Integumentary system

lichen planus.

*️⃣Papulosquamous Skin Disorders ▷Cause Exposure to drugs or chemicals, abnormal T-cell response to epithelial cells recognized as foreign ▷Lesion Nonscaling, violet pruritic papules

Hirsutism

.excess of hair• female hirsutism in male areas is usually a sign of hormonal disturbances

2. The dermis is composed of all of the following except: a. melanocytes. b. collagen. c. elastin. d. apocrine sweat glands. e. sebaceous glands.

ANS: A

Which does not occur as the skin ages? a. more melanocytes b. decreased Langerhans cells c. loss of rete pegs d. loss of elastin fibers e. depressed immune response

ANS: A

Squamous cell carcinoma of the skin is manifested as: a. irregular pigmentation. b. elevated, firm lesions. c. a smooth, pearly lesion with multiple telangiectasia. d. multifocal purplish, brown macules.

ANS: B *️⃣Cancerous Skin Lesions ▷Cause Sunlight-exposed skin; arise from premalignant lesions ▷Growth Rate/ Metastasis Moderate growth; some lesions metastasize ▷Appearance Multifocal purplish Rough, firm nodule with an indurated base, ulceration, bleeding

Acantholysis is observed in: a. herpes simplex. b. pemphigus. c. erythema multiforme. d. Stevens-Johnson syndrome. e. Both c and d are correct.

ANS: B Pemphigus is a rare, chronic, blister forming disease of the skin and oral mucous membranes with several different types. An autoimmune disease, pemphigus is caused by circulating immunoglobulin G (IgG) autoantibodies and complement component C3, which react with the intracellular cement of substance that holds the epidermal cells together. The antibody reaction likely causes the intraepidermal blister formation and acanthol- ysis, or loss of cohesion between epidermal cells. Pemphigus vulgaris is the most common form, with acantholysis at the deeper suprabasal level. Oral lesions precede the onset of skin blistering, which is more prominent on the face, scalp, and axilla. The blisters rup- ture easily because of thin, fragile overlying epidermis. Pemphigus vegetans is a variant of pemphigus vulgaris, with large blisters occurring in the tissue folds of the axilla and groin. Pemphigus foliaceus is a milder form involving acantholysis at the more superficial, subcorneal level, with blistering, erosions, scaling, crusting, and erythema usually of the face and chest. Oral mucous membranes are rarely involved. Pemphigus erythemato- sus is a subset of pemphigus foliaceus often associated with systemic lupus erythematosus with the presence of serum antinuclear antibodies. The lesions are generally less widely distributed. In the diagnosis of pemphigus, immunofluorescence demonstrates the presence of antibodies at the site of blister formation. The primary treatment for pemphigus is systemic corticosteroids, usually in high doses to suppress the immune response during acute episodes or when there is widespread involvement.

An untreated basal cell carcinoma: a. metastasizes frequently. b. often involves regional lymphatics. c. ulcerates and involves local tissue. d. grows rapidly. e. will eventually require removal of nearby lymph nodes.

ANS: C

The usual manifestation of HSV is a: a. painful nodule. b. pustule. c. cold sore or fever blister. d. wheal.

ANS: C

Which malignant skin lesion metastasizes the earliest? a. basal cell carcinoma b. squamous cell carcinoma c. malignant melanoma d. Kaposi sarcoma

ANS: C For malignant melanomas, wide and deep excisions and removal of lymph nodes are required. Early recognition of malignant melanomas affects the surgical cure of these lesions. Survival is poor for malignant melanoma because it metastasizes quickly.

Arteriovenous anastomoses in the dermis: a. prevent skin drying. b. regulate vasoconstriction. c. oppose evaporative heat loss. d. facilitate the regulation of body temperature. e. None of the above is correct.

ANS: D

The cause of atopic dermatitis is: a. unknown. b. venous stasis. c. increased activity of sebaceous glands. d. mast cell degranulation, T-cell and monocyte interaction. e. nonimmunologic inflammation to chemicals.

ANS: D

The cause of Kaposi sarcoma likely is: a. solar radiation. b. steroidal hormones. c. precursor nevi. d. immunodeficiency. e. keratinization.

ANS: D *️⃣Cancerous Skin Lesions ▷Cause Immunodeficient states; genetics and male gender—black, Jewish, or Italian males ▷Growth Rate/ Metastasis Slow spread through skin; some aggressive change ▷Appearance Multifocal purplish, brown vascular macules that develop into plaques and nodules that may be painful and pruritic; may affect gastrointestinal and respiratory tract lymph nodes

A circular, demarcated, salmon-pink scale within a plaque is characteristic of: a. psoriasis. b. seborrheic dermatitis. c. acne rosacea. d. pityriasis rosea. e. lichen planus.

ANS: D *️⃣Papulosquamous Skin Disorders ▷Cause Possible herpes-like virus ▷Lesion Pruritus, demarcated salmon-pink scale within a plaque

Which are most likely to undergo malignant transition? a. seborrheic keratosis and keratoacanthoma b. seborrheic keratosis and actinic keratosis c. nevi and keratoacanthoma d. nevi and actinic keratosis e. None of the above is correct.

ANS: D ▷Nevi, or moles, are pigmented or nonpigmented lesions that form from melanocytes. During early devel- opment, the melanocytes accumulate at the junction of the dermis and epidermis and become macular lesions. Over time, the cells move into the dermis and become nodular and palpable. Nevi may appear anywhere on the skin singly or in groups and vary in size. Nevi can undergo transition to malignant melanoma; if irritated, they may be excised. ▷Actinic keratosis is a premalignant lesion found on skin surfaces exposed to UV radiation of the sun. The lesions can progress to squamous cell carcinoma. The prevalence is highest in individuals with unprotected, light-colored skin. The lesions appear as pigmented patches of rough, adherent scale, and surrounding areas may have telangiectasia. Freezing with liquid nitrogen provides quick, effective treatment. Excisions provide tissue for biopsy.

