
circular turning frame.
Apply prescribe topical agents to reduce
bacterial population in the wounds.
Warm compress
Careful oral hygiene mouthwashes are
usually prescribed to get rid of mouth
debris, soothe ulcerative areas and control
mouth odor.
Ointment / pretrolatum is applied to lips.
Attaining fluid balance v/s, uo and
sensorium are observed for hypovolemia.
Weigh client daily
Tube feeding/ parenteral nutrition may be
necessary daily calorie count
 Prevent hypothermia warm air, cotton
blankets and heat shields
Relieve pain prescribed analgesic,
emotional support and self-
management techniques.
Reduce anxiety nursing support,
honest communication and hope that
situation can be improved.
Monitor potential complications
sepsis, conjunctival retraction, scars
and corneal lesions.
 LYME DISEASE
A multisystem inflammatory disorder
caused by infection acquired through ticks
that live in wooded areas and survive by
attaching themselves to animal and human
host.
Caused by spirochete borrelia burgdorferi.
Difficult to diagnose because it
masquerades as other illness.
Assessment
First symptoms occur after several days of
tick bite.
Small red pimple, macule or papule that
spreads into a ring shaped rash in 4-20 days.
Rash may be large or small or do not occur
at all making diagnosis difficult.
Assess for flue like symptoms; headache,
stiff neck, muscle aches and fatigue,
Several weeks CNS abnormalities, heart
disease symptoms and joint pain.
Third stage arthritis progresses and large
joints are usually involved.
PCR (polymerase chain reaction) test
identifies persistent lyme arthritis that may
Implementations
Blood test usually negative during early
phases.
Administer antibiotics depends on
severity of symptoms.
Penicillin drugs given as soon as possible
shorten course of disease.
Prevention is best treatment
Avoid areas that contain ticks wooded,
grassy especially in summer months.
Wear tight-fitting clothing and spray
body with tick repellent.
Examine entire body for ticks upon
return home; remove with tweezers and
wash skin with antiseptic and preserve
 HERPES
ZOSTER/SHINGLES
Caused by reactivation of the
dormant varicella-zoster virus in
clients who have previously had
chickenpox.
Multiple lesions occur in a segmental
distribution on the skin area
innervated by the infected nerve.
Eruption lasts several weeks.
Postherpetic neuralgia occurs after
lesions have resolved.
 TREATMENT
Antivirals, such asacyclovir(Zovirax),
valacyclovir(Valtrex), orfamciclovir
(Famvir), can reduce the severity and
duration of the rash if started early
(within 72 hours of the appearance of
the rash).
Pain medications may be needed for
symptom control. Bothnonsteroidal anti-
inflammatory medicationsand narcotic
pain-control medications may be used
forpain managementin shingles.
 The affected area should be kept
clean. Bathing is permitted, and the
area can be cleansed with soap and
water.
Cool compresses and anti-
itchinglotions, such ascalamine
lotion, may also provide relief.
An aluminum acetate solution
(Burow's or Domeboro solution)can
be used to help dry up the blisters
and oozing.
 BENIGN TUMORS
Cysts
Seborrheic keratoses
Keloids
Nevi
Warts
Hemangiomas:
Nevus flammeus
Cherry hemangiomas
 SKIN CANCER
Abnormal growth of epithelial cells of the
skin tends to spread into surroundings.
Skin cancer begins as scaly or warty spots
called keratoses from which thick scales
loosen and fall off.
Others begin as waxy pimples or whitish,
blackhead-like nodules.

Cavernous hemangiomas strawberry

Etiology and Risk Factors
Actinic keratoses- premalignant lesions of
the cells; common in people with
chronically sun- damage skin.
Squamous cell carcinoma cancer of
epidermis; lesions on the ear, lip and
external genitalia are more likely to invade
and spread; occurs with chronic skin
damage from repeated injury or irritation.
Basal cell carcinoma arise from the basal
cell layer of the epidermis; genetic
predisposition and chronic irritation are
risk factors, however UV exposure is the
most common cause.
 Melanomas pigmented cancers arising in
the melanin-producing epidermal cells.
Genetic predisposition, excessive UV light
exposure and presence of one or more
precursor lesions that resemble unusual
moles are the risk factors.
Race light and less pigmented skin
Age older than 60 years old
Occupational factors
Congenital Nevus Atypical
Nevus
Skin cancers

