Integumentary System

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Integumentary System
A. Structure.
1. Epidermis—outermost layer; contains the melanocytes and keratinocytes.
2. Dermis—connective tissue below epidermis; vascular;
assists in body temperature and blood pressure
B. Glands on the skin.
1. Sebaceous glands: produce sebum, which is an oily
secretion that is emptied into the hair shaft.
2. Apocrine glands: secrete an odorless fluid from the
hair shaft, which, on contact with bacteria, produces
a distinctive body odor.
a. Located in the axilla, anal region, scrotum, and
labia majora.
b. Become more active at the time of puberty.
c. Eccrine glands: sweat glands that are stimulated
by elevated temperature and emotional stress.
(1) Located all over the body, especially on the
forehead, palms of the hands, and soles of
the feet.
(2) Under control of the sympathetic nervous
C. Functions of the skin.
1. Protection: primary function.
2. Sensory: major receptor for general sensation.
3. Water balance.
a. 600 to 900 mL of water is lost daily through
insensible perspiration.
b. Forms a barrier that prevents loss of water and
electrolytes from the internal environment.
4. Temperature regulation.
5. Involved in the activation of vitamin D.
6. Involved in wheal-and-flare reaction.
a. Wheal: swelling.
b. Flare: diffused redness.
c. These responses are due to local edema caused by
increased capillary permeability and dilation of the
surrounding arterioles.
d. Reaction is initiated by the release of histamine
and the kinins.
System Assessment
A. Health history.
1. How long has the particular rash or lesion been
2. Is there any itching, burning, or discomfort associated
with the problem?
3. Has the client been in contact with any irritants, sun,
unusual cold, or unhygienic conditions?
4. Has anyone in the family ever had this same type of
problem with his or her skin?
5. Is the client taking any medications?
6. What is the diet history? Does the client have any
food allergies?
B. Physical assessment (Box 11-1).
1. Inspection.
a. Assess the skin for color.
(1) Jaundice.
(2) Vitiligo: loss of melanin, resulting in white,
depigmented area.
(3) Areas to assess include the sclera, conjunctiva,
nail beds, lips, and buccal mucosa.
b. Assess for vascularity.
(1) Determine whether there are areas of bruising,
purpura, or petechiae.
(2) Determine whether skin blanches on direct
c. Assess lesions for type, color, size, distribution,
and grouping; location and consistency.
(1) Use metric rulers to measure the size of the
(2) Use appropriate specific terminology to
describe and report type of lesion (Table
d. Assess for unusual odors, especially around lesions
or in the intertriginous areas (axilla, overhanging
abdominal folds, and groin).
e. Assess for chronic UV exposure and photoaging
of skin—appearance of actinic (sun) keratoses
(precancerous lesions), wrinkling, and telangiectasia.
CHAPTER 11 Integumentary System
(1) UVB—major factor of sunburn and nonmelanoma skin cancer.
(2) UVA—contributes to cancerous effects of
f. Inspect hair (head and body for distribution)
and nails (grooves, ridges, smoothness-thickness,
detachment from nailbed).
2. Palpation.
a. Determine temperature (use back of hand), tissue
turgor (pinch under clavicle or back of hand), and
b. Evaluate moisture and texture.
ALERT Perform a risk assessment—evaluation of skin integrity.
Differences in Skin Assessment
• Increased wrinkling and sagging, redundant flesh around
eyes, slowness of skin to flatten when pinched together
• Dry, flaking skin: excoriation from scratching
• Decreased rate of wound healing
• Evidence of bruising
• Graying; dry, scaly scalp
• Thinning, baldness
• Thick, brittle nails with diminished growth; ridging
• Prolonged return of blood with blanching
Table 11-1
Acne Vulgaris
Acne is an inflammatory disorder of the sebaceous glands
and their hair follicles.
A. More common in teenagers; may persist into adulthood.
B. Under hormonal influence during puberty; affected by
presence of androgen, which stimulates the sebaceous
glands to secrete sebum.
C. Inflammatory lesions or pustules; noninflammatory
lesions such as open comedones (blackheads) and closed
comedones (whiteheads).
D. Cysts: deep nodules that may produce scarring.
A. Medical: topical or systemic therapy.
1. Antibacterial and peeling agents: benzoyl peroxide
and retinoic acid.
2. Long-term antibiotic therapy.
3. Isotretinoin (Accutane)—derivative of vitamin A,
causes serious side effects; teratogenic; contraindicated during pregnancy.
Goal: To promote psychologic adjustment related to body
image and appearance.
A. Counsel and assure client that problem is not related
to uncleanliness, dietary intake, masturbation, or sexual
B. Encourage client to talk about the problem with
C. Make sure client recognizes that picking and squeezing
lesions will worsen condition.
Primary Lesions
Secondary Lesions
Macule: Flat, circumscribed area of color change in the skin
without surface elevation; less than 1 cm in diameter (freckle,
Papule: Solid, elevated lesion, less than 1 cm in diameter (wart,
elevated mole)
Plaque: Circumscribed, solid lesion, greater than 1 cm in diameter
(psoriasis, seborrheic keratosis)
Nodule: Raised, solid lesion that is larger and deeper than a
Vesicle: Small elevation in skin, usually filled with serous fluid or
blood; bulla: larger than a vesicle; pustule: vesicle or bulla filled
with pus (chicken pox, burn, herpes zoster-shingles)
Wheal: Elevation of the skin caused by edema of the dermis
(insect bite, urticaria)
Cyst: Mass of fluid-filled tissue that extends to the subcutaneous
tissue or dermis
Fissure: Linear crack; may be dry or moist (athlete’s foot, crack
in corner of mouth)
Scale: Excess epidermal cells caused by shedding (flaking of the
Scar: Abnormal connective tissue that replaces normal skin
(healed surgical incision)
Ulcer: Loss of epidermis and dermis; crater-like; irregular shape
(pressure ulcer, chancre)
Atrophy: Depression in skin resulting from thinning of the
layers (aged skin, striae)
Excoriation: Area where epidermis is missing, exposing the
dermis (scabies, abrasion, scratch)
CHAPTER 11 Integumentary System
Home Care
A. Instruct client to cleanse face twice daily but to avoid
B. May use a polyester sponge pad to cleanse, because
it provides a mechanical removal of the epidermal
C. Instruct client to keep hands away from face and to avoid
any friction or trauma to the area; avoid propping hands
against face, rubbing face, etc.