The nurse educator is preparing an education module on skin, hair, and nails for the nursing staff. Which of these statements about the dermal layer of the skin should be included in the module? a. Contains mostly fat cells b. Consists mostly of keratin c. Is replaced every 4 weeks d. Contains sensory receptors

ANS: D The dermis has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks. The dermal layer consists mostly of collagen, not fat or keratin cells and is not replaced every 4 weeks.

The nurse educator is preparing an education module on skin, hair, and nails for the nursing staff. Which of these statements about the epidermal layer of the skin should be included in the module? a. Highly vascular b. Thick and tough c. Thin and nonstratified d. Replaced every 4 weeks

ANS: D The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones. The epidermis is avascular, not highly vascular; thin and tough, not thick; and stratified into several zones, not nonstratified. The epidermis is also replaced every 4 weeks.

The cause of impetigo in the adult is: a. Streptococcus aureus. b. group A streptococci. c. coagulase-positive staphylococci. d. beta-hemolytic streptococci. e. Both c and d are correct.

ANS: E

The skin lesion of psoriasis is a(n): a. nonscaling, violet pruritic papule. b. comedo. c. pruritic vesicle. d. erythematous, butterfly-shaped rash. e. thick, scaly, erythematous plaque.

ANS: E

Of the benign tumors of the skin, keratoacanthomas are characterized by: a. proliferation of basal cells. b. hyperkeratotic scales. c. origination from hair follicles. d. a proliferative stage that produces a nodule with a central crust. e. Both c and d are correct.

ANS: E A keratoacanthoma is a benign, self-limiting tumor that arises from hair follicles. It usually occurs on sun-exposed surfaces and develops in elderly individuals. The lesion develops in stages. The proliferative stage produces a rapid-growing, dome-shaped nodule with a central crust. In the mature stage, the lesion is filled with whitish keratin. The mature lesion requires differentia- tion from squamous cell carcinoma. The involution stage usually occurs over a 3- to 4-month period as the lesion regresses. Although the lesion will resolve spontaneously, it can be removed surgically.

Systemic antihistamines

Advise of side effects and risks associated with driving or operating heavy machinery

External Devices

An external device applied to or around the skin exerts pressure or friction on the skin. Assess all surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic braces.

Describe what is indicated by the ABCDEs of malignant melanoma. A B C D E

Asymmetry: one half unlike the other half; Border: irregular and poorly circumscribed; Color: varied within lesion; Diameter: larger than 6 mm; Evolving: look and appearance is changing

Topical fluorouracil

Avoid sunlight; causes photosensitivity; warn patient that it will cause painful, eroded dermatitis before healing

Impaired skin integrity related to irritation and erosion; fluid volume deficit related to water loss [PRIMARY NURSING DIAGNOSIS]

Basal cell carcinoma (BCC) is the most common skin malignancy in humans and commonly occurs from overexposure to the sun. About 75% to 85% of primary BCCs are found on the head or neck, and the most common location is the nose. In the United States each year, 900,000 people are diagnosed with BCC, and the estimated lifetime risk in the white population is about 35% for men and 25% for women. Although BCC is a malignant neoplasm, it rarely metastasizes and death rates are very low. The physiological changes that occur in skin cells arise from cancer-causing factors that lead to changes in undifferentiated basal cells. These cells become cancerous instead of differentiating into specialized cells such as sweat glands, sebum (a fatty secretion of the sebaceous glands of the skin), and hair. Over time, if left untreated, basal cell epitheliomas can become indurated and invasive, and this is followed by nodule formation and ulceration. •CAUSES BCC, and the actual cancerous tumor, basal cell epitheliomas, are thought to be caused by a number of factors. Extended, long-term exposure to sunlight or radiation creates changes in pig- mentation and DNA damage that may foster the development of skin cancers. Fair-skinned persons are more susceptible to basal cell epithelioma, which is the most common malignant tumor that affects fair-skinned whites. Burns and trauma can accelerate otherwise normal tissue growth or can exacerbate previously existing lesions. Arsenic ingestion is thought to be a contributing factor as well. Patients may ingest arsenic through well water, medications, insecticides, or exposure to an industrial mining site. Vaccination sites can create skin cell proliferation and permanent damage through scarring, and this creates a risk for development of BCC. •HISTORY. Elicit a history of skin problems, the length of time skin disorders have existed, daily routine skin care, and current medications. Ask the patient about exposure to sunlight; in particular, establish long-term patterns of exposure to sunlight, either at work or in recreational activities, and determine what form of sun protection the patient has customarily used. Record the patient's history of scars, vaccination sites, and burns. Establish a patient history of exposure to radiation or arsenic; be sure to ask about the patient's occupational history to discover if he or she has been at risk of ingesting arsenic at an industrial site. •PHYSICAL EXAMINATION. Observe the color, texture, turgor, and pigmentation of the patient's skin for deviations from normal skin parameters. Note in detail any lesions, nodules, or plaques. •PSYCHOSOCIAL. Patients with BCC at the early stages can recover with minimal intervention, although some patients may experience distress over facial lesions that alter their appearance. Patients may have to deal with changes in activities that bring them into extended contact with environmental risk factors. Patients with more advanced cancer or of an older age may have to cope with more aggressive and repeated treatments and surgery with some permanent disfigurement and poor prognosis. •Diagnostic Highlights Lesion biopsy- Excisional biopsy may be treatment for small tumors; during excision, intraoperative frozen section analysis occurs to confirm negative margins of lesion •

CASE STUDY Cellulitis Patient Profile -W.B., a 72-year-old man, cut his lower arm on a kitchen knife. At the time of the injury he did not seek medical attention. On the third day following the injury he began to be concerned about the condition of the wound and the way he was feeling. Subjective Data • States he has a fever and has had a general feeling of malaise • Has pain in the area of the cut and the entire lower arm Objective Data • 4-cm area around cut is hot, erythematous, and edematous with redness extending both up and down his arm • Temp: 100.8°F (38.2°C) Discussion Questions Using a separate sheet of paper, answer the following questions: 1. What other assessment data are needed before treatment begins? 2. What care of the wound should W.B. have taken to prevent the occurrence of cellulitis? 3. What are the usual etiologies of this type of infection? 4. What would you tell W.B. about the usual treatment of cellulitis? 5. What could result if treatment is not initiated and maintained? 6. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?