Irregular Mole

Suspected Mole
Assessment
Family history of skin cancer.
Any past surgery for removal of skin
growth, recent changes in the size, color or
sensation of any mole, birthmark, wart or
scar.
Obtain information about occupational and
recreational activities in relation to sun
exposure
Obtain information if client has experienced
severe skin injury that resulted in a scar.
Skin Cancers

melanoma
appearance

Uncommon type
 Pathophysiology
Risk factors

Formation of lesions

Scaly or warty spot waxy

pimples/whitish/blackhead
like nodules

Grow rapidly, broader, deeper & grow slowly, small and

shallow ulcers form ulcers that bleeds easily in the center of
broad, firm nodules

Become larger, malignant cells little pain, spread over

considerable often spread through lymph to areas before they
begin to travel & surrounding underlying structuresthrough
lymph or blood channels

Metastasis to distant part of the body

Form another kind of cancer
Interventions
Non-surgical
Drug therapy topical chemotherapy with
5-fluorouracil cream is used for treatment of
multiple actinic keratoses or for widespread
superficial basal cell carcinoma. Cool
compresses and topical corticosteroid
preparations help decrease inflammation
promote comfort after treatment is
discontinued.
Drug therapy with interferon is now an
accepted treatment after surgery for
melanomas that are stage III or higher.
 Radiation therapy it is limited to older
clients with large, deeply invasive basal cell
tumors and to those who have poor risk for
surgery.
Immunotherapy melanoma vaccine; an
experimental treatment for clients with
melanoma that has spread to distant sites.
Surgical
Cryosurgery involves the local application
of liquid nitrogen to isolated lesions, causing
cell death and tissue destruction.
Curettage and electrodessication used to
destroy the cancerous cells of small lesions
with well defined borders while minimizing
damage to the surrounding uninvolved
 Excision wide excision is used with large
or poorly defined skin cancers, recurrent
tumors and deeply invasive cancers.
Mohs surgery used to treat basal and
squamous cell carcinomas. The
cancerous tissue is sectioned
horizontally in layers and each layer is
examined histologically to determine the
presence of residual tumor cells.
Prevention
Avoid sun exposure between 9am to 4 pm.
Use sunscreens with the appropriate skin
protection factor for your skin type.
 Wear hat, opaque clothing and sunglasses
when out in the sun.
Examine your body monthly for possibly
cancerous or precancerous lesions.
Seek medical advice if you note any of
the following:
Change in color, size and shape of
lesion.
Redness or swelling of the skin around
the lesion
A change in the sensation especially
itching or increased tenderness of a
lesion.

Skin Cancers

Sun damage
Bowens
disease

Sun Damage
Actinic Keratosis

Actinic
Precancerous skin growth

Basal cell
carcinoma

Melanomas
 SKIN CANCER
Actinic keratoses
Squamous cell carcinomas
Basal cell carcinomas
Melanomashighly metastatic;
survival depends on early
diagnosis and treatment
 Treatment of Skin Cancer
Drugs: topical chemotherapy 5-
fluorouracil, systemic
chemotherapeutic agents,
interferon
Radiation therapy
Immunotherapy
Surgical management
Cryosurgery
Curettage and electrodesiccation
Excision
 Surgical Management
Preoperative care
Operative procedures
Postoperative care
Monitoring for complications and
wound infection
Pressure dressings
Comfort measures
Edema and discoloration at the
operative site
 PEMPHIGUS VULGARIS
with CHRONIC
BLISTERING
Rare, chronic blistering disease
with high morbidity and mortality.
Caused by autoimmune (IgG)
disorder that occurs most often
during middle and old age.
Occurs in both men and women
and usually begin after the age 40.
Associated with penicillins and
captopril and with myasthenia
gravis.
 Clinical Manifestation
Lesions are painful, bleeds
easily and heal slowly.
Enlarge bullae, rupture and
leave large, painful eroded
areas accompanied by crusting
and oozing.
Offensive odor and bacterial
super infection is common.
Complications
 Interventions
Early recognition and treatment.
Consult physician on first
appearance of lesion.
Oatmeal or starch bath
Compresses of 1:5000 solution
of potassium permanganate
Systemic steroids and cytotoxic
agents
Topical antibiotic creams
 LEPROSY

