Integumentary Problems

Question 1

Anatomy and Physiology

Answer 1

• skin is the largest sensory organ and weights about 4kg (9lb).
• acts as the first line of defense, protects underlying tissues and organs, and receives stimuli from the external environment (touch, pressure, pain, and temp); relays information to the CNS.
• regulates normal body temp, excretes salt, water, and organic wastes; protects body from excessive water loss.
• synthesizes vit D3, which converts to calcitriol, for normal calcium metabolism; stores nutrients.
• layers: epidermis, dermis, hypodermis (subcutaneous fat).
• epidermal appendages: nails, hair, glands (sebaceous and sweat).
• normal bacteria flora: gram-positive and negative staphylococci, pseudomonas, streptococcus.
• a pH of 4.2 to 5.6 halts bacteria growth.

Question 2

Risk Factors for Integumentary Problems

Answer 2

• exposure to chemical and environmental pollutants
• exposure to radiation
• race and age
• exposure to the sun or use of indoor tanning
• lack of personal hygiene habits
• use of harsh soaps or other harsh products
• some medications (such as long-term glucocorticoid or herbal preparations)
• nutritional deficiencies
• moderate to severe emotional stress
• infection, with injured areas (potential entry points)
• repeated injury and irritation
• genetic predisposition
• systemic illness

Question 3

Phases of wound healing

Answer 3

• inflammatory: begins at the time of injury and lasts 3-5 days; local edema, pain, redness, and warmth.
• fibroblastic: begins the 4th day after injury and lasts 2-4 weeks; scar tissue forms and granulation tissue forms in the tissue bed.
• maturation: begins as early as 3 weeks after injury and may last for 1 year; scar tissue becomes thinner and is firm and inelastic on palpation.

Question 4

Wound healing by intention

Answer 4

• 1st intention: wound edges are approximated and held in place (sutures) until healing occurs; wound is easily closed and dead space is eliminated.
• 2nd intention: occurs with injuries or wounds that have tissue loss and require gradual filling in of the dead space with connective tissue.
• 3rd intention: involves delayed primary closure and occurs with wounds that are intentionally left open for several days for irrigating or removal of debris and exudates; once debris has been removed and inflammation resolves, the wound is closed by 1st intention.

Question 5

Types of exudate from wounds

Answer 5

• serous: clear or straw colored, occurs as a normal part of the healing process.
• serosanguineous: pink colored due to blood cells mixed with serous; normal part of the process.
• sanguineous: red drainage from trauma to a blood vessel; abnormal finding.
• hemorrhaging: frank blood from a leaking blood vessel; may require emergency treatment; abnormal.
• purulent: yellow, gray, or green drainage due to infection in the wound.

Question 6

Diagnostic tests: skin biopsy

Answer 6

• collection of a small piece of skin tissue.
• methods: punch, excisional, and shave.
• preop: informed consent, cleanse site as prescribed.
• postop: place specimen in appropriate container and send to lab; surgically aseptic technique for dressing; assess site for bleeding and infection; instruct to keep dressing in place for at least 8hs and then clean daily and use ATB ointment as prescribed (sutures are usually removed 7-10 days after).

Question 7

Diagnostic tests: skin/wound cultures

Answer 7

• small skin culture sample is obtained with a sterile applicator and appropriate type of tube (bacterial or viral)
• methods: scraping, punch biopsy, and collecting fluid (local anesthesia may be used)
• nasal swab is also commonly done to determine previous exposure to certain types of bacteria.
• postop: viral culture is placed immediately on ice.

Question 8

Diagnostic tests: Wood’s light examination

Answer 8

• skin is viewed under ultraviolet light through a special glass (Wood’s glass) to identify superficial infections.
• preprocedure: explain and reassure that the light is not harmful to the skin or eyes; darken the room.

Question 9

Diagnostic tests: Diascopy

Answer 9

• technique allows clearer inspection of lesions by eliminating the erythema caused by increased blood flow to the area.
• a glass slide is pressed over the lesion, causing blanching and revealing the lesion more clearly.

