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Alterations in Skin Integrity and Would Healing. Lisa M. Dunn MSN/Ed, RN, CCRN, CNE. Exemplar: Xerosis (Dryness). A common problem among older patients Fine flaking of the stratum corneum Generalized pruritus

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Alterations in skin integrity and would healing

Alterations in Skin Integrity and Would Healing

Lisa M. Dunn MSN/Ed, RN, CCRN, CNE


Exemplar xerosis dryness
Exemplar: Xerosis (Dryness)

  • A common problem among older patients

  • Fine flaking of the stratum corneum

  • Generalized pruritus

  • Scratching may result in secondary skin lesions, excoriations, lichenification, and infection


Collaborative management
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.


Exemplar pruritus itching
Exemplar: Pruritus (Itching)

  • Pruritus is caused by stimulation of itch-specific nerve fibers at the dermal-epidermal junction.

  • Itching is a subjective symptom similar to pain.

  • “Itch-scratch-itch” cycle.

  • Cool sleeping environment is helpful.

  • Fingernails should be trimmed short.

  • Antihistamines.

  • Topical steroids.


  • The nurse is applying a topical corticosteroid to a client with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Back

  • Axilla

  • Soles of the feet

  • Palms of the hands


Exemplar sunburn
Exemplar: Sunburn with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • First-degree, superficial burn

  • Cool baths

  • Soothing lotions

  • Antibiotic ointments for blistering and infected skin

  • Topical corticosteroids for pain


Exemplar urticaria hives
Exemplar: Urticaria (Hives) with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Urticaria—presence of white or red edematous papules or plaques of varying sizes

  • Removal of triggering substances

  • Antihistamines helpful

  • Avoidance of overexertion, alcohol consumption, and warm environments, which can worsen symptoms


Exemplar trauma
Exemplar: Trauma with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Phases of wound healing:

    • Inflammatory phase

    • Fibroblastic or connected tissue repair phase

    • Maturation or remodeling phase


Question
Question with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • The nurse manager is observing a new nursing graduate caring for a burn patient in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique?

    A. Using sterile sheets and linens

    B. Performing strict hand-washing technique

    C. Wearing gloves and a gown only when giving direct care to the patient.

    D. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron


Process of wound healing
Process of Wound Healing with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Process of wound healing cont d
Process of Wound Healing (Cont’d) with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • First intention resulting in a thin scar

  • Second intention (granulation) and contraction—a deeper tissue injury or wound

  • Third intention (delayed closure)—high risk for infection with a resultant scar


Exemplar partial thickness wounds
Exemplar: Partial-Thickness Wounds with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Involve damage to the epidermis and upper layers of the dermis

  • Heal by re-epithelialization within 5 to 7 days

  • Skin injury immediately followed by local inflammation


Re epithelialization
Re-epithelialization with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Exemplar full thickness wounds
Exemplar: Full-Thickness Wounds with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Damage extends into the lower layers of the dermis and underlying subcutaneous tissue.

  • Removal of the damaged tissue results in a defect that must be filled with granulation tissue to heal.

  • Contraction develops in healing process.

  • Wound may tunnel


Exemplar pressure ulcer
Exemplar: Pressure Ulcer with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period.

  • Mechanical forces that create ulcers:

    • Pressure

    • Friction

    • Shear


Shearing force
Shearing Force with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Identification of high risk patients
Identification of High-Risk Patients with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Mental status changes

  • Independent mobility

  • Nutritional status

  • Incontinence


Pressure relieving techniques
Pressure-Relieving Techniques with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Adequate pressure relief key to prevention of pressure ulcers

  • Capillary closing pressure

  • Pressure-relief products and devices

  • Positioning


Question1
Question with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • The evening nurse reviews the nursing documentation in the patient’s chart and notes that the day nurse has documented that the patient has a stage II pressure ulcer in the sacral area. Which of the following would the nurses expect to note on assessment of the patient’s sacral area?