Also called Hansens disease. A

chronic contagious, systemic
mycobacterial infection of the
peripheral nervous system.
Causative agent mycobacterium
leprae
Predisposing factors contracted
in childhood and previous contact
 Types
Tuberculoid
Lepromatous
Intermediate
 LEPROSY
Also called Hansens disease. A
chronic contagious, systemic mycobacterial
infection of the peripheral nervous system
with skin involvement characterized by the
appearance of nodules in the skin or
mucous membranes or by changes in the
nerves, leading to anesthesia, paralysis or
other changes.
Causative agent mycobacterium
leprae
Predisposing factors contracted in
childhood and previous
contact
 Clinical manifestation
Early stage loss of sensation
Paralysis of extremities
Anhydrosis
Nasal obstruction
Loss of hair (eyebrow)
Eye redness change in the skin
color
Ulcers that does not heal
Muscle weakness
 Late symptoms
Contractures
Leonine appearance
Lagopthalmus
Madarosis
Gynecomastia
Sinking bridge of the nose
Cardinal signs
Presence of Hansens bacilli in a
smear of biopsy material
Presence of localized areas of
anesthesia
Peripheral nerve enlargement
 Diagnostic exam
lepromin reactions a positive test
develops a nodule at the site of
inoculation.
Interventions
Segregate and treat open cases of
leprosy.
Full, wholesome, generous diet.
TSB for fever
Encourage patient to have a daily
cleansing bath and change of clothing.
Good oral hygiene
Meticulous skin care for ulcers
Multiple drug therapy
Paubacillary treatment 6 months
or until negative results occurs.
Rifampicin and Dapsone (drug of
choice)
Multibacillary treatment for 2
consecutive years or until negative
for leprosy test. Rifampicin,
lamprene if resistant with dapsone
and dapsone.
 Interventions
Segregate and treat open cases of
leprosy.
Full, wholesome, generous diet.
TSB for fever
Encourage patient to have a daily
cleansing bath and change of
clothing.
Good oral hygiene
Meticulous skin care for ulcers
Multiple drug therapy
 NAIL DISORDERS
Ingrown toenails can cause pain
and infection.
Treatment should be given twice
daily with soaking.
Surgical removal is a possible
option, but it is not always
successful and recurrence is
possible.
 Burns
First degree or partial thickness burn
Only epidermis is damaged
Erythema, mild edema, surface layer
shed
Healing a few days to two weeks
No scarring
 Second degree- deep partial-layer
burn
Destroys epidermis
Blisters form
Healing depends on survival of
accessory organs
No scars unless infected
 Third degree or full-thickness burn
Destroys epidermis, dermis and
accessory organs of the skin
Healing occurs from margins inward
Skin grafting may be needed
Autograft
Homograft
Rule of Nines
 GERONTOLOGIC CONSIDERATION
Protein malnutrition contributes to
increase infections.
Decrease cardiovascular, renal and
pulmonary functions increase the
needs for close supervision.
Margin of difference between
hypovolemia and fluid overload is very
small.
Suppress immunologic response,
malnutrition and metabolic stressors
further compromise elderly patients
ability to heal.
Close monitoring and prompt treatment
of complications are mandatory.
DERMATOLOGIC
AND
PLASTIC
RECONSTRUCTIVE