D. Emphasize the importance of a nutritious diet; encourage adequate food intake and use of vitamin A.
E. Avoid the use of cosmetics, shaving creams, and lotion,
because they may exacerbate acne; if cosmetics are to be
used, water-based makeup is preferable.
F. Instruct the client to administer medication appropriately: topical application; avoid sunlight while using
medications, etc.
Psoriasis is a chronic inflammatory disorder characterized
by rapid turnover of epidermal cells.
A. Silvery scaling, plaques on the elbows, scalp, knees,
palms, soles, and fingernails.
B. If scales are scraped away, a dark red base of the lesion
is seen, which will produce multiple bleeding points.
C. May improve but often recurs throughout life.
D. Bilateral symmetry of symptoms is common.
A. Medical.
1. Topical therapy.
a. Coal tar preparation (Anthralin).
b. Corticosteroids.
2. Photo chemotherapy (PUVA therapy): psoralen,
ultraviolet A therapy (must wear protective eyewear
during treatment and for 24 hours after therapy).
3. Systemic therapy: antimetabolites (methotrexate);
Home Care
A. Encourage verbalization of anxiety regarding
B. Instruct client to use a soft brush to remove scales while
C. Assess client to determine factors that may trigger skin
condition (e.g., emotional stress, trauma, seasonal
D. Make sure client understands treatment and implications of care related to PUVA therapy and other
Atopic Dermatitis
Atopic dermatitis (also called eczema) is a superficial,
chronic inflammatory disorder associated with allergy
with a hereditary tendency (atopy); condition commonly
occurs during infancy, usually between 2 and 6 months
of age and often persists in adulthood.
A. Symptoms are similar with both adults and children;
reddened lesions, occur on the cheeks, arms, and legs;
antecubital and popliteal space in adults; may have
oozing vesicles.
B. Intense itching (worse at night).
C. As the child gets older, the lesions tend to be dry with
a thickening of the skin (lichenification).
D. Infants with eczema are more likely to have allergies as
children and adults and to develop asthma.
A. Milk, eggs, wheat, and peanuts are the most commonly
suspected causes in children; food allergies are not associated with adult atopic dermatitis.
B. Pruritus is treated with Benadryl, topical steroids, and
C. Systemic steroids are prescribed if condition is severe.
Home Care
A. Teach parents about dietary restrictions; provide them
with written guidelines.
B. Keep fingernails and toenails cut short.
C. Feed the child when he is well rested and is not itching.
D. Assist parents to identify foods that contain eggs and
other “hidden” allergenic foods.
E. Avoid overheating; decrease likelihood of perspiration
(no nylon clothing).
F. Child should avoid contact with persons who have the
chicken pox virus or herpes simplex.
G. Avoid immunizations with live vaccines because of the
possibility of severe reactions.
H. Child should wear nonirritating clothing; wool and
abrasive fabrics should be avoided.
I. Tepid bath with mild soap or an emulsifying oil followed
immediately by application of an emollient; cool compresses to decrease itching.
J. Teach adults to avoid things that cause a flare-up of the
condition and to treat symptoms with topical medication
when they occur.
NURSING PRIORITY Apply emollients (medications)
immediately after bathing while skin is slightly moist to treat dry
Contact Dermatitis
Contact dermatitis is an inflammatory skin reaction that
results because the skin has come in contact with a specific
irritant (irritant contact dermatitis, which occurs immediately after injury to skin; diaper dermatitis, which occurs
after prolonged contact with urine, feces, ointments,
soaps, or friction) or an allergen (allergic contact dermatitis,
which is usually a symptom of delayed hypersensitivity).
CHAPTER 11 Integumentary System
A. Causes.
1. Poison ivy and poison oak; fabrics such as wool,
2. Cosmetics; household products such as detergents,
soap, hair dye.
3. Industrial substances: paints, dyes, insecticides, rubber
compounds, etc.
4. Prolonged contact with diaper wetness, fecal enzymes,
increased skin pH due to urine, and friction/
B. Clinical manifestations.
1. Pruritus; hive-like papules, vesicles, and plaques
(more chronic).
2. Sharply circumscribed areas (with occasional vesicle
formation) that crust and ooze.
A. Medical.
1. Topical steroids; oral steroids for severe cases.
2. Antihistamines, antipruritic agents, and antifungals
(diaper dermatitis).
3. Oatmeal baths and topical soaks.
B. Skin testing to determine allergen; skin lesions usually
appear within 12 to 48 hours after contact with allergen.
Home Care
A. Teach importance of washing exposed skin with cool
water and soap as soon as possible after exposure (within
15 minutes is best).
B. Provide cool, tepid bath; trim fingernails, and use measures to control itching.
C. Teach about fallacy of blister fluid spreading the disease.
D. Frequent diaper changes, keep skin dry, and use protective ointment (zinc oxide or petrolatum).
PEDIATRIC PRIORITY Talc powders may keep skin dry,
but they are harmful if breathed. Plain cornstarch is safer to use.
Insect Bites
Insect bites (wasp, bee, yellow jacket, hornet, fire ants,
black widow spider, brown recluse spider, scorpion, tick)
can range from non–life-threatening reactions to serious
life-threatening reactions (due to anaphylaxis).
A. Sharp pain, localized wheal, erythema, localized itching.
B. Non–life-threatening systemic reactions (begin several
minutes to hours after bite)—urticaria, angioedema.
C. Life-threatening reactions—anaphylaxis.
A. Medical.
1. Antihistamines, antipruritic agents, soothing baths.
2. Administration of antivenom—black widow, scorpion bite.
B. Anaphylaxis—epinephrine, corticosteroids.
Home Care
A. Teach family that hypersensitive child should wear
medical alert bracelet.
B. Transfer to emergency medical care for scorpion bites in
young children.
Pressure Ulcer
A pressure ulcer (decubitus ulcer, bedsore) is localized
injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction.