Case Study 1. The nurse would assess the size and depth of the injury, what the knife was being used for before the patient cut himself, and whether the patient had problems like this in the past. 2. W.B. should have cleansed the wound with soap and water and sought medical care for cleaning and suturing. A sterile dressing should have been applied and the arm should have been elevated to reduce edema. 3. Staphylococcus aureus and streptococcus are the usual etiologies of this type of infection. 4. Systemic antibiotics will be necessary and warm, moist packs or dressings should be used to help localize the infection. Hospitalization will be necessary if it becomes severe. 5. If treatment is not initiated and maintained, gangrene of the extremity and possible septicemia could occur. 6. Nursing diagnoses: • Impaired skin integrity related to trauma • Acute pain related to inflammatory process • Hyperthermia related to inflammatory process • Readiness for enhanced coping related to self-care post injury • Deficient knowledge related to self-care post injury Collaborative problems: Potential complications: gangrene, septicemia

Topical antibiotics

Clean skin; no occlusive dressings

Warts

Common warts are caused by a virus and are transmitted by touch usually occur on your fingers or hands and may be: Small, fleshy, grainy bumps Flesh-colored, white, pink or tan Rough to the touch Sprinkled with black pinpoints, which are small, clotted blood vessels

Pubic lice

Commonly called crabs, these lice occur on the skin and hair of the pubic area and, less frequently, on coarse body hair, such as chest hair, eyebrows or eyelashes

Topical corticosteroids

Diagnosis of the lesion first; thin layers; massage at prescribed frequency

xerosis

Dry skin often has an environmental cause. (weather, heat, hot baths, harsh soaps and detergents, other skin conditions. People with skin conditions such as atopic dermatitis (eczema) or psoriasis are prone to dry skin. A feeling of skin tightness, especially after showering, bathing or swimming Skin that feels and looks rough Itching (pruritus) Slight to severe flaking, scaling or peeling Fine lines or cracks Gray, ashy skin Redness Deep cracks that may bleed

Acne

Excess oil (sebum) production Hair follicles clogged by oil and dead skin cells Bacteria Inflammation Whiteheads (closed plugged pores) Blackheads (open plugged pores) Small red, tender bumps (papules) Pimples (pustules), which are papules with pus at their tips Large, solid, painful lumps under the skin (nodules) Painful, pus-filled lumps under the skin (cystic lesions)

vitamin B-6 deficiency

Foods rich in folate include: Dark green leafy vegetables Nuts Enriched grain products, such as bread, cereal, pasta and rice Fruits and fruit juices Folate, also known as vitamin B-9, is a nutrient found mainly in fruits and leafy green vegetables. A diet consistently lacking in these foods can lead to a deficiency. Deficiency can also result if your body is unable to absorb folate from food. Most nutrients from food are absorbed in your small intestine. You might have difficulty absorbing folate or folic acid, the synthetic form of folate that's added to foods and supplements, if: You have a disease of the small intestine, such as celiac disease You've had a large part of the small intestine surgically removed or bypassed You drink excessive amounts of alcohol You take certain prescription drugs, such as some anti-seizure medications Pregnant women and women who are breast-feeding have an increased demand for folate, as do people undergoing dialysis for kidney disease. Failure to meet this increased demand can result in a deficiency.

Vascular Insufficiency

Inadequate arterial supply to tissues and impaired venous return decrease circulation to the extremities. Inadequate blood flow causes ischemia and breakdown. Risk of infection also exists because delivery of nutrients, oxygen, and white blood cells to injured tissues is inadequate.

Paronychia

Inflammation of the skin around the nail, an infection of the epidermis bordering the nail, commonly is precipitated by localized trauma. Treatment consists of incision and drainage, warm-water soaks and, sometimes, oral antibiotics

Generalized vitiligo (vitiligo vulgaris)

Many parts of your body. With this most common type, widespread macules and patches that are often, the discolored patches often progress similarly on corresponding body parts (symmetrically)

Secretions and Excretions on the Skin

Moisture on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. Presence of perspiration, urine, watery fecal material, and wound drainage on the skin results in breakdown and infection.

universal vitiligo

Nearly all skin surfaces. With this type, called universal vitiligo, the discoloration affects nearly all skin surfaces

Pigmented lesions

Normal skin contains numerous brownish pigmentary lesion has 3 types: freckles, lentigo, and nevi.

localized (focal) vitiligo

One or only a few areas of your body.

segmental vitiligo

Only one side or part of your body. This type, called segmental vitiligo, tends to occur at a younger age, progress for a year or two, then stop

Vitamin deficiency anemia

Pale or yellowish skin Vitamin B-12 — 2.4 micrograms (mcg) Folate or folic acid — 400 mcg Vitamin C — 75 to 90 milligrams

Reduced Sensation

Patients with paralysis, circulatory insufficiency, or local nerve damage are unable to sense an injury to the skin. During a bath assess the status of sensory nerve function by checking for pain, tactile sensation, and temperature sensation