 Plastic/reconstructive surgery
perform to reconstruct or alter
congenital/acquired defects to
restore/improve the bodys form and
functions.
Includes
Closure of wounds
Removal of skin tumors
Repair of soft tissue injuries or burns
Correction of deformities
Repair of cosmetic defects
 Wound coverage
Skin grafts a section of the skin
is detached from its own blood
supply and transferred as free tissue
to a distant (recipient) site.
Classifications
Autograft from patient own skin.
Allograft (homograft) from donor of the
same species.
Xenograft (heterograft) from other
species.
Donor site selection
Closest possible color match
Texture and hair-bearing qualities
Thickest possible skin graft without
jeopardizing the healing of donor site.
Consider cosmetic effects of donor site.
 Donor site care
Single layer of non-adherent, fine-mesh
gauze over donor site.
Absorbent gauze dressing to absorb
blood/serum from wound.
Op-site use and provides certain
advantages.
After healing keep site soft and pliable
with cream (lanolin/olive oil).
Protect from extremes in temp.,
external trauma and sunlight.
 Nursing interventions
Instruct client to keep affected part
immobilized. Face avoid strenuous
activity; hand splint and leg keep
elevated.
Instruct to inspect dressing daily
unusual drainage or inflammatory
reactions.
After healing application of cream to
moisten the graft.
Flaps is a segment of tissue that
remains attached at one end while the
other end is moved to a recipient area.
More likely to survive than grafts.
FREE FLAPS
 Chemical face feeling involves
applying a chemical mixture to destruct
epidermis to treat fine wrinkles,
keratoses and pigment problems.
Complication is chemical burns.
Management
Reassure that after 6-8 hours, face
becomes edematous and eyelids
usually swell.
Caution to move facial muscles.
Elevate head, administer liquids
through a straw.
2nd day- patient may be permitted to
wash face with lukewarm water and
apply prescribed ointment.
Explains that redness gradually
subside over the next 4-12 weeks.
Avoid exposure to direct sunlight
SKIN PEELS LASER
RESURFACING

DERMAL
FILLERS
 Dermabrasion the epidermis and
some superficial dermis are removed
used to correct acne, scarring, aging and
sun-damage skin.
Management
Instruct client that edema occurs first
48 hrs and may cause eyelid to close.
Elevated the head of the bed to
hasten fluid drainage.
Client applies prescribed ointment to
prevent hard crusting and to keep the
abraded area soft and flexible.
Clear water for cleansing.
Advice client to avoid extreme cold
and heat, excessive straining or
lifting.
Direct or reflected sunlight should be
 DERMABRASION BOTULINUM
INJECTIONS

Botulinum
toxin type A
(Botox) can be injected to
temporarily improve the
appearance of
moderate to severe
frown lines between
the eyebrows (glabellar
 Facial Reconstructive Surgery
individualized to patients needs and
desired outcomes.
For repair of deformities or restore
normal function as possible.
Assess for clients emotional responses,
identifies strengths, coping
mechanism and family support.
Reinforce facts and clarifies
misconceptions to the extent of
disfigurement and limitations of surgery.
Instruct post-operative measures like
IV, NGT, wound flaps, skin grafts and
change in dressings.
 BLEPHAROPLASTY - Is a surgical
removal of excess skin and periorbital fat
from the upper or lower eyelid.
 Management
Maintain airway and pulmonary
function.
Relieving pain and achieving comfort.
Maintaining adequate nutrition.
Enhancing communication, improving
self- concept and promoting family
coping.
Monitoring and managing potential
complications.
 RHINOPLASTY - Rhinoplasty is the
surgical correction of nasal deformities.
BODY
CONTOURING
SURGERY (LIPECTOMY)
LIPOSUCTION
ABDOMINOPLASTY

SKIN FLAPS
 Face Lift ( rhytidectomy) removes soft tissue
folds and minimize cutaneous wrinkles on the face.
Performed to create youthful appearance.
Management
Encourage client to rest 2 postoperative days
until dressing is removed.
Elevated head of the bed, avoid neck flexion to
avoid compromising the circulation and the
suture line.
Analgesic to relieve discomfort.
Liquid diet given through straw.
Advise client not to lift or bend for 7-10 days to
decrease edema and bleeding.
Sudden pain indicates that blood is
accumulating underneath the skin flaps
report to surgeon immediately.
Stop smoking cause skin slough in some
RHYTIDECTOMY SKIN
EXPANSION
(FACE LIFT)
 Laser Treatment
Argon laser use to treat vascular
lesions. Cold compress for 6 hours to
minimize edema.
Carbon dioxide laser a precise
surgical instrument that vaporizes
and excises tissue with minimal
damage. Use for bleeding disorders,
removing nevi, tattoos, keloids, etc.
cover wound with antibacterial
ointment, analgesic for pain and
avoid sun exposure.
Pulse-dye laser- for dermatologic
surgeries such as telangiectasia and
port-wine stain. Special glasses for
personnel; apply ice to area and light