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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 52.2
Slide 36
Intertrigo
• Pathophysiology
• Inflammation where two skin surfaces touch: axillae, abdominal skinfolds, and under
the breasts
• The affected area is usually red and “weeping” with clear margins; may be surrounded
TALKING POINTS:
• What infection may occur in the area of intertrigo?
Slide 37
Intertrigo (cont.)
• Medical diagnosis and treatment
• Based on site/appearance of inflamed skin
TALKING POINTS:
• Why is cornstarch contraindicated?
• Wet soaks with tap water or Burow’s solution are sometimes ordered to remove exudate if
an infection is present.
Slide 38
Intertrigo (cont.)
• Assessment
• Complaints of pain, irritation, or redness in body folds
• Inspect susceptible areas daily
TALKING POINTS:
Slide 39
Intertrigo (cont.)
• Interventions
• Impaired skin integrity
• Risk for infection
Slide 40
Intertrigo (cont.)
• Interventions
• Areas where skin surfaces are in contact must be kept clean and dry
• Apply topical medications as ordered
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LESSON 52.2
Slide 41
Fungal Infections
• Pathophysiology
• Tinea pedis (athlete’s foot)
• Tinea manus (hand)
• Tinea cruris (groin)
TALKING POINTS:
• The lay term ringworm is sometimes used to describe these circular lesions of tinea.
• Which types of tinea are commonly spread by sharing contaminated objects?
Slide 42
Fungal Infections (cont.)
• Cause and risk factors
• Spread through direct contact or by inanimate objects
• Lesions may be scaly patches with raised borders
• Pruritus common symptom
• Medical diagnosis
Slide 43
Fungal Infections (cont.)
• Assessment
• Conditions that might make a person susceptible to fungal infections
• Inspect the skin and mucous membranes for lesions
• Interventions
• Disturbed body image
• Impaired oral mucous membrane
• Risk for injury
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 52.2
Slide 44
Acne
• Pathophysiology
• Affects the hair follicles and sebaceous glands
• Comedones (whiteheads, blackheads), pustules, cysts
TALKING POINTS:
• Acne commonly begins in adolescence and may last into adulthood.
• Can acne be caused by fatty foods, chocolate, or poor hygiene?
• Exacerbations of acne can be triggered by high levels of progestin in birth control pills, oil–
based cosmetics, high doses of systemic corticosteroids, hormonal changes associated
with the menstrual period, and some endocrine disorders.
Slide 45
Acne (cont.)
• Medical treatment
• Topical medications: antibiotics, keratolytics such as benzoyl peroxide, topical vitamin
A preparations
• Oral antibiotics given over several months
Slide 46
Acne (cont.)
• Isotretinoin (Accutane)prescribed for severe cases unresponsive to other treatments
• Oral medication; has drying effect on the skin
• Skin appearance worsens, then improves
• Teratogenic effect; harmful to fetus
Slide 47
Acne (cont.)
• Assessment
• Document any treatments being used
• Inspect skin to determine extent and severity
• Interventions
• Disturbed body image
• Ineffective self-health management
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LESSON 52.2
Slide 48
Herpes Simplex
• Cause and risk factors
• Viral infection begins with itching and burning and progresses to vesicles that rupture
and form crusts
TALKING POINTS:
• Patients typically have repeated outbreaks and remissions.
• Herpes simplex virus can be transmitted by direct contact.
• How are genital lesions commonly spread?
Slide 49
Herpes Simplex (cont.)
• Medical diagnosis
• Laboratory studies of exudate from a lesion and blood studies to detect specific
antibodies
• Medical treatment
• Acyclovir (Zovirax)
Slide 50
Herpes Simplex (cont.)
• Assessment
• Describe the development of the herpetic lesions
• Sexual contacts documented so that they can be advised of the need for medical
evaluation
• Inspect the lesions
• Interventions
• Acute pain
• Ineffective coping
• Ineffective self- health management
Slide 51
Herpes Zoster
• Cause and risk factors
• Commonly called shingles
• Varicella zoster virus; also causes chickenpox
• Symptoms: pain, itching, and heightened sensitivity along a nerve pathway, followed
TALKING POINTS:
• The lesions typically last approximately 2 weeks.
• What are the possible complications of herpes zoster?
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 52.2
Slide 52
stimulation, nerve blocks, and acupuncture.
Herpes Zoster (cont.)
• Medical diagnosis
• Health history and physical examination findings
• Tzanck smear or viral culture of material from a lesion
• Medical treatment
TALKING POINTS:
• What route are antiviral agents administered to patients who have impaired immune
system function?