Sarcoidosis Eye symptoms

Sarcoidosis can affect the eyes without causing any symptoms, so it's important to have your eyes checked regularly. When eye signs and symptoms do occur, they may include: Blurred vision Eye pain Burning, itching or dry eyes Severe redness Sensitivity to light

Sarcoidosis

Sarcoidosis is a disease characterized by the growth of tiny collections of inflammatory cells (granulomas) in any part of your body — most commonly the lungs and lymph nodes. But it can also affect the eyes, skin, heart and other organs

Sarcoidosis Skin symptoms

Sarcoidosis may cause skin problems, which may include: A rash of red or reddish-purple bumps, usually located on the shins or ankles, which may be warm and tender to the touch Disfiguring sores (lesions) on the nose, cheeks and ears Areas of skin that are darker or lighter in color Growths under the skin (nodules), particularly around scars or tattoos

Impaired skin integrity related to diminished or absent glandular secretions [PRIMARY NURSING DIAGNOSIS]

Sjögren's syndrome (SS) is the most common autoimmune rheumatic disorder after rheumatoid arthritis (RA). It is a chronic, progressive disease that is associated with other diseases such as RA in approximately 50% of the cases. SS is characterized by failure of exocrine glands and by diminished tearing and salivary secretion (sicca complex). It results from chronic exocrine gland dysfunction, although the disorder may also involve other organs such as the lung and kidney. SS may be a primary disorder, or it may be associated with connective tissue disorders, such as RA, scleroderma, systemic lupus erythematosus, and primary biliary cirrhosis. Tissue damage results either from infiltration by lymphocytes or from the deposition of immune complexes. The overall prognosis for patients with SS is good, and the disease seldom leads to significant compli- cations. •CAUSES The direct cause of SS is unknown. It seems likely that both environmental and genetic factors (see Genetic Considerations) contribute to its development. In a genetically suscep- tible individual, either bacterial or viral infection or exposure to pollen may be the catalyst for SS. •HISTORY. Establish a history of either autoimmune or lymphoproliferative disorders. Rule out other causes of oral and ocular dryness; ask about any history of sarcoidosis, endocrine dis- orders, anxiety or depression, and radiation therapy to the head and neck. Many commonly used medications produce dry mouth as a side effect, so take a thorough history of medications. In patients with salivary gland enlargement and severe lymphoid infiltration, rule out malignancy. Approximately 50% of patients with SS have confirmed RA. When you ask about symptoms, the patient may report gritty or sandy sensations in the eye or a film across the visual field. Patients may also report dryness of the mouth, burning oral discomfort, difficulty in chewing and swallowing dry foods, increased thirst, and reduced taste. The patient may also report the incidence of many dental caries and chronic middle ear infections. Dryness of the vagina and vulva leads to reports of painful urination, itching, and painful or difficult sexual intercourse. The patient's tongue is often red and dry with atrophic taste buds. Unilateral or bilateral parotid and salivary glands may be hardened and nontender. Dental caries are a common finding. The dryness may make talking difficult. Patients may have a dry, chronic cough and an increased incidence of upper and lower respiratory tract infections, which has resulted in a chronic vocal hoarseness. Nasal mucosa may be dry and reddened. Gastrointestinal tract involvement may lead to gastritis, esophageal mucosal atrophy, and difficulty in swallowing. Genitalia may appear dry and possibly ulcerated. Involvement of the exocrine glands leads to dry, tough, scaly skin; decreased sweat; and chronic itching. The patient with SS has complaints that may have been attributed to multiple causes, possibly over years. Because SS is closely related to systemic lupus erythematosus and RA, the patient may have been misdiagnosed, causing considerable emotional distress. Because SS affects senses, such as sight and taste, and also sexuality, assess the patient's ability to cope with the presenting symptoms and other common complaints. •Diagnostic Highlights (1)Salivary gland biopsy; Identifies abnormal cells in secretory glands and ducts (2)Slit-lamp examination; Identifies reduced tear film and dryness of eyes

Impaired skin integrity related to cutaneous lesions [PRIMARY NURSING DIAGNOSIS]