ALERT Identify potential for skin breakdown: a pressure ulcer
can be and should be prevented. Identify those clients at
increased risk for ulcer development and begin preventative care
as soon as possible. Do not wait for the reddened area to occur
before preventative measures are initiated.
A. Risk factors/etiology.
1. Prolonged pressure caused by immobility.
2. Malnutrition, hypoproteinemia, vitamin deficiency.
3. Infection.
4. Skin dryness, maceration, excessive skin moisture.
5. Advancing age.
6. Equipment such as casts, restraints, traction devices,
B. Risk assessment instruments.
1. Braden Scale.
a. Scores six subscales: sensory perception, moisture,
activity-mobility, nutrition, friction, and shear.
b. Total score range is 6 to 23; a lower score indicates
a higher risk for pressure ulcer development.
c. Most reliable and most often used assessment
scale for pressure ulcer risk; score of 18 is cut-off
for adults.
2. Pressure Ulcer Scale for Healing (PUSH Tool).
a. Developed by the National Pressure Ulcer
Advisory Panel (NPUAP) as a quick, reliable tool
to monitor the change in pressure ulcer status
over time.
b. Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area (0-10),
exudate (0-3), and type of wound tissue (0-4).
c. Monitor scoring over time: 0 = healed; 17 = not
C. Clinical manifestations—see Table 11-2.
A. Medical and surgical.
1. Debridement (initial care is to remove moist, devitalized tissue).
a. Sharp debridement: use of a scalpel or other
instrument; used primarily, especially with cellulitis or sepsis.
b. Mechanical debridement: wet-to-dry dressings,
hydrotherapy, wound irrigation, and dextranomers
CHAPTER 11 Integumentary System
Table 11-2
Further Description
Suspected Deep Tissue Injury
Purple or maroon localized area of
discolored intact skin or blood-filled
blister caused by damage of
underlying soft tissue from pressure
and/or shear. The area may be
preceded by tissue that is painful,
firm, mushy, boggy, warmer, or
cooler compared with adjacent
Deep tissue injury may be difficult to
detect in individuals with dark skin
tones. Evolution may include a thin
blister over a dark wound bed. The
wound may further evolve and
become covered by thin eschar.
Evolution may be rapid, exposing
additional layers of tissue even with
optimal treatment.
Stage I
Intact skin with non-blanchable
redness of a localized area usually
over a bony prominence. Darkly
pigmented skin may not have visible
blanching; its color may differ from
the surrounding area.
Stage II
Partial-thickness loss of dermis
presenting as a shallow open ulcer
with a red-pink wound bed, without
slough. May also present as an
intact or open/ruptured serum-filled
The area may be painful, firm, soft,
warmer, or cooler compared with
adjacent tissue. Stage I may be
difficult to detect in individuals
with dark skin tones. May indicate
“at risk” persons (a heralding sign
of risk).
Presents as a shiny or dry shallow
ulcer without slough or bruising.*
This stage should not be used to
describe skin tears, tape burns,
perineal dermatitis, maceration or
*Bruising indicates suspected deep
tissue injury.
(small beads poured over secreting wounds to
absorb exudate).
c. Enzymatic and autolytic debridement: use of
enzymes or synthetic dressings that cover wound
and self-digest devitalized tissue by the action of
enzymes that are present in wound fluids.
2. Wound cleansing (use normal saline solution for most
a. Use minimal mechanical force when cleansing to
avoid trauma to the wound bed.
b. Avoid the use of antiseptics (e.g., Dakin’s solution,
iodine, hydrogen peroxide).
CHAPTER 11 Integumentary System
Table 11-2
Stage III
Full-thickness tissue loss. Subcutaneous
fat may be visible, but bone, tendon,
and/or muscle are not exposed.
Slough may be present but does not
obscure the depth of tissue loss.
May include undermining and
Stage IV
Full-thickness tissue loss with exposed
bone, tendon, or muscle. Slough or
eschar may be present on some parts
of the wound bed. Often includes
undermining and tunneling.
Full-thickness tissue loss in which the
base of the ulcer is covered by
slough (yellow, tan, gray, green, or
brown) and/or eschar (tan, brown,
or black) in the wound bed.
Further Description
The depth of a stage III pressure ulcer
varies by anatomic location. The
bridge of the nose, ear, occiput,
and malleolus do not have
subcutaneous tissue, and stage III
ulcers can be shallow. In contrast,
areas of significant adiposity can
develop extremely deep stage III
pressure ulcers. Bone/tendon is not
visible or directly palpable.
The depth of a stage IV pressure ulcer
varies by anatomic location. The
bridge of the nose, ear, occiput, and
malleolus do not have subcutaneous
tissue, and these ulcers can be
shallow. Stage IV ulcers can extend
into muscle and/or supporting
structures (e.g., fascia, tendon, or
joint capsule), making osteomyelitis
possible. Exposed bone/tendon is
visible or directly palpable.
Until enough slough and/or eschar are
removed to expose the base of the
wound, the true depth and stage
cannot be determined. Stable (dry,
adherent, intact without erythema
or fluctuance) eschar on the heels
serves as “the body’s natural
(biologic) cover” and should not be
Reprinted with permission from National Pressure Ulcer Advisory Panel: Updated staging system, 2007. Available at Accessed July 31, 2008,
CHAPTER 11 Integumentary System
3. Dressings (should protect wound, be biocompatible,
and hydrate).
a. Moistened gauze.
b. Film (transparent).
c. Hydrocolloid (moisture and oxygen retaining).
NURSING PRIORITY Keep the ulcer tissue moist and the
surrounding intact skin dry.
B. Dietary.
1. Increased carbohydrates and protein.
2. Increased vitamin C and zinc.
Nursing Interventions
Goal: To prevent or relieve pressure and stimulate
A. Frequent change of position; turn client every 1 to 2
B. Special beds with mattresses that provide for a continuous change in pressure across the mattress.
C. Silicone gel pads placed under the buttocks of clients in
D. Sheepskin pads to provide a soft surface to protect the
skin from abrasion.
E. Eggcrate-style or other foam mattress to allow circulation under the body and keep the area dry.
F. Active and passive exercises to promote circulation.
Goal: To keep skin clean and healthy and prevent the
occurrence of a pressure ulcer.
A. Wash skin with mild soap and blot completely dry with
soft towel.