Slide 53
Herpes Zoster (cont.)
• Assessment
• Conditions or treatments that might cause the patient to have a reduced immune
response
• Distribution and appearance of the lesions
• Interventions
• Impaired skin integrity
• Acute pain
• Ineffective coping
Slide 54
Necrotizing Fasciitis
• Infection of deep fascial structures under the skin
• Aerobic and anaerobic organisms: Streptococcus, Staphylococcus, Peptostreptococcus,
TALKING POINTS:
• When should necrotizing fasciitis be suspected?
• The infection may progress rapidly with loss of large amounts of tissue and can result in
death.
Slide 55
Infestations
• Lice
• Scabies
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LESSON 52.2
Slide 56
Pemphigus
• Chronic autoimmune condition: bullae (blisters) develop on the face, back, chest, groin,
and umbilicus
• Blisters rupture easily, releasing a foul-smelling drainage
• Potassium permanganate baths, Domeboro solution, and oatmeal products soothe the
Slide 57
Actinic Keratosis
• Precancerous lesions most often found on the face, neck, forearms, and backs of the
hands—all areas exposed to sunlight
• May become malignant if not treated
• Most common among older white adults
TALKING POINTS:
• What drugs are commonly used to treat actinic keratosis?
Slide 58
Nonmelanoma Skin Cancer
• Basal cell carcinoma
• Painless, nodular lesions; pearly appearance
• Related to sun exposure
• Grow slowly and rarely metastasize
TALKING POINTS:
• Why should basal cell carcinomas be removed?
Slide 59
Nonmelanoma Skin Cancer (cont.)
• Squamous cell carcinoma
• Scaly ulcers or raised lesions
• Develop on sun-exposed areas including the lips, and in the mouth
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 52.2
Slide 60
Melanoma
• Arises from pigment-producing cells in the skin
• Most serious form of skin cancer; fatal if it metastasizes
• Found anywhere on the body
TALKING POINTS:
• What is Mohs technique?
Cutaneous T-Cell Lymphoma
• Migration of malignant T cells to the skin
• Mycosis fungoides and Sézary syndrome
Slide 62
Kaposi Sarcoma
• Malignancy of the blood vessels
• Red, blue, purple macules with pain, itching, swelling
• Lesions appear first on the legs and then on the upper body, face, and mouth
Slide 63
Infections
• Usually indicated by redness, swelling, and pain around the margin of the nail
• Treated with warm soaks and topical or systemic antiinfectives
• Incision and drainage may be necessary
Ingrown Toenail
• Painful inflammation at distal corner of nail
• Caused by trimming nail too short at the corners or wearing shoes that are too tight
Slide 65
Care of the Patient with a Nail Disorder
• Assessment
• Health history should document the diagnoses of diabetes mellitus or peripheral
vascular disease
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LESSON 52.2
Slide 66
Care of the Patient with a Nail Disorder (cont.)
• Interventions
• Risk for injury
• Ineffective self-health management
Slide 67
Care of the Patient with a Nail Disorder (cont.)
• Intervention
• Teach patients how to trim their nails correctly and the importance of properly fitting
shoes
TALKING POINTS:
Definition of Burns
• Tissue injuries caused by heat
TALKING POINTS:
• 75% of all burn injuries can be prevented.
Slide 69
Classification
• Burn size
• Rule of nines
• Lund and Browder method
• Burn depth
• Superficial burn (first degree)
• Affect only the epidermis
TALKING POINTS:
• Burns are classified by the size and depth of the tissue injury.
• How is the extent of a burn often defined?
• The rule of nines estimates the percentage of body surface area burned. Areas of the
body are assigned percentage values of nine or multiples of nine.
• The Lund and Browder method also estimates the percentage of body surface burned, but
the body is divided into smaller segments.
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 52.2
Slide 70
Burn Severity
• American Burn Association criteria
• Burn size: 25% or more body surface area for people younger than 40 years; 20% or
more body surface area for older than 40 years
• Disfiguring or disabling injuries to the face, eyes, ears, hands, feet, or perineum
• High-voltage electrical burn injury
• Inhalation injury
• Major trauma in addition to the burn
Slide 71
Pathophysiology of Burn Injury
• Local effects
• Tissue releases chemicals that cause increased capillary permeability, which permits
plasma to leak into the tissues
• Injury to cell membranes permits excess sodium to enter cell and potassium to
Slide 72
Pathophysiology of Burn Injury (cont.)