Skin cancer is the most common malignancy in the United States, accounting for over 50% of all diagnosed cancers. The majority of skin cancers (more than 90%) are classified as non- melanoma skin cancers (NMSCs) of which there are two types: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Approximately 75% of skin cancers are BCC; SCC is the next most common skin cancer, followed in frequency by melanoma. More than 1.3 million cases of NMSC are diagnosed annually. Other, less frequently occurring skin cancers include skin adnexal tumors, Kaposi's sarcoma, various types of sarcomas, Merkel cell carcinoma, and cuta- neous lymphoma, all of which together account for fewer than 1% of NMSCs. BCC is a slow-growing, nonmetastasizing neoplasm of the nonkeratinizing cells of the basal layer of the epidermis, that extends wide and deep if left untreated. If distant metastasis does occur to the bone, brain, lung, and liver, the prognosis is grave. BCC is most frequently found on the head, neck, and on skin that has hair. There are two types of BCC. The nodular ulcerative BCC is a nodulocystic structure that begins as a small, flesh-colored, smooth nodule that enlarges over time. A central depression forms that progressess to an ulcer surrounded by a waxy border. The superficial BCC is often seen on the chest or back and begins as a flat, nonpalpable, erythematous plaque that enlarges and becomes red and scaly with nodular borders. Although BCC can be treated effectively, it is not uncommon for it to return after treatment. From 35% to 50% of people diagnosed with one BCC will develop a new skin cancer within 5 years of the first diagnosis. SCC leads to an invasive tumor that can metastasize to the lymph nodes and visceral organs. SCC, which constitutes 20% of all skin cancers, is characterized by lesions on the squamous epithelium of the skin and mucous membranes. SCC appears as a red, scaling, keratotic, slightly elevated lesion with an irregular border, usually with a shallow chronic ulcer. The risk of metastasis is associated with the size and penetration of the tumor, the tumor morphology, and the causative factors. Complications of NMSCs include disfigurement of facial structures and metastasis to other tissues and organs. Because occurrence of NMSC is not reported, incidence can only be estimated. It is suspected that more than 1 million cases of BCC occur each year, and 1000 to 2000 deaths occur from BCC. The 5-year survival rate for patients with BCC is greater than 99%; although BCCs rarely spread to lymph nodes or other organs, those patients who do have metastasized BCC have a 5-year sur- vival rate of only 10%. The overall 5-year survival rate for patients with SCC is more than 95%; for patients with spread of SCC to lymph nodes or other organs, the 5-year survival rate is 25%. •CAUSES The cause of NMSCs may be environmental (ultraviolet [UV] radiation or UVB exposure), occupational (arsenic, mineral oils, or ionizing radiation exposure), viral (human immunodefi- ciency virus or human papillomavirus [HPV]), related to medical conditions (immunosuppres- sion or scars from removed SCC or BCC), or related to heredity (xeroderma pigmentosum, or albinism). More than 90% of NMSCs are attributed to exposure to UV radiation from the sun. •OUTCOMES. Tissue integrity: Skin and mucous membranes; Wound healing: Primary intention; Knowledge: Treatment regimen; Nutritional status; Treatment behavior: Illness or injury •INTERVENTIONS. Incision site care; Wound care; Skin surveillance; Medication administra- tion; Infection control; Nutrition management •Pharmacologic Highlights (1)Chemotherapeutic Topical application Fluorouracil (5-FU) Manage premalignant conditions such as actinic keratosis (2)Biologic response modifier Topical application Imiquimod Cause the body to react and destroy the lesion •HISTORY. Assess the patient for a personal or family history of skin cancer. Ask if the patient has an exposure to risk factors, including environmental or occupational exposure, at-risk medical conditions, or exposure to viruses. Note that outdoor employment and living in a sunny, warm climate such as the southeastern (Florida) or southwestern (New Mexico, Arizona, California) United States, Australia, or New Zealand place the patient at risk. Question the patient about any bleeding lesions or changes in skin color. Explore the history of nonhealing wounds or lesions that have been present for several years without any change. Question the patient about the presence of atypical moles, an unusual number of moles, or any noticeable change in a mole. •PHYSICAL EXAMINATION. Inspect the patient for additional risk factors, such as light skin and hair (red, blond, light brown), freckling, and light eye color (blue or green). Examine the patient's skin for the presence of lesions. Use a bright white light and magnification during the skin examination. Stretch the skin throughout the examination to note any nodules or translucent lesions. Examine folds or wrinkles in the skin. Assess the skin for ulcerations, sites of poor heal- ing, old scars, drainage, pain, and bleeding. Because more than 70% of NMSCs occur on the face, head, and neck, closely examine these areas. Complete the skin assessment, considering that, in order of frequency, the remainder of NMSCs occurs on the trunk, upper extremities, lower extremities, and lastly, the genitals. Determine if the patient has precursor lesions of SCC, such as actinic keratoses (a hornlike projection on the skin from excessive sun exposure) and/or Bowen's disease (intraepidermal carcinoma). No assessment of precursor lesions for BCC is necessary because no equivalent lesions exist. Assess for the characteristic lesions of BCC, which tend to be asymptomatic, grow slowly, be 0.5 to 1.0 cm in size, and have overlying telangiectasis (vascular lesions formed by dilated blood vessels). BCCs are classified as nodular (the most common type), superficial, pigmented, morpheaform, and keratotic. Nodular BCC appears as a translucent, nodular growth. Superficial BCC, frequently appearing on the trunk, presents as a scaly lesion with a distinct, raised, pearly margin. Pigmented BCC has a characteristic dark or bluish color with a raised and pearly border. The morpheaform BCC lesion is poorly demarcated, is light in color, and has a plaquelike appearance. Keratotic BCC lesions appear similar to ulcerating nodular BCC. Assess for the characteristic lesions of SCC, which are usually found on sun-damaged skin. The lesions tend to be scaly, 0.5 to 1.5 cm in size, and likely to metastasize; they also grow rapidly. SCC lesions are usually covered by a warty scale surrounded by erythema that bleeds easily with minimal trauma. The tumor appears nodular, plaquelike, and without a distinct margin. When SCC is invasive, the lesion appears firm, dome-shaped, erythematous, and with an ulcerating core. •

turgor

Skin moisture. • Assess by inspection and palpation; skin usually is warm and dry. • Assess a patient with excessively moist skin (profuse diaphoresis) further because this finding may indicate conditions such as hyperthermia, anxiety, exposure to hot environment, or hyperthyroidism. • Assess a patient with excessively dry skin further because this finding may indicate conditions such as dehydration, excessive exposure to the sun, overzealous bathing, or hypothyroidism. • Assess a patient with oily skin further because this finding may be due to excessive sebaceous gland secretion or sebaceous gland inflammation (acne), commonly associated with adolescence. •. Assess skin turgor to determine elasticity of the skin, which reflects hydration status; pinch skin on anterior chest below the clavicle, sternum, forehead, or inner thigh and note how long it takes to return to its original position.

Koilonychia

Spoon nails, concave curves signs of iron deficiency anemia, syphilis, use of strong detergents

Warm saline dressings

Tepid or warm solutions should be used when the purpose is debridement and saline is a common debridement solution.

Candidiasis of skin

The appearance of candidiasis on the skin shows diffuse papular erythematous rash with pinpoint satellites around the affected area.