Question 10

Candida Albicans

Answer 10

• superficial fungal infection of the skin and mucous membranes.
• also known as yeast infection (oral) or thrush.
• risk factors: immunosuppression, long-term ATB therapy, DM, and obesity.
• common areas: skin folds, perineum, vagina, axilla, and under the breasts.
• assessment: skin red and irritated (itches and stings); mucous membranes of the mouth shows red and whitish patches.
• interventions: keep skin clean and dry; turn and reposition client frequently; provide frequent mouth care; provide foods and fluids that are tepid in temp and nonirritating; antifungal meds may be prescribed.

Question 11

Herpes Zoster (shingles): description

Answer 11

• can occur during any immunocompromised state in a client with a history of chickenpox; cause by reactivation of the varicella zoster virus.
• dormant virus is located in the dorsal nerve root ganglia of the sensory cranial and spinal nerves.
• eruptions occur in a segmental distribution on the skin area along the infected nerve and show up after several days of discomfort in the area.
• diagnosis is determined by visual examination and by Tzanck smear to verify and a viral culture to identify the organism.
• postherpetic neuralgia (severe pain) can remain after the lesions resolve.
• is contagious to individuals who never had chickenpox and who have not been vaccinated against the disease.
• herpes simplex virus is another type of virus; type 1 infection typically causes a cold sore (usually on the lip) and type 2 causes genital herpes typically below the waist (both types are contagious and may be present together).

Question 12

Herpes Zoster (shingles): assessment and interventions

Answer 12

• assessment: unilaterally clustered skin vesicles along peripheral sensory nerves on the trunk, thorax, or face; fever, malaise, burning and pain, paresthesia, and puritus.
• interventions: isolate the client (standard and contact precautions as long as vesicles are present); assess for signs and symptoms of infection and necrosis; assess neurovascular status and 7th cranial nerve function (Bell’s palsy is a complication); keep environment cool (warmth and touch aggravate the pain); prevent client from scratching and rubbing; instruct to wear loose and light clothing; keep skin clean; topical and antiviral meds may be prescribed; vaccination for shingles is recommended for adults 50 years or older.

Question 13

Methicillin-Resistent Staphylococcus aureus (MRSA)

Answer 13

• can be community or hospital acquired.
• infection can range from mild to severe and can present as folliculitis or furuncles.
• folliculitis is a superficial infection of the follicle and presents as a raised red rash and pustules.
• furuncles occur deep in the follicle, presenting as very painful large, raised bumps that may or may not have a pustule.
• if MRSA infects the blood, sepsis, organ damage, and death can occur.
• assessment: culture and sensitivity test of the skin or wound confirms the infection.
• interventions: standard and contact precautions, monitor the client for signs of systemic or organ damage, adm ATB as prescribed.

Question 14

Erysipelas and Cellulitis

Answer 14

• Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics caused by group A Streptococcus, which enters the tissue via an abrasion, bite, trauma, or wounds.
• Cellulitis is an infection of the dermis and underlying hypodermis caused usually by group A Streptococcus or Staphylococcus aureus.
• assessment: pain, tenderness, erythema, warmth, edema, fever.
• interventions: promote rest of affected area; apply warm compresses (promote circulation and decrease discomfort, erythema, and edema); apply ATB dressing, ointments, or gels as prescribed; adm ATB and obtain cultures as prescribed.

Question 15

Poison Ivy, Poison Oak, and Poison Sumac

Answer 15

• a dermatitis that develops from contact with urushiol from poison ivy, oak, or sumac plants.
• assessment: papulovesicular lesions, severe puritus.
• interventions: cleanse the skin immediately; apply cool, wet compresses or topical products to relieve the itching; topical or oral glucocorticoids may be prescribed for severe reactions.

Question 16

Spider Bites

Answer 16

• almost all types of spider bites are venomous and most are not harmful, but bites from brown recluse, black widow, and tarantulas can produce toxic reactions.
• tetanus prophylaxis should be current because spider bites can be contaminated with tetanus spores.
• Brown recluse: can cause skin lesion, a necrotic wound, or systemic effects from the toxin (loxoscelism); application of ice decreases enzyme activity and limits tissue necrosis (should be done immediately and intermittently for up to 4 days after the bite); topical antiseptics and ATB may be necessary (if becomes infected).
• Black widow: bite causes a small red papule; venom causes neurotoxicity; ice is applied immediately to inhibit the action of the neurotoxin; systemic toxicity can occur, and the victim may require supportive therapy in the hospital.
• Tarantulas: bite causes swelling, redness, numbness, lymph inflammation, and pain; it launches its barbed hairs (which can penetrate the skin and eyes) producing a severe inflammatory reaction; hairs are removed ASAP, using sticky tape and then is thoroughly irrigated (for eyes use saline); involved extremity is elevated and immobilized to reduce pain and swelling; antihistamines and topical or systemic corticosteroids may be prescribed; tetanus prophylaxis is necessary.

Question 17

Scorpion Stings

Answer 17

• inject venom through a stinging apparatus on their tail.
• cause local pain, inflammation, and mild systemic reactions that are treated with analgesics,wound care, and supportive treatment.
• bark scorpion can inflict a severe and potential fatal systemic response (specially children and elderly); venom is neurotoxic and the victim should be taken to the ED immediately (an antivenom is adm).

Question 18

Bees and Wasps

Answer 18

• usually cause a wheal and flare reaction.
• emergency care involves quick removal of the stinger (tweezers are not used because there is a risk of pinching the venom sac) and application of an ice pack
• if victim is allergic, a severe reaction can occur and these individuals should carry an IM epinephrine autoinjector.

Question 19

Snake bites

Answer 19

• some snakes are venomous and can cause a serious systemic reaction.
• victim should be immediately removed to a safe area away from the snake and should rest to decrease venom circulation; extremity is immobilized and kept bellow the level of the heart.
• constricting clothing and jewelry are removed before swelling occurs.
• victim is kept warm and is not allowed to consume caffeinated or alcoholic beverages, which may speed absorption of the venom.
• a constricting band may be applied proximal to the wound to slow venom circulation (monitor and loosen band if edema occurs).
• wound is NOT incised or sucked to remove the venom; ice is NOT applied to the wound.
• emergency care in hospital is required; an antivenom may be adm.
• snake should not be transported with the victim for identification purposes unless it can be safely placed in a sealed container during transportation.
• Poison Control Center should be contacted ASAP to determine best initial management.

Question 20

Frostbite

Answer 20

• is damage to tissues and blood vessels as a result of prolonged exposure to cold.
• 1st-degree: involves white plaque surrounded by a ring of hyperemia and edema.
• 2nd-degree: large, clear fluid-filled blisters with partial-thickness skin necrosis.
• 3rd-degree: involves the formation of small hemorrhagic blisters, usually followed by eschar formation involving the hypodermis requiring debridement.
• 4th-degree: no blisters or edema; full thickness necrosis with visible tissue loss extending into the muscle and bone, which may result in gangrene; amputation may be required.
• interventions: rewarm the affected part with warm water bath or towels at 40-42C (104-107.6F); avoid using dry heat and never rub or massage the area (handle gently and immobilize); apply loose and nonadherent sterile dressings (avoid compression); monitor for signs of compartment syndrome; tetanus prophylaxis is necessary and topical and systemic ATB may be prescribed; debridement of necrotic tissue may be needed or amputation if gangrene develops.

Question 21

Actinic Keratoses

Answer 21

• caused by chronic exposure to the sun and appear as rough, scaly, red, or brown lesions that are usually found on the face, scalp, arms, and backs of the hands.
• lesions are considered premalignant, and there is risk for slow progression to squamous cell carcinoma.
• treatment includes meds, excision, cryotherapy, curettage, and laser therapy.

Question 22

Skin Cancer: description and types

Answer 22

• is a malignant lesion, which may metastasize.
• over exposure to the sun is a primary cause; other causes include chronic skin damage from repeated injury and irritation such as tanning and use of tanning beds, genetic predisposition, ionizing radiation, light-skinned race, age older than 60y, an outdoor occupation, and exposure to chemical carcinogens.
• diagnosis is confirmed by skin biopsy.
  Types
• Base cell: arises from the basal cells contained in the epidermis; metastasis is rare, but underlying tissue destruction can progress to organ tissue.
• Squamous cell: is a tumor of the epidermal keratinocytes and can infiltrate surrounding structures and metastasize to lymph nodes.
• Melanoma: may occur any place on the body, especially where birthmarks or new moles are apparent; it is highly metastatic to the brain, lungs, bone, and liver, with survival depending on early diagnosis and treatment.

Question 23

Skin Cancer: assessment and interventions

Answer 23

Assessment:
- change in color, size, or shape of preexisting lesion; pruritus and local soreness.
Interventions:
- instruct risk factors and preventive measures.
- monthly skin assessment to monitor lesions that do not heal or that change characteristics.
- management may include surgical (cryosurgery, curettage and electrodessication) or nonsurgical interventions.

Question 24

Psoriasis

Answer 24

• a chronic, noninfectious skin inflammation occuring with remissions and an autoimmune reactions; a genetic predisposition may also be a cause.
• may be exacerbated by the use of certain meds and some individuals develop arthritis.
• Koebner phenomenon is the development of psoriatic lesions at a site of injury (prompt cleansing may prevent or lessen).
• the goal of therapy is to reduce cell proliferation and inflammation, and the type of therapy prescribed depends on the extent of the disease and client’s response.
• assessment: pruritus, shedding, yellow discoloration, pitting, and thickening of the nails, joint inflammation.
• interventions: emotional support, instruct in the use of prescribed meds, avoid over-the-counter meds, keep skin lubricated, wear light cotton clothing and reduce stress.

Question 25

Acne Vulgaris: description and interventions

Answer 25

• chronic skin disorder that usually begins in puberty and is more common in males; oily skin and a genetic predisposition may be contributing factors.
• lesions develop on the face, neck, chest, shoulders, and back.
• requires active treatment for control until it resolves.
• types of lesions: comedones, pustules, papules, and nodules.
• exact cause is unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium, organism that converts sebum into irritant fatty acids.
• interventions: instruct skin-cleansing and using only prescribed topical agents; not to squeeze, prick, or pick at lesions; use products labeled non-comedogenic and cosmetics that are water based, and avoid products with excessive oil base.

Question 26

Acne Vulgaris: assessment

Answer 26

• closed comedones are whiteheads and noninflamed lesions that develop as follicles enlarge, with the retention of horny cells.
• open comedones are blackheads that result from continuing accumulation of horny cells and sebum, which dilates the follicles.
• pustules and papules result as the inflammatory process progresses.
• nodules result from total disintengration of a comedone and subsequent collapse of the follicle.
• deep scaring can result from nodules.

Question 27

Stevens-Johnson Syndrome

Answer 27

• a medication-induced skin reaction that occurs through an immunological response.
• common meds: ATB (especially sulfonamides), antiseizure meds, and nonsteroidal antiinflammatory drugs (NSAIDs).
• similar to toxic epidermal necrolysis, another medication-induced skin reaction that results in diffuse erythema and large blister formation on the skin and mucous membranes.
• may be mild or severe, and may cause vesicles, erosions, and crusts on the skin; if severe, systemic reaction occur that involve the respiratory system, renal system, and eyes (resulting in blindness), and it can be fatal.
• initial manifestation include flu-like symptoms and erythema of the skin and mucous membranes; serious systemic symptoms and complications occur when the ulcerations involve the larynx, bronchi, and esopgagus.
• most commonly occurs in clients who have impaired immune systems.
• treatment icludes immediate discontinuation of the med, ATB, corticosteroids, and supportive therapy.

Question 28

Pressure injury: description and interventions

Answer 28

• is an impairment of skin integrity and can occur anywhere on the body.
• tissue damage results when the skin and underlying tissue are compressed between a bony prominence and an external surface for an extended period.
• tissue compression restricts blood flow to the skin, which can result in tissue ischemia, inflammation, and necrosis; once a pressure injury forms, it is difficult to heal.
• prevention is a major role for the nurse.
• risk factors: skin pressure, skin shearing and friction, immobility, malnutrition, incontinence, decreased sensory perception.
• Interventions: identify clients at risk and institute measures to prevent; perform frequent skin assessment; keep skin dry and use creams and lotions to lubricate the skin; turn and reposition the immobile client every 2h or more and provide passive and range-of-motion exercises; if injury present, record location, size and characteristics.
• treatment include wound dressing and debridement; skin graft may be necessary.

Question 29

Assessment and Stages of Pressure Injuries

Answer 29

• Stage 1: skin is intact and does not blanch with external pressure; area may be painful, firm, soft, warmer, or cooler compered with adjacent tissue.
• Stage 2: skin is not intact; partial-thickness skin loss of the dermis occurs; presents as a shallow open ulceration with a red-pink wound bed or as intact or open/ruptured serum-filled blister.
• Stage 3: full-thickness skin loss extends into the dermis and subcutaneous tissues, and slough may be present; subcutaneous tissue may be visible; undermining and tunneling may be present.
• Stage 4: Full-thickness skin loss is present with exposed bone, tendon, or muscle; slough or eschar may be present; undermining and tunneling may develop.
• Suspected deep-tissue injury: ischemic subcutaneous tissue injury under intact skin; appears purple or maroon colored; may be painful, firm, or boggy.
• Unstageable: full thickness tissue loss in which the wound bed is covered by slough and/or eschar; the true depth, and therefore stage, of the wound cannot be determined until the slough and/or eschar is removed to visualize the wound bed.

Question 30

Types of dressing and mechanisms of action for pressure injuries

Answer 30

• Stage 1: none, transparent or hydrocolloid dressing. Slow resolution within 7-10 days.
• Stage 2: composite film, hydrocolloid dressing, hydrogel. Heals through reepithelialization.
• Stage 3: hydrocolloid, hydrogel covered with foam dressing, gauze, growth factors. Heals through granulation and reepithelialization.
• Stage 4: hydrogel covered with foam dressing, calcium alginate, gauze. Heals through granulation, reepithelialization, and scar tissue development.
• Unstageable: adherent film, gauze with a prescribed solution, enzymes, none. Eschar loosens and lifts at the edges as healing occurs; surgical debridement may be necessary.

Question 31

Types of Dressings: Alginate

Answer 31

• provides hemostasis, debridement, absorption, and protection.
• can be used as packing for deep wounds and for infected wounds.
• requires a secondary dressing for securing.
• changes should be done when dressing is saturated (every 3-5 days) or more frequently.

Question 32

Types of Dressings: Biological

Answer 32

• provides protection and debridement after eschar removal.
• may be used for dormant and nonhealing wounds that do not respond to other topical therapies.
• may be used for burns or before pigskin and cadaver skin grafts.
• conforms to uneven wound surfaces
• reduces pain
• requires a secondary dressing for securing.
• topical growth factors should be changed daily.
• skin substitutes: the need for dressing change varies.

Question 33

Types of Dressings: Cotton gauze

Answer 33

• continuous dry dressing provides absorption and protection.
• continuous wet dressing provides protection, a means for the delivery of topical treatment, and debridement.
• wet to damp dressing provides atraumatic mechanical debridement.
• may be painful on removal.
• clean base: change every 12-24h.
• necrotic base: every 4-6h.

Question 34

Types of Dressings: Foam

Answer 34

• provides absorption, protection, insulation, and debridement.
• conforms to uneven wound surfaces.
• requires a secondary dressing for securing.
• change dressing when is saturated or more frequently; can remain for a maximum of 7 days.

Question 35

Types of Dressings: Hydrocolloidal

Answer 35

• provides absorption, protection, and debridement.
• is waterproof and painless on removal.
• clean base: change on leakage of exudates.
• necrotic base: change every 24h.

Question 36

Types of Dressings: Hydrogel

Answer 36

• provides absorption, protection, and debridement.
• conducive to use with topical agents.
• conforms to uneven wound surfaces but allows only partial wound visualization.
• requires a secondary dressing for securing.
• can promote the growth of Pseudomonas and other microorganisms.
• clean base: change every 24h.
• necrotic base: change every 6-8h.

Question 37

Types of Dressings: Adhesive transparent film

Answer 37

• provides protection for partial-thickness lesion and debridement and serves as a secondary (cover) dressing.
• provides good wound visualization.
• is waterproof and reduces pain.
• use is limited to superficial lesions.
• is nonabsorbent, adheres to normal and healing tissue.
• dressing may be difficult to apply.
• clean base: change on leakage of exudates.
• necrotic base: change every 24h.

Question 38

Other treatments for Pressure Injury

Answer 38

• electrical stimulation: increases blood vessel growth and stimulates granulation.
• vacuum-assisted wound closure: removes infectious material from the wound and promotes granulation.
• hyperbaric oxygen therapy: adm of oxygen under high pressure raises tissue oxygen concentration.
• topical growth factors: biologically active substances that stimulate cell growth.