• Systemic effects
• Fluid balance
• Gastrointestinal function
• Immune system
• Respiratory system
• Myocardial depression
• Psychological effects
Slide 73
Stages of Burn Injury
• Emergent: begins with the injury and ends when fluid shifts have stabilized
• Acute: begins with fluid stabilization and ends when all but 10% of burn wounds are
closed or when all wounds are closed
• Rehabilitation: lasts as long as efforts continue to promote improvement
Slide 74
Medical Treatment: Emergent Stage
• Assess airway, breathing, and circulation and then determine whether the patient has
injuries in addition to the burn
• If inhalation injury, oxygen therapy is started
• May require intubation if airway is compromised
• IV lines established to begin fluid resuscitation and to provide emergency vascular access
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LESSON 52.2
• Wound is cleaned, débrided, and inspected
Medical Treatment: Emergent Stage (cont.)
• Indwelling urinary catheter and a nasogastric tube usually inserted
• Blood drawn for baseline laboratory studies
TALKING POINTS:
• What laboratory work should be ordered?
Slide 76
Medical Treatment: Emergent Stage (cont.)
• Patient with serious burns is transferred to a burn specialty care unit or a critical care unit
• IV essential during the first few days of burn treatment
• Volume based on patient’s weight and extent of injury
• First 24 hours, IV fluids may consist of various combinations of electrolyte, colloid,
and dextrose solutions
Slide 77
Wound Care
• Open method: topical antimicrobials but no dressings
• Closed care: topical medications covered by dressings
• Topical medications: silver sulfadiazine (Silvadene) and mafenide acetate (Sulfamylon)
• Tetanus booster given if patient has not been immunized within the past 5 years
TALKING POINTS:
• What is wound care after a burn injury intended to do?
• Open care is less restrictive and simpler than closed care but provides greater opportunity
Slide 78
Wound Care (cont.)
• For clean partial-thickness wounds that will heal without grafting, temporary wound
coverings
• Amniotic membranes, grafts from cadavers or pigs, and a number of synthetic
materials
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 52.2
Slide 79
Wound Care (cont.)
• Débridement
• Removal of debris and necrotic tissue from a wound
• By scissors, forceps, surgical excision, or enzymes
• Skin grafting
• Autograft: the patient’s own skin
• Split-thickness or a full-thickness graft
• Scarring
• Can be reduced with pressure dressings in the early stages of care, followed by
custom-fitted garments that apply continuous pressure
TALKING POINTS:
Slide 80
Care of the Patient with Burn Injury
• Health history
• Circumstances surrounding the burn injury
• Chronic diseases, surgeries, or hospitalizations
• Medications and allergies
• Family history even though not specific to burn injuries; it may alert the staff to other
problems
• Review of systems detects current problems
• Habits and lifestyle, roles and responsibilities, stressors, and coping strategies
Slide 81
Care of the Patient with Burn Injury (cont.)
• Physical examination
• Vital signs
• Inspect for burn wounds and other lesions
• Wound color and the presence of eschar
• Palpate intact skin for temperature and turgor
• Chest expansion observed, and the lungs auscultated for wheezing, stridor, or
atelectasis
• Apical pulse be auscultated for rate and rhythm
• Abdomen assessed: active bowel sounds/distention
• Extremities are inspected for injury and deformity
• Range of motion assessment is delayed if extremity immobilized
Slide 82
Care of the Patient with Burn Injury (cont.)
• Interventions
• Decreased cardiac output
• Excess fluid volume
• Acute pain
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LESSON 52.2
Slide 83
Aesthetic Surgery
• Alters a body feature that is structurally normal but perceived by the patient as
unattractive
• Examples: rhytidectomy, blepharoplasty, chin implants, rhinoplasty, abdominoplasty,
breast augmentation, and breast reduction
Slide 84
Reconstructive Surgery
• Repair disfiguring scars, restore body contours after radical surgery like mastectomy,
eliminate benign lesions such as birthmarks, restore features damaged by trauma or
disease, and correct developmental defects
Preoperative Nursing Care
• Assessment: health history
• Patient’s description of plastic surgery and what he or she expects the procedure to
• Deficient knowledge
TALKING POINTS:
• Physical appearance is a component of body image and may affect self-esteem.
• It is important not to judge the patient’s motivation for seeking surgery.
• How can the patient’s anxiety be reduced?
Slide 86
Postoperative Nursing Care
• Assessment
• Vital signs and level of consciousness
• Inspect dressings for drainage or bleeding, but do not remove them without specific
orders
• Observe flaps and grafts for color and evidence of fluid accumulation, and palpate for
warmth
Slide 87
• Risk for deficient fluid volume
• Disturbed body image
Postoperative Nursing Care (cont.)