Wegener's granulomatosis

The condition can lead to inflamed, narrowed blood vessels and harmful inflammatory tissue masses (granulomas). Granulomas can destroy normal tissue, and narrowed blood vessels reduce the amount of blood and oxygen that reaches your body's tissues and organs. Pus-like drainage with crusts from your nose, stuffiness, sinus infections and nosebleeds Coughing, sometimes with bloody phlegm Shortness of breath or wheezing Fever Fatigue Joint pain Numbness in your limbs, fingers or toes Weight loss Blood in your urine Skin sores, bruising or rashes Eye redness, burning or pain, and vision problems Ear inflammation and hearing problems

acrofacial vitiligo

The face and hands. With this type, called acrofacial vitiligo, the affected skin is on the face and hands, and around body openings, such as the eyes, nose and ears.

Felon of the fingertip

The patient presented with three days of increased swelling, redness, and severe pain of the fingertip.

Body lice.

These lice live in clothing and on bedding and move onto your skin to feed. Body lice most often affect people who aren't able to bathe or launder clothing regularly, such as homeless individuals. These lice live in clothing and on bedding and move onto your skin to feed. Body lice most often affect people who aren't able to bathe or launder clothing regularly, such as homeless individuals

Candidiasis (Thrush)

Thick, white, raised patches in the mouth

Altered peripheral tissue perfusion related to obstructed venous blood flow [PRIMARY NURSING DIAGNOSIS]

Thrombophlebitis, inflammation of a vein with an associated blood clot (thrombus), typically occurs in the veins of the lower extremities when fibrin and platelets accumulate at areas of sta- sis or turbulence near venous valves. Deep vein thrombophlebitis (deep vein thrombosis [DVT]) occurs more than 90% of the time in small veins, such as the lesser saphenous, or in large veins, such as the femoral and popliteal. DVT and its possible consequence, pulmonary embolism, are the leading causes of preventable mortality in hospitalized patients in the United States. DVT occurs in approximately 1 person in 20 over her/his lifetime, but in hospitalized patients, the incidence of DVT ranges from 20% to 70%. DVT is potentially more serious than that of the superficial veins because the deep veins carry approximately 90% of the blood flow as it leaves the lower extremities. Once a thrombus begins to move, it becomes an embolus (a detached intravascular mass carried by the blood). If it reaches the lungs, a pulmonary embolus, it is potentially fatal. •CAUSES Venous stasis, hypercoagulability, and vascular injury are major causes of thrombophlebitis. Venous stasis results from prolonged immobility, pregnancy, obesity, chronic heart disease such as congestive heart failure (CHF) or myocardial infarction, recovery from major surgery (surgi- cal procedures lasting more than 30 minutes), cerebrovascular accidents, and advanced age. Hypercoagulability is associated with pregnancy, cigarette smoking, dehydration, deficiencies of substances involved in clot breakdown, disseminated intravascular coagulation, estrogen sup- plements and oral contraceptives, and sepsis. Vascular injury can occur with lower extremity fractures, surgery, burns, multiple trauma, childbirth, infections, irritating intravenous (IV) solutions, venipuncture, and venulitis. Other diseases that may lead to thrombus formation are cancer of the lung, gastrointestinal tract, and genitourinary tract and also atrial fibrillation; individuals older than 55 years are also particularly susceptible to thrombophlebitis. •HISTORY. Although almost half of the patients with deep and superficial thrombophlebitis are asymptomatic, patients with DVT may have complaints of calf muscle or groin tenderness, pain, fever (rarely above 101°F), chills, general weakness, and lethargy. •PHYSICAL EXAMINATION. Observe both legs, noting alterations in symmetry, color, and temperature of one leg compared with the other. In DVT, the affected limb may reveal redness, warmth, swelling, and discoloration when compared with the contralateral limb. In addition, super- ficial veins over the area may be distended. Note the presence of calf pain with dorsiflexion of the foot of the affected extremity, which is a positive Homans' sign. This positive finding occurs in 33% of patients with DVT and is considered an inconsistent and unreliable physical sign. Superficial vein thrombosis may be asymptomatic or may lead to pain, redness, induration, and swelling in the local area of the thrombus. Note the presence of local redness and nodules on the skin or extremity edema, which is rare. Palpate over the suspected vein involved. It may feel like a cord or thickness that extends upward along the entire length of the vein. •PSYCHOSOCIAL. The patient has not only an unexpected, sudden illness but also an increased risk for life-threatening complications such as pulmonary embolism. Assess the patient's ability to cope. In addition, assess the patient's degree of anxiety about the illness and potential complications. •Diagnostic Highlights (1)D-dimer, measured by latex agglutination or by an enzyme-linked immunosorbent assay (ELISA) test; D-dimer fragments are present in a fresh fibrin clot and levels are elevated for 7 days when clots form (2)Doppler ultrasound; duplex Doppler venous scanning;

Shingles

Varicella-zoster is part of a group of viruses called herpes viruses, which includes the viruses that cause cold sores and genital herpes. Because of this, shingles is also known as herpes zoster. But the virus that causes chickenpox and shingles is not the same virus responsible for cold sores or genital herpes, a sexually transmitted infection. Pain, burning, numbness or tingling Sensitivity to touch A red rash that begins a few days after the pain Fluid-filled blisters that break open and crust over Itching

Immobilization

When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation to affected tissues. Know which patients require help to turn and change positions.

chloasma

a pigmentation disorder characterized by brownish spots on the face

telangiectasia (spider angioma)

a tiny, red blood vessel lesion formed by the dilation of a group of blood vessels radiating from a central arteriole, most commonly on the face, neck, or chest surgical interventions: Electrodessication or electrocoagulation

Identify the functions of the skin.