  • A. Intact skin

  • B. Full-thickness skin loss

  • C. Exposed bone, tendon, or muscle

  • D. Partial- thickness skin loss of the dermis


Wound assessment
Wound Assessment with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Pressure ulcers and their features are classified and assessed in four stages:

    • Stage I

    • Stage II

    • Stage III

    • Stage IV


Four stages of pressure ulceration
Four Stages of Pressure Ulceration with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Wound assessment1
Wound Assessment with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Location

  • Size

  • Color

  • Extent of tissue involvement

  • Cell types in the wound base and margins

  • Exudate

  • Condition of surrounding tissue

  • Presence of foreign bodies


Exemplar wound contamination wound infection
Exemplar: Wound Contamination/Wound Infection with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • A wound that is exposed is always contaminated but not always infected. Contamination is the presence of organisms without any manifestations of infection.

  • Wound infection is contamination with pathogenic organisms to the degree that growth and spread cannot be controlled by the body’s immune defenses.


Nonsurgical management
Nonsurgical Management with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Dressings:

    • Mechanical débridement

    • Natural chemical débridement

    • Hydrophobic material

    • Hydrophilic material


Nonsurgical therapy
Nonsurgical Therapy with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Physical therapy

  • Drug therapy

  • Nutrition therapy

  • New technologies:

    • Electrical stimulation

    • Vacuum-assisted wound closure (VAC)

    • Hyperbaric oxygen (HBO)

    • Topical growth factors

    • Skin substitutes


Hyperbaric oxygen therapy
Hyperbaric Oxygen Therapy with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Surgical management
Surgical Management with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Surgical débridement

  • Skin grafting


Community based care
Community-Based Care with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Home care management

  • Health teaching

  • Health care resources


Exemplar bacterial infections
Exemplar: Bacterial Infections with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Folliculitis—superficial infection involving only the upper portion of the follicle

  • Furuncle (boil)—much deeper infection in the follicle

  • Cellulitis—generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue


Furuncle
Furuncle with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Cellulitis
Cellulitis with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Question2
Question with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • The nurse is reviewing the health record of the patients scheduled to be seen at the health clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder?

  • A. An adolescent

  • B. An older female

  • C. A physical education teacher

  • D. An outdoor construction worker


Exemplar herpes simplex virus
Exemplar: Herpes Simplex Virus with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Type 1 herpes simplex virus (HSV-1)—classic recurring cold sore

  • Type 2 herpes simplex virus (HSV-2)—genital herpes

  • Herpes zoster (shingles)


Herpes simplex virus cont d
Herpes Simplex Virus with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?(Cont’d)

  • Herpetic whitlow—a form of herpes simplex infection occurring on the fingertips of medical personnel who have come in contact with viral secretions


Exemplar herpes zoster shingles
Exemplar: Herpes Zoster/Shingles with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Caused by reactivation of the dormant varicella-zoster virus in patients 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.


Exemplar fungal infections dermatophyte
Exemplar: Fungal Infections ( with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?Dermatophyte)

  • Tinea pedis

  • Tinea manus

  • Tinea cruris

  • Tinea capitis

  • Tinea corporis

  • Candida albicans


Assessment
Assessment with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • History

  • Laboratory assessment:

    • Tzanck smear

    • Swab culture

    • Potassium hydroxide (KOH) test


Interventions
Interventions with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Skin care with proper cleansing

  • Isolation Precautions

  • Drug therapy


Skin care
Skin Care with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Bathe daily with an antibacterial soap.

  • Remove any pustules or crusts gently.

  • Apply warm compress twice a day to furuncles or areas of cellulitis.

  • Apply Burow's solution to viral lesions.

  • Avoid excessive moisture.

  • Ensure optimal patient positioning.


Drug therapy for skin disorders
Drug Therapy for Skin Disorders with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Antibacterial drugs

  • Antifungal drugs

  • Anti-inflammatory drugs


  • A topical with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?corticosteriod is prescribed for the client with dermatitis. The nurse provides instructions to the client regarding the use of the medication. Which of the following, if stated by the client, would indicate a need for further instruction?

  • “I need to apply the medication in a thin film.”

  • “I should gently rub the medication into the skin.”

  • “The medication will help relieve the inflammation and itching.”

  • “I should place a bandage over the site after applying the medication.”