• Acute pain
• Risk for infection
• Risk for injury
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 52.2
Activities
Classroom Choose from below to make 30 minutes
6
DISCUSS
• Discuss the uses of phototherapy.
PRACTICE
• Divide the class into three groups and have
each group discuss patient benefits and
nursing considerations for patients who
receive the following:
7
DISCUSS
• Discuss the methods used to diagnose
disorders of the skin.
• Discuss the classification and treatment of
burn patients.
PRACTICE
• Assign a specific skin disorder to each
student in the class (pruritus, eczema, herpes
zoster, acne, fungal infections, psoriasis,
basal cell carcinoma, melanoma, second-
32 Chapter 52Skin Disorders __________________________________________________________________
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LESSON 52.2
8
DISCUSS
• Discuss the special risks encountered by the
burn patient and the ways in which the nurse
can educate the patient to avoid these risks.
• Discuss the difference between
reconstructive surgery and aesthetic
surgery.
• Discuss nutrition considerations (p. 1188).
Determine the ways this information would
help in formulating a nursing care plan for a
patient with a skin disorder.
PRACTICE
• A 26-year-old patient admitted to the
emergency department with a laceration of
the foot also has head lice. Ask the class to:
• Describe the signs and symptoms of
head lice.
Critical Thinking Question
A 72-year-old patient who had surgery 72 hours ago for a torn rotator cuff complains of
severe shooting pain, itching, and burning around her torso. The patient’s wound is healing
well, and she has been making good progress in physical therapy. She is now febrile,
anorexic, and fatigued. The nurse notes red spots and several small blisters on the left side of
the patient’s abdomen. What is the probable cause of the red spots and blisters? What
question should the nurse ask to confirm this? What acute care can the nurse provide?
What instruction should he or she give about the skin problem?
Discussion Guidelines: This patient probably has herpes zoster (shingles). The nurse should ask
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 52.2
Instructor Notes/Student Feedback
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52
Assessments for
Skin Disorders
CHAPTER OBJECTIVES
Lesson 52.1:
2. Define terms used to describe the skin and skin lesions.
4. Explain the tests and procedures used to diagnose skin disorders.
5. Explain the nurse’s responsibilities regarding the tests and procedures for diagnosing skin disorders.
Lesson 52.2:
6. Explain the therapeutic benefits and nursing considerations for patients who receive dressings, soaks
and wet wraps, phototherapy, and drug therapy for skin problems.
8. Assist in developing a nursing care plan for the patient with a skin disorder.
Assessments by Lesson & Objective
1
Study Guide
• Part IH: 1-2 (p. 356)
• Part II I: 19 (p. 358)
• Part IIIK: 7 (p. 361)
2
Study Guide
Evolve Instructor Resources
• Test Bank: 1, 2, 4, 26
• Open Book Quiz: 1
Evolve Student Resources
• NCLEX Review: 8
3
Study Guide
• Part II I: 2, 3, 5 (pp. 356-357)
Evolve Instructor Resources
• Test Bank: 3, 30
4
Study Guide
• Part IA: 1-15 (pp. 351-352)
• Part II I: 4 (p. 357)
Evolve Instructor Resources
• Test Bank: 19
• Open Book Quiz: 2
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Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
5
Study Guide
• Part IIIK: 6 (p. 361)
Evolve Instructor Resources
• Test Bank: 28
Evolve Student Resources
• NCLEX Review: 1
• Prioritization: 2, 3
6
Study Guide
• Part IE: 4-8 (p. 355)
• Part II I: 24, 31 (p. 358)
• Part IIJ: 1-9 (p. 360)
Evolve Instructor Resources
• Test Bank: 5, 7, 8, 12, 15, 27
• Part IG: 1, 2 (p. 355)
• Part II I: 8, 9, 11-18, 20, 21, 23, 25-30, 32-37 (pp. 357-359)
• Part IIIK: 4 (p. 361)
• Part IIIL: 3, 4 (p. 361)
Evolve Instructor Resources
• Test Bank: 10, 13, 16-18, 21, 25, 29
• Open Book Quiz: 4-9
8
Study Guide
• Part II I: 6, 7, 10, 22 (pp. 357-258)
• Part IIIK: 1-3, 5 (pp. 360-361)
• Part IIIL 1, 2, 5 (pp. 361-362)
Evolve Instructor Resources
• Test Bank: 9, 11, 14, 20, 22–24
• Open Book Quiz: 10
Evolve Student Resources
• NCLEX Review: 4, 9
36 Chapter 52Skin Disorders __________________________________________________________________
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Assessments by Lesson & Objective
Instructor’s Notes/Student Feedback