1. Avoid hot water and excessive rubbing.
2. Use lotion or protective moisturizer after bathing.
B. Inspect skin frequently, especially over bony prominences.
NURSING PRIORITY Avoid massage over bony
prominences. When the sidelying position is used in bed, avoid
positioning client directly on the trochanter; use the 30° lateral
inclined position. Do not use donut-type devices. Maintain the
head of the bed at or below 30° or at the lowest degree of
elevation. Teach chair-bound persons, who are able, to shift
weight every 15 minutes.
C. Remove any foreign material from the bed, because it
may serve as a source of irritation; keep sheets tightly
stretched on bed to prevent wrinkles.
Goal: To promote healing of pressure ulcer.
A. Use methods discussed to decrease the pressure on the
area in which the pressure ulcer is found.
1. Air-fluidized beds—stage III or stage IV pressure
2. Static support surfaces—not recommended for stage
III or IV.
B. Keep the ulcer area dry.
1. Minimize skin exposure to moisture caused by incontinence, perspiration, or wound drainage.
2. Use only underpads or briefs that are made of materials that absorb moisture and provide a quick-drying
surface next to the skin.
3. Position the client with the ulcer exposed to air; may
use light to increase drying and promote healing.
C. Use skin barriers to decrease contamination and increase
healing of a noninfected ulcer.
D. Observe the ulcer for signs of infection. Infected ulcers
will have to be debrided, if healing is to occur.
Impetigo is a bacterial skin infection caused by invasion of
the epidermis by pathogenic Staphylococcus aureus and/or
group A beta-hemolytic streptococci.
A. Pustule-like lesions with moist honey-colored crusts surrounded by redness.
B. Pruritus; spreads to surrounding areas.
C. Appears more commonly on the face, especially around
the mouth.
A. Medical.
1. Local: topical treatment.
a. Gentle washing two to three times a day to remove
b. Topical mupirocin (Bactroban) antibiotic cream,
if only a couple of lesions are found.
2. Systemic antibiotic therapy is the treatment of choice
with extensive lesions.
Home Care
A. Teach the client and family the importance of good
handwashing and assure them that lesions heal without
B. Encourage adherence to therapeutic regimen, especially
taking the full course of antibiotics.
C. Untreated impetigo may result in glomerulonephritis.
Cellulitis is an inflammation of the subcutaneous tissues
often following a break in the skin caused by Staphylococcus
aureus, Streptococcus, or Haemophilus influenzae.
A. Intense redness, edema with diffuse border, and
B. Chills, malaise, and fever.
A. Medical.
1. Moist heat, immobilization, and elevation of part.
2. Systemic antibiotic therapy is the treatment of choice
with extensive lesions.
CHAPTER 11 Integumentary System
Home Care
A. Teach the client and family the importance of good
B. Encourage adherence to therapeutic regimen, especially
taking the full course of antibiotics.
Fungal (Dermatophyte) Infections
A. Types.
1. Tinea corporis (ringworm): temporary hair loss, if
scalp is affected.
2. Tinea cruris (jock itch): small, red, scaly patches in
the groin area.
3. Tinea pedis (athlete’s foot): scaling, maceration, erythema, blistering, and pruritus; usually found between
the toes.
4. Tinea unguium (onychomycosis): thickened, crumbling nails (usually toes) with yellowish discoloration.
5. Candidiasis: caused by Candida albicans, known as
moniliasis, may affect oral mucosa, groin, and moist
areas; white plaques in mouth; diffuse red rash
on skin.
A. Topical antifungal cream (see Appendix 11-2).
B. Oral antifungal medication.
C. Systemic therapy: griseofulvin; used primarily for extensive cases.
Home Care
A. To prevent athlete’s foot, client should be instructed to
keep feet as dry as possible and wear socks made of
absorbent cotton.
1. Talcum powder or antifungal powder may be used;
Tinactin may be applied twice daily.
2. Encourage aeration of shoes to allow them to completely dry out.
B. Client should maintain hygienic measures to prevent
the spread of fungal diseases, specifically ringworm of
the scalp.
1. Family members should avoid using the same comb.
2. Scarves and hats should be washed thoroughly.
3. Examine family and household pets frequently for
symptoms of the disease.
C. Client should avoid infection.
1. Any activity that allows heat, friction, and maceration
to occur may lead to skin breakdown and infection.
2. Loose-fitting clothing and cotton underwear are to
be encouraged.
Parasitic Infestations
A. Pediculosis.
1. Types.
a. Pediculus humanus capitis: head lice.
b. Pediculus humanus corporis: body lice.
c. Phthirus pubis: pubic lice or crabs.
2. Clinical manifestations.
a. Intense pruritus, which may lead to secondary
excoriation and infection.
b. Tiny, red, noninflammatory lesions.
c. Eggs (nits) of both head and body lice are often
attached to the hair shafts.
d. Pubic lice are often spread by sexual contact.
B. Scabies: an infestation of the skin by Sarcoptes scabiei
1. Intense itching, especially at night.
2. Burrows are seen, especially between fingers, on the
surfaces of wrists, and in axillary folds.
3. Redness, swelling, and vesicular formation may
be noted.
A. Pediculosis.
1. Permethrin 1% liquid (Nix): effective against nits and
lice with just one application; shampoo hair first,
leave Nix on hair for 10 minutes, rinse off; may repeat
in 7 days.
2. Pyrethrin compounds (e.g., Rid) for pubic and head
B. Scabies: permethrin 5% cream (Elimite); cream is applied
to the skin from head to soles of feet and left on for 8 to
14 hours, then washed off; only one application needed.
Home Care
A. All family members and close contacts need to be treated
for parasitic disorders; lice can survive up to 48 hours;
nits can hatch in 7-10 days when shed in the
B. Bedding and clothing that may have lice or nits should
be washed or dry-cleaned; furniture and rugs should be
vacuumed or treated.
C. Nurses should wear gloves when examining scalp to
prevent spread to others.
D. When shampooing hair, use a fine-tooth comb or tweezers to remove remaining nits.
Viral Infections
A. Herpes simplex virus (fever blister, cold sore): herpes
virus type 1 (HSV-1).