Exemplar cutaneous anthrax
Exemplar: Cutaneous Anthrax with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Infection caused by the spores of the bacterium Bacillus anthracis

  • Diagnosis based on appearance of the lesions and culture or anthrax antibodies in the blood

  • Oral antibiotics for 60 days—ciprofloxacin or doxycycline


Cutaneous anthrax
Cutaneous Anthrax with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Exemplar pediculosis
Exemplar: Pediculosis with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Pediculosis—infestation by human lice:

    • Head lice—pediculosis capitis

    • Body lice—pediculosis corporis

    • Pubic or crab lice—pediculosis pubis

  • Pruritus most common symptom

  • Drugs

  • Laundering of clothing and bed linen


Question3
Question with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • The home health nurse visits a client suspected of having scabies. Which of the following precautions will the nurse institute during the assessment of the client?

  • A. Wear gloves only

  • B. Wear a mask and gloves

  • C. Wear a gown and gloves

  • D. Avoid touching the client’s home furnishings


Scabies
Scabies with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • 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.


Common inflammations
Common Inflammations with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Contact dermatitis, atopic dermatitis

  • Interventions include:

    • Steroids

    • Avoidance of oil-based products

    • Antihistamines

    • Compresses and baths


Psoriasis
Psoriasis with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Lifelong disorder with exacerbations and remissions

  • Scaling disorder with underlying dermal inflammation; possibly an autoimmune reaction

  • Psoriasis vulgaris most often seen

  • Exfoliative psoriasis—an explosively eruptive and inflammatory form of the disease


Exemplar psoriasis vulgaris
Exemplar: Psoriasis Vulgaris with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Treatment of psoriasis
Treatment of Psoriasis with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Corticosteroids

  • Tar preparations

  • Other topical therapies

  • Ultraviolet light therapy

  • Systemic therapy:

    • Biologic agents

    • Cytotoxic agents

    • Immunosuppressants

  • Emotional support


Exemplar benign tumors
Exemplar: Benign Tumors with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Cysts

  • Seborrheic keratoses

  • Keloids

  • Nevi (moles)


Exemplar skin cancer
Exemplar: Skin Cancer with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Actinic keratoses

  • Squamous cell carcinomas

  • Basal cell carcinomas

  • Melanomas—highly metastatic; survival depends on early diagnosis and treatment


Skin cancer cont d
Skin Cancer (Cont’d) with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


Surgical management of skin cancer
Surgical Management of Skin Cancer with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

Surgical management:

  • Cryosurgery

  • Curettage and electrodesiccation

  • Excision

  • Mohs’ surgery

  • Wide excision


Nonsurgical management of skin cancer
Nonsurgical Management of Skin Cancer with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Drug therapy

  • Radiation therapy


Exemplar plastic surgery
Exemplar: Plastic Surgery with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Rhytidectomy (face-lift)

  • Rhinoplasty (reconstruction of the nose)


Exemplar acne
Exemplar: Acne with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Red pustular eruption affecting the sebaceous glands of the skin

  • Progressive disorder that manifests as noninflammatory comedones, inflammatory papules, pustules, and cysts

  • Topical agents

  • Systemic antibiotics and possibly isotretinoin (Accutane) helpful


Exemplar other skin disorders
Exemplar; Other Skin Disorders with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

  • Lichen planus with itchy papules

  • Pemphigus vulgaris with chronic blistering

  • Toxic epidermal necrolysis—a rare, acute drug reaction

  • Stevens-Johnson syndrome

  • Leprosy


Steven Johnson Syndrome with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?


References with eczema. The nurse would be concerned about the potential for increased systemic absorption of the medication if the medication were being applied to which of the following body areas?

Ignatavicius, D., & Workman, M.L. (Ed.). (2010). Medical-Surgical Nursing

Critical Thinking For Collaborative Care. (6th Ed.) St. Louis: Elsevier

Saunders.

MedicineNet.com: We Bring Doctors’ Knowledge To You. (2010) Skin Health

Center. Retrieved April 8, 2010, from:

http://www.medicinenet.com/skin/focus.htm

Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed). St. Louis,

Missouri: Mosby.


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