a. Protection b. Sensation c. Temperature regulation d. Excretion and secretion

Identify the factors that influence a personal preference for hygiene. [Nursing Knowledge Base]

a. Social practices b. Personal preferences c. Body image d. Socioeconomic status e. Health beliefs and motivation f. Cultural variables

A patient is a 78-year-old woman who has had chronic respiratory disease for 30 years. She weighs 212 lb (96.4 kg) and is 5 ft, 1 in (152.5 cm) tall. She has recently completed corticosteroid and antibiotic treatment for an exacerbation of her respiratory disease. Identify four specific predisposing factors for bacterial skin infection in this patient.

a. chronic disease; b. obesity; c. recent antibiotic therapy; d.recent corticosteroid therapy

A woman calls the health clinic and describes a rash that she has over the abdomen and chest. She tells the nurse it has raised, fluid-filled, small blisters that are distinct. a. Identify the type of primary skin lesion described by this patient. b. What is the distribution terminology for these lesions? c. What additional information does the nurse need to document the critical components of these lesions?

a. vesicles; b. discrete, localized to the chest and abdomen. c. color, size, and configuration

Pyogenic flexor tenosynovitis

acute synovial space infection involving a flexor tendon sheath. Treatment consists of parenteral antibiotics and sheath irrigation

The patient has diabetes mellitus and chronic obstructive pulmonary disease that has been treated with high-dose corticosteroids for the past several years. Which dermatologic manifestations could be related to these systemic problems (select all that apply)? a. Acne b. Increased sweating c. Dry, coarse, brittle hair d. Impaired wound healing e. Erythematous plaques of the shins f. Decreased subcutaneous fat over extremities

ans a, d, e, f. Glucocorticoid excess can cause acne and decreased subcutaneous fat over the extremities. Diabetes mellitus can cause erythematous plaques of the shins and both the corticosteroids and diabetes can impair or delay wound healing. Increased sweating is seen with hyperthyroidism and coarse, brittle hair is seen with hypothyroidism.

What is the most common diagnostic test used to determine a causative agent of skin infections? a. Culture b. Tzanck test c. Immunofluorescent studies d. Potassium hydroxide (KOH) slides

ans a. A culture can be performed to distinguish among fungal, bacterial, and viral infections. A Tzanck test is specific for herpesvirus infections, potassium hydroxide slides are specific for fungal infections, and immunofluorescent studies are specific for infections that cause abnormal antibody proteins.

To prevent lichenification related to chronic skin problems, what does the nurse encourage the patient to do? a. Use measures to control itching. b. Wear sterile gloves when touching the lesions. c. Use careful hand washing and safe disposal of soiled dressings. d. Use topical antibiotics with wet-to-dry dressings over the lesions.

ans a. Lichenification is thickening of the skin caused by chronic scratching or rubbing and can be prevented by controlling itching. It is not an infection, nor is it contagious, as the other options indicate.

The patient asks the nurse what telangiectasia looks like. Which is the best description for the nurse to give the patient? a. A circumscribed, flat discoloration b. Small, superficial, dilated blood vessels c. Benign tumor of blood or lymph vessels d. Tiny purple spots resulting from tiny hemorrhages

ans b. Telangiectasia looks like small, superficial, dilated blood vessels. A small circumscribed, flat discoloration describes a macule. A benign tumor of blood or lymph vessels describes an angioma. Tiny purple spots resulting from tiny hemorrhages describes petechiae.

A patient has a plaque lesion on the dorsal forearm. Which type of biopsy is most likely to be used for diagnosis of the lesion? a. Punch biopsy b. Shave biopsy c. Incisional biopsy d. Excisional biopsy

ans b. A shave biopsy is done for superficial lesions that can be scraped with a razor blade, removing the full thickness of the stratum corneum. An excisional biopsy is done when the entire removal of a lesion is desired. Punch biopsies are done with larger nodules to examine for pathology, as are incisional biopsies.

The nurse observes that redness remains after palpation of a discolored lesion on the patient's leg. This finding is characteristic of a. varicosities. b. intradermal bleeding. c. dilated blood vessels. d. erythematous lesions.

ans b. Discolored lesions that are caused by intradermal or subcutaneous bleeding do not blanch with pressure, whereas those caused by inflammation and dilated blood vessels will blanch and refill after palpation. Varicosities are engorged, dilated veins that may empty with pressure applied along the vein.

A home health nurse is visiting an older obese woman who has recently had hip surgery. She tells the patient's caregiver that the patient has intertrigo. When the caregiver asks what that is, the nurse should tell the caregiver that it is a. thickening of the skin. b. dermatitis in the folds of her skin. c. loss of color in diffuse areas of her skin. d. a firm plaque caused by fluid in the dermis.

ans b. Intertrigo is dermatitis in the folds of her skin. Thickening of the skin is lichenification. Loss of color in diffuse areas of skin is vitiligo. A firm plaque caused by fluid in the dermis is a wheal.

An active athletic person calls the clinic and describes her feet as having linear breaks through the skin. What is the most likely diagnosis of this problem? a. Scales b. Fissure c. Pustule d. Comedo

ans b. Scales are excess dead epidermal cells. A pustule is a circumscribed collection of leukocytes and free fluid. Comedo is associated with acne vulgaris.

What is an appropriate intervention to promote debridement and removal of scales and crusts of skin lesions? a. Warm oatmeal baths b. Warm saline dressings c. Cool sodium bicarbonate baths d. Cool magnesium sulfate dressings

ans b. Tepid or warm solutions should be used when the purpose is debridement and saline is a common debridement solution. Baths are appropriate for debridement but sodium bicarbonate and oatmeal are used for pruritus.