1. Painful, local reaction consisting of vesicles with an
erythematous base; most often appears around the
2. Contagious by direct contact; is recurrent; there is no
3. Chronic disorder that may be exacerbated by stress,
trauma, menses, sunlight, fatigue, or systemic
4. Recurrent episodes are characterized by appearance
of lesions in the same place.
5. Not to be confused with HSV-2, which primarily
occurs below the waist (genital herpes).
6. It is possible for the HSV-1 to cause genital lesions
and for HSV-2 to cause oral lesions (see Sexually
Transmitted Diseases in Chapter 22).
CHAPTER 11 Integumentary System
B. Herpes zoster (shingles).
1. Related to the chicken pox virus: varicella.
2. Contagious to anyone who has not had chicken pox
or who may be immunosuppressed.
3. Linear patches of vesicles with an erythematous
base are located along spinal and cranial nerve
4. Often unilateral and appears on the trunk; however,
may also appear on the face.
5. Pain, burning, and neuralgia occur at the site before
outbreak of vesicles.
6. Often precipitated by the same factors as herpes
simplex infection.
C. Herpetic whitlow: occurs on fingertips and around nail
cuticles; often seen in medical personnel.
A. Usually symptomatic; application of soothing moist
B. Analgesics; gabapentin (Neurontin) for postherpetic
C. Antiviral agents (see Appendix 11-2).
D. Zoster vaccine is recommended for adults over 60 years
regardless of whether they report a prior episode of
herpes zoster.
Home Care
A. Alleviate pain by administering analgesics.
B. Antihistamines may be administered to control the
C. Usually, lesions heal without complications; herpes
simplex usually heals without scarring, whereas herpes
zoster may cause scarring.
D. If hospitalized, establish contact precautions for herpes
Nonmelanoma Skin Cancers
A. Risk factors.
1. Overexposure to sunlight.
2. Fair skin type (blond or red hair and blue or green
3. Exposure to chemicals.
4. Scars from severe burns.
B. Types.
1. Actinic keratosis: premalignant type.
a. Small macules or papules with dry, rough, adherent yellow or brown scales.
b. Appears on face, neck, back of hand, and forearm.
c. May slowly progress to squamous cell carcinoma.
2. Basal cell carcinoma: most common type of skin
a. Appears as a small, waxy nodule with a translucent
pearly border.
b. Appears more frequently on the face, usually
between the hairline and upper lip.
3. Squamous cell carcinoma: malignant proliferation
arising from the epidermis; usually on sun-damaged
skin or skin that has been irradiated or excessively
a. May metastasize.
b. Appears as a firm nodule with an indistinct border;
may be opaque.
Malignant Melanoma
A. Risk factors.
1. Chronic UV exposure without protection or overexposure to artificial light (tanning bed).
2. Fair skin, genetic (first-degree relative).
3. Has the highest mortality rate of any form of skin
cancer (Box 11-2).
a. Often appears in preexisting moles in the skin.
b. Common sites include back and legs (women);
trunk, head, and neck (men).
c. Sudden or progressive change or increase in size,
color, or shape of a mole.
A. Surgical.
1. Excisional surgery; laser treatment.
2. Cryosurgery.
3. Electrodesiccation and curettage.
B. Medical.
1. Radiation therapy.
2. Chemotherapy—topical 5FU (skin cancer, except
3. Biologic therapy (alpha-interferon, interleukin-2)—
malignant melanoma.
Nursing Interventions
Goal: To assist client to understand disease process, importance of follow-up treatment, and measures to maintain
A. Teach the importance of avoiding unnecessary exposure
to sunlight.
B. Apply protective sunscreen when outside.
C. Teach the warning signs of cancer.
D. Treat moles found in areas where there is friction or
repeated irritation.
Goal: To support the client and promote psychologic
Melanomas tend to have:
A Asymmetry
B Border irregularity
C Color variegation
D Diameter great than 6 mm
E Evolving or changing in some way
CHAPTER 11 Integumentary System
A. Allow for verbalization of fear and anxiety.
B. Encourage verbalization relating to altered body image
when large, wide, full-thickness excisions must be made
to treat malignant melanoma.
C. Point out client’s resources and support effective coping
D. Teach the importance of examining and checking moles
and any new lesions.
A. Purpose: to improve self-image.
B. Types of elective cosmetic surgery.
1. Chemical face-lift or peel: superficial destruction of
the upper layers of skin with a cauterant solution.
2. Tretinoin (Retin-A) and alpha-hydroxy acids: topical
application provides reversal of photodamaged skin
and normal aging by influencing epithelial cell growth
and differentiation.
3. Microdermabrasion: removal of epidermis to treat
acne, scars, wrinkles, etc.
4. Botulinum toxin injection: neurotoxin that causes
temporary interference with neuromuscular transmission, paralyzing the affected muscle.
5. Face-lift (rhytidectomy): lifting and repositioning of
facial and neck tissues.
6. Eyelid-lift (blepharoplasty): removal of redundant
(excess) eyelid tissue.
7. Liposuction: technique for removing subcutaneous
fat from face and body.
Nursing Interventions
Goal: To provide preoperative care.
A. Reinforce information from informed consent obtained
by physician.
B. Instruct client to avoid taking vitamin E and aspirin at
least 1 week before surgery to prevent bleeding.
C. Explain that wound healing and final results may not be
complete until 1 year after procedure.
Goal: To provide postoperative care.
A. Administer analgesics for pain management.
B. Observe for bleeding.
C. Teach client signs and symptoms of infection.
D. Teach client who had a chemical peel to avoid the sun
for 6 months to prevent hyperpigmentation, because a
reduction of melanin in the skin occurs as a result of the
E. Teach client who has liposuction to wear spandex compression garments to reduce risk for bleeding and prevent
fluid accumulation.
A. Types of burns.
1. Thermal injury: most common type of burn injury;
results from flames, flash (explosion), scald, or direct
contact with hot object.
2. Electrical injury: intense heat is generated from electrical current and causes coagulation necrosis as
current flows through the body.
3. Chemical injury: results from contact with a corrosive
4. Smoke and inhalation injury: results from inhalation
of air or noxious chemicals; the respiratory system
frequently sustains two types of burn injuries:
a. Smoke inhalation and topical burns on face,
neck, and chest may precipitate airway edema
and obstruction within 24 to 48 hours after
burn injury.
b. Inhalation of carbon monoxide combines with
hemoglobin, thereby decreasing availability of
oxygen to cells.
B. Fluid considerations.
1. Fluid shift and edema formation occur within first 12
hours post burn and can continue 24 to 36 hours after
burn injury.
2. Fluid mobilization and diuresis occur around 48 to
72 hours post burn when the capillary integrity is
3. Serum potassium levels increase and hematocrit levels
increase because of hemoconcentration.
4. The increased capillary permeability and the histamine released from the injured cells precipitate a
decrease in fluid volume.
A. Respiratory—determine circumstances surrounding
injury: did fire occur in an enclosed space, is there a
risk for an inhalation injury?
1. Assess for burns on the face and in the mouth.
2. Examine mouth and sputum for black particles and
the nasal septum for edema.
3. Assess for change in respiratory pattern indicating
impending respiratory obstruction.
a. Increased hoarseness.
b. Drooling or difficulty swallowing.
c. Audible wheezing, crackles, presence of stridor.
4. Assess for development of carbon monoxide poisoning.
a. Mild: headache, decreased vision.
b. Moderate: tinnitus, drowsiness, vertigo, altered
mental state, decreased B/P, “cherry red” color
from vasodilatation.
B. Evaluate cardiac output and peripheral circulation.
1. Tachycardia and hypotension may occur early.
2. Evaluate urine output to determine adequacy of tissue
3. Evaluate peripheral circulation.
C. Identify when client ate last; check gastrointestinal
D. Determine hydration status.
1. Presence of hematuria.
2. Urine output (should be at least 30 mL/hr).
3. Hypotension (blood pressure below 90/60 mm Hg).
CHAPTER 11 Integumentary System
E. Presence of confusion and disorientation may occur
secondary to hypoxia, low B/P, or carbon monoxide
NURSING PRIORITY The client with burn injury is often
awake, mentally alert, and cooperative at first. The level of
consciousness may change as respiratory status deteriorates or
as the fluid shift occurs, precipitating hypovolemia.
F. Determine the severity of the burn injury (Box 11-3 and
Figure 11-1).
1. Extent of burn surface (burn surface area).
a. Rule of nines: generally used for adults (Figure
11-2) and estimation in children (Figure 11-3).
b. Pediatric burns are calculated by taking into
account the client’s age in relation to proportion
of body parts.
2. Area of burn.
a. Circumferential burns (burns surrounding an
entire extremity) may cause severe reduction of
circulation to an extremity as a result of edema
Degree of burn
Hair follicle
Sweat gland
FIGURE 11-1 Levels of human skin involved in burns. (From Lewis SL,
et al: Medical-surgical nursing: assessment and management of clinical
problems, ed 7, St. Louis, 2007, Mosby.)
• Superficial or first-degree burn: Area is reddened and
blanches with pressure; no edema present; area is generally
painful to touch.
• Partial-thickness or second-degree burn: Dermis and epidermis are affected; formation of large, thick-walled blisters;
underlying skin is erythematous.
• Full-thickness or third- and fourth-degree burn: All of the
skin is destroyed; may have damage to the subcutaneous
tissue and muscle; usually has a dry appearance, may be
white or charred; will require skin grafting to cover area;
underlying structures (fascia, tendons, and bones) are
severely damaged, usually blackened.
FIGURE 11-2 Rule of nines.
formation and lack of elasticity of the eschar,
leading to compartmental syndrome.
b. Location of the burn is related to the severity of
the injury:
(1) Face, neck, chest → respiratory obstruction
(2) Hands, feet, joints, and eyes → self-care
(3) Ears, nose → infection
3. Age.
a. Infants have an immature immune system and
poor body defense.
b. Older adult clients heal more slowly and are more
likely to have wound infection problems and pulmonary complications.
4. Presence of other health problems: diabetes and
peripheral vascular disease delay wound healing.
A. Respiratory status takes priority over the treatment of
the burn injury.
B. If the burn area is small (less than approximately a 10%
BSA), apply cold compresses or immerse injured area in
cool water to decrease heat; ice should not be directly
applied to the burn area.
C. Administer tetanus injection.
D. Do not put any ointment or salves on the burn area.
E. If the cause of the burn is chemical, thoroughly rinse the
area with large amounts of cool water.
F. Fluid resuscitation.
1. Used for clients with burns on 15% to 20% or more
of body surface area.
2. Placement of large bore IV catheters on admission to
3. Fluid replacement: calculation of fluid replacement
begins from time of burn, not time of admission
to ED.
CHAPTER 11 Integumentary System
FIGURE 11-3 Estimation of distribution of burns in children. A, Children from birth to 5 years. B, Older children. (From Hockenberry MJ,
Wilson D: Wong’s essentials of pediatric nursing, ed 8, St. Louis, 2009,
a. One-half of first 24-hour fluid replacement is
given during first 8 hours after burn injury.
b. One-fourth of remaining amount is given during
the second and third 8-hour periods.
c. Urine output is most sensitive indicator of
fluid status; fluid replacement may be titrated to
keep urine output at 0.5 mL/kg or average of
30 mL/hour.
G. Maintain NPO (nothing by mouth) status; assess need
for nasogastric tube.
H. Analgesics are given intravenously; do not give intramuscularly, subcutaneously, or orally because they will
not be absorbed effectively.
I. Methods of wound care (area is cleaned and debrided of
necrotic burned tissue).
1. Open method (exposure): burn is covered with
a topical antibiotic cream and no dressing is
2. Closed method of dressing: fine mesh is used to
cover the burned surface; may be impregnated with
antibiotic ointment, or ointment may be applied
before the dressing is applied.
3. Escharotomy: procedure involves excision through
the eschar to increase circulation to an extremity with
circumferential burns.
4. Enzymatic debriders: collagenase, fibrinolysin, and
Accuzyme may be used.
5. Wound grafting: as eschar is debrided and granulation tissue begins to form, grafts are used to protect
the wound and to promote healing.
J. Nutritional support.
1. Diet is high in calories and protein.
2. In clients who have large burn surface areas, supplemental gastric tube feedings or hyperalimentation
may be used.
Nursing Interventions
Goal: To maintain patent airway and prevent hypoxia.
A. Anticipate respiratory difficulty if there are any indications of inhalation injury.
1. Remain with client; frequent assessment of respiratory status.
2. Supplemental oxygen.
3. Be prepared to intubate client: airway edema can
occur rapidly.
4. Assess airway as fluid resuscitation begins; may precipitate more edema.
B. Assess for carbon monoxide poisoning.
C. Anticipate transfer to burn unit if burns cover more than
15% to 20% of body surface area, depending on depth
of burn, age of client, and presence of other chronic
Goal: To evaluate fluid status and determine circulatory
status and adequacy of fluid replacement.
A. Obtain client’s weight on admission.
B. Assess status and time frame of fluid resuscitation; calculation of fluid replacement begins at time of burn injury,
not on arrival at hospital.
C. Evaluate renal status and urine output: adequate output
for children is 1 mL/kg/hr.
Goal: To prevent or decrease infection.
A. Implement infection control procedures to protect the
B. After eschar sloughs or is removed, assess wound for
infection; infection is difficult to identify before the
eschar sloughs.
CHAPTER 11 Integumentary System
Goal: To maintain nutrition and promote positive nitrogen
balance for healing.
A. Work with dietitian to maintain nutritional intake.
B. Provide tube feedings as indicated.
C. Care of total parenteral nutrition as indicated (see
Appendix 18-7).
D. Daily weight.
Goal: To prevent contractures and scarring.
A. Assist client to attempt mobilization and ambulation as
soon as possible.
B. Passive and active range of motion should be initiated
from the beginning of burn therapy and throughout
C. Position client to prevent flexion contractures; position
of comfort for the client may increase contracture
D. Use splints and exercises to prevent flexion contractures.
E. Use pressure dressings and garments to contour healing
burn area to keep scars flat and prevent elevation and
enlargement above the original burn injury area.
Goal: To promote acceptance and adaptation to alterations
in body image.
A. Employ counselors and resource team members.
B. Maintain open communication and encourage expression of feelings.
C. Anticipate depression as a normal consequence of burn
trauma; it should decrease as condition improves.
NURSING PRIORITY It is important to recognize that the
client’s anger is not a direct attack on the care provider; it is an
expression of grief and sorrow.
Home Care
A. Physical therapy.
B. Continue high-calorie, high-protein diet.
C. Wound care management.
D. Avoid exposure of burn area to direct sunlight.
Skin Testing Purpose: confirm sensitivity to a specific allergen by placing antigen
on or directly below skin (intradermal) to check for presence of
1. Three methods—allergen applied to arms or back.
Cutaneous scratch test (also known as a tine or prick test): allergen applied to a superficial scratch on skin.
Intracutaneous injection: small amount of the allergen is
injected intradermally in rows; more accurate; high risk for
severe allergic reaction; used only for those who do not react
to cutaneous method.
Patch test: used to determine whether client is allergic to testing material (small amount applied on back)—returns in 48
hours for evaluation.
2. Interpreting results.
Immediate reaction: appears within minutes after the injection;
marked by erythema and a wheal; denotes a positive reaction.
Positive reaction: indicates an antibody response to previous
exposure; local wheal-and-flare response occurs.
Negative reaction: inconclusive; may indicate that antibodies
have not formed yet or that antigen was deposited too deeply
in skin (not an intradermal injection); may also indicate
3. Complications: range from minor itching to anaphylaxis (see
Chapter 7).
NURSING PRIORITY Never leave client alone during skin
testing, because of the risk for anaphylaxis. If a severe reaction
occurs, anticipate anti-inflammatory topical cream applied to
skin site (scratch test) or a tourniquet applied to the arm
(intracutaneous test) and possible epinephrine injection.
Wood’s Lamp (black light) Purpose: examination of skin with long-wave ultraviolet light that
causes specific substances or areas to fluoresce (e.g., Pseudomonas
species, fungi, patches of vitiligo).
Biopsy Types: punch, excisional, incisional, shave
1. Verify if informed consent is needed.
2. Apply dressing and give postprocedure instructions—watch for
Skin Culture Purpose: identify fungal, bacterial, and viral organisms.
1. Scrap or swab affected area; label specimen and send to lab.
Microscopic Tests Potassium hydroxide (KOH)—identifies fungal infection
Tzanck test—diagnoses of herpes infections
Mineral oil slides—diagnoses of infestations
Immunofluorescent—identifying abnormal antibody proteins (can
also be a serum test)
CHAPTER 11 Integumentary System
General Nursing Implications
—Topical medications are used primarily for local effects when systemic absorption is undesirable.
—For topical application:
—Apply after shower or bath for best absorption, because skin is hydrated.
—Apply small amount of medication and rub in well.
Antifungal: Inhibits or damages fungal cell membrane, either altering permeability or disrupting cell
Clotrimazole (Lotrimin): topical
Nystatin (Mycolog): topical
Ketoconazole (Nizoral): PO, topical
Griseofulvin (Fulvicin): PO
Nausea, vomiting, abdominal pain.
Hypersensitivity reaction: rash,
urticaria, pruritus
Gynecomastia (ketoconazole)
1. Monitor hepatic function (when oral
medication is given).
2. Avoid alcohol because of potential liver
3. Check for local burning, irritation, or
itching with topical application.
4. Prolonged therapy (weeks or months)
is usually necessary, especially with
griseofulvin (Fulvicin).
5. Take griseofulvin (Fulvicin) with foods
high in fat (e.g., milk, ice cream) to
decrease GI upset and assist in
6. Uses: tinea infections, fungal infections,
candidiasis, diaper dermatitis.
Antiviral: Reduces viral shedding, pain, and time to heal.
Acyclovir (Zovirax): topical, PO, IV
Penciclovir (Denavir): topical
Vidarabine (Ara-A, Vir-A): IV,
IV: phlebitis, rash, hives
PO: nausea, vomiting
Topical: burning, stinging, pruritus
Anorexia, nausea, vomiting
Ophthalmic: burning, itching
1. Apply topically to affected area six times
per day.
2. Avoid autoinoculation; wash hands
frequently; apply with gloved hand.
3. Avoid sexual intercourse while genital
lesions are present.
4. Drink adequate fluids.
5. Infuse IV preparations over 1 hour; use
an infusion pump for accurate delivery.
6. Uses: herpes infections.
Antiinflammatory: Decreases the inflammatory response.
Triamcinolone acetonide (Aristocort):
Skin thinning, superficial dilated blood
vessels (telangiectasis), acne-like
eruptions, adrenal suppression
1. Triamcinolone and hydrocortisone creams
come in various strengths and potency.
Watch the percent strength.
2. Applied 2-3 times a day.
3. Use an occlusive dressing only if ordered.
4. Encourage client to use the least amount
possible and for the shortest period of
Immunosuppressant: Suppresses T cells and decreases release of inflammatory mediators;
alternative to glucocorticoids.
Pimecrolimus cream (Elidel): topical
Tacrolimus ointment (Protopic): topical
Erythema, pruritus
Burning sensation at application site
GI, Gastrointestinal; IV, intravenously; PO, by mouth (orally).
1. Teach clients to use sunscreen, because
medication makes client sensitized to UV
2. Long-term effects can lead to skin cancer
and lymphoma.
CHAPTER 11 Integumentary System
Topical Antibiotics: Prevent and treat infection at the burn site.
Silver sulfadiazine (Silvadene)
Hypersensitivity: rash, itching, or
burning sensation in unburned skin
1. Liberal amounts are spread topically with a
sterile, gloved hand or on impregnated
gauze rolls over the burned surface.
2. If discoloration occurs in the Silvadene
cream, do not use.
3. A thin layer of cream is spread evenly over
the entire burn surface area; reapplication is
done every 12 hours.
4. Client should be bathed, “tubbed”, or
showered daily to aid in debridement.
5. Medication does not penetrate eschar.
6. For clients with extensive burns, monitor
urine output and renal function; a
significant amount of sulfa may be
Mafenide acetate (Sulfamylon 10%)
Pain, burning, or stinging at application
sites; excessive loss of body water;
excoriation of new tissue; may be
systemically absorbed and cause
metabolic acidosis
1. Bacteriostatic medication diffuses rapidly
through burned skin and eschar and is
effective against bacteria under the eschar.
2. Dressings are not required but are
frequently used. A thin layer of cream is
spread evenly over the entire burn surface.
3. Monitor renal function and possible
acidosis, because medication is rapidly
absorbed from the burn surface and
eliminated via the kidneys.
4. Pain occurs on application.
5. Watch for hyperventilation, as a
compensatory mechanism when acidosis
CHAPTER 11 Integumentary System
Study Questions Integumentary System
1. A client has extensive burns with eschar on the anterior
trunk. What is the nurse’s primary concern regarding
eschar formation?
1 It prevents fluid remobilization in the first 48 hours
after burn trauma.
2 Infection is difficult to assess before the eschar
3 It restricts the ability of the client to move about.
4 Circulation to the extremities is diminished because
of edema formation.
2. A client comes to the outpatient clinic with impetigo
on his left arm. What information would the nurse give
this client?
1 Apply antibiotic ointment to the dried lesion.
2 Wash the lesions with soap and water, then apply a
steroid ointment.
3 Soak the scabs off the lesion and apply an antibiotic
4 Wash the lesions with hydrogen peroxide and apply
an antifungal cream.
3. A teacher notifies the school nurse that many of the
students in her third-grade class have been scratching
their heads and complaining of intense itching of the
scalp. The nurse notices tiny white material at the base
of a student’s hair shaft. What condition does this
assessment reflect?
1 Tinea capitis
2 Pediculosis capitis
3 Dandruff
4 Scabies
4. In which situation would it be appropriate for the nurse
to administer a patch skin test?
1 A toddler with a possible diagnosis of cystic
2 A client who has a transdermal patch ordered
3 A client scheduled for electromyography
4 A child who is to receive ampicillin for the first time
5. What is the type of skin cancer that is most difficult to
1 Oat cell
2 Malignant melanoma
3 Basal cell epithelioma
4 Squamous cell epithelioma
6. An older adult client has an open wound over the coccyx
that extends through the dermis and subcutaneous
tissue, exposing the deep fascia. The wound edges are
distinct, and the wound bed is a pink-red color. There
is no bruising or sloughing. What stage of pressure ulcer
is this wound?
1 Stage I
2 Stage II
3 Stage III
4 Stage IV
More questions on
companion CD!
7. The nurse understands that scaling around the toes,
blistering, and pruritus is characteristic of what
1 Eczema
2 Psoriasis
3 Tinea pedis
4 Pediculosis corporis
8. What are the physical characteristics of a client who
is most susceptible to development of malignant
1 Light to pale skin, blond hair, blue eyes
2 Olive complexion, oily skin, dark eyes
3 Dark skin with freckles, dry flaky skin, hazel eyes
4 Coarse skin, ruddy complexion, brown eyes
9. Herpes zoster has been diagnosed in an older adult
client. What will the nursing management include?
1 Apply antifungal cream to the areas daily.
2 Maintain client on contact precautions.
3 Administer a herpes zoster immunization.
4 Expect to find lesions in the perineal area.
10. Which of the following nursing interventions will assist
in reducing pressure points that may lead to pressure
ulcers? Select all that apply:
______ 1 Position the client directly on the trochanter
when sidelying.
______ 2 Avoid the use of donut-type devices.
______ 3 Massage bony prominences.
______ 4 Elevate the head of the bed as little as
______ 5 When the client is sidelying, use the
30-degree lateral inclined position.
______ 6 Avoid uninterrupted sitting in any chair or
11. The nurse is teaching self-care to an older adult client.
What would the nurse encourage the client do for his
dry, itchy skin?
1 Apply a moisturizer on all dry areas daily.
2 Shower twice a day with a mild soap.
3 Use a pumice stone and exfoliating sponge on areas
to remove dry scaly patches.
4 Wear protective pads on areas that show the most
12. What is the priority assessment finding for a client who
has sustained burns on the face and neck?
1 Spreading, large, clear vesicles
2 Increased hoarseness
3 Difficulty with vision
4 Increased thirst
Answers and rationales to these questions are in the section at
the end of the book titled Chapter Study Questions: Answers
and Rationales.

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