When the nurse is assessing the skin of an older adult, which factor is likely to contribute to dry skin? a. Increased bruising b. Excess perspiration c. Decreased extracellular fluid d. Decreased peripheral blood supply

ans c. In older adults the dermis loses volume and has fewer blood vessels, which contributes to decreased extracellular water. Some older people do not drink enough fluids and this can also contribute to dry skin. In older adults there are also decreased surface lipids and apocrine and sebaceous gland activity. Increased bruising from capillary fragility does not contribute to dry skin.

When obtaining important health information from a patient during assessment of the skin, it is important for the nurse to ask about a. a history of freckles as a child. b. patterns of weight gain and loss. c. communicable childhood illnesses. d. skin problems related to the use of medications.

ans d. A careful medication history is important because many medications cause dermatologic side effects and patients also use many over-the-counter preparations to treat skin problems. Freckles are common in childhood and are not related to skin disease. Communicable childhood illnesses are not directly related to skin problems, although varicella viruses may affect the skin in adulthood. Patterns of weight gain and loss are not significant but the presence of obesity may cause skin problems in overlapping skin areas.

What is the primary difference between an excoriation and an ulcer? a. Ulcers do not penetrate below the epidermal junction. b. Excoriations involve only thinning of the epidermis and dermis. c. Excoriations will form crusts or scabs whereas ulcers remain open. d. An excoriation heals without scarring because the dermis is not involved.

ans d. An excoriation is a focal loss of epidermis; it does not involve the dermis and, as such, does not scar with healing. Ulcers do penetrate into and through the dermis and scarring does occur with these deeper lesions. Epidermal and dermal thinning is atrophy of the skin but does not involve a break in skin integrity. Both excoriations and ulcers have a break in skin integrity and may develop crusts or scabs over the lesions.

5. Priority Decision: When performing a physical assessment of the skin, what should the nurse do first? a. Palpate the temperature of the skin with the fingertips. b. Assess the degree of turgor by pinching the skin on the forearm. c. Inspect specific lesions before performing a general examination of the skin. d. Ask the patient to undress completely so all areas of the skin can be inspected.

ans d. It is necessary for the patient to be completely undressed for an examination of the skin. Gowns should be provided and exposure minimized as the skin is inspected generally first, followed by a lesion-specific examination. Skin temperature is best assessed with the back of the hand and turgor is best assessed with the skin over the sternum.

Priority Decision: A 46-year-old African American patient is scheduled to have a basal cell carcinoma on his cheek excised in the health care provider's office. What factor is most important for the nurse to obtain in the patient's history? a. Protected sun exposure b. Radiation treatment for acne c. Prior treatments for the lesion d. Exposure to harsh irritants such as ammonia

ans: b. Thirty years ago, when the patient was a teenager, radiation therapy was used to treat cystic acne with the result that many of these patients now have developed basal cell carcinoma. For a person with dark skin, radiation therapy is a higher risk factor for skin cancer than exposure to the sun or other irritants.

Priority Decision: A patient is receiving chemotherapy. She calls the physician's office and says she is experiencing itching in her groin and under her breasts. What is the first nursing assessment that would be done before the nurse makes an appointment for the patient with the physician to determine the treatment? a. Her height and weight b. What the areas look like c. If chemotherapy was completed d. Culture and sensitivity of the areas

ans: b. The appearance of candidiasis on the skin shows diffuse papular erythematous rash with pinpoint satellites around the affected area. Height and weight could show if the patient is obese but it would be better to ask if the areas affected are moist. The chemotherapy could contribute to candidiasis but it does not matter if the chemotherapy treatments are finished. Culture and sensitivity of the area may be ordered by the physician at the patient's appointment.

Which stratum of the epidermis contains dead keratinocytes? a. corneum b. lucidum c. granulosum d. spinosum e. germinativum

ans: A

What is the name for papillomavirus infection seen on the skin? a. Furuncle b. Carbuncle c. Erysipelas d. Plantar wart

ans: D A plantar wart is caused by human papillomavirus (HPV). A furuncle is a deep skin infection with staphylococci around the hair follicle. A carbuncle is multiple, interconnecting furuncles. Erysipelas is superficial cellulitis primarily involving the dermis

Which statements are true about skin and skin care (select all that apply)? a. One of the detrimental effects of obesity on the skin is increased sweating. b. The nutrient that is critical in maintaining and repairing the structure of epithelial cells is vitamin C. c. Exposure to UVA rays is believed to be the most important factor in the development of skin cancer. d. The photosensitivity caused by various drugs can be blocked by the use of topical hydrocortisone. e. Photosensitivity results when certain chemicals in body cells and tissues absorb light from the sun and release energy that harms the tissues and cells. f. When teaching a patient about the use of sunscreens that protect against exposure to both UVA and UVB rays, the nurse advises the patient to look for the inclusion of benzophenones.

ans: a, e, f. Vitamin A, not vitamin C, is critical in maintaining and repairing the structure of epithelial cells. Exposure to UVB rays, not UVA rays, is believed to be the most important factor in the development of skin cancer. Sunscreen, not topical hydrocortisone, can block the photosensitivity caused by various drugs.

What are the most appropriate dressings to use to promote comfort for a patient with an inflamed, pruritic dermatitis? a. Cool tap water dressings b. Cool acetic acid dressings c. Warm sterile saline dressings d. Warm potassium permanganate dressings

ans: a. Dressings used to treat pruritic lesions should be cool to cause vasoconstriction and to have an antiinflammatory effect. Water is most commonly used and it does not need to be sterile. Acetic acid solutions are bacteriocidal and are used to treat skin infections.

What is the most common reason elective cosmetic surgery is requested by patients? a. Improve self-image b. Remove deep acne scars c. Lighten the skin in pigmentation problems d. Prevent skin changes associated with aging

ans: a. Improvement of body image is the most common reason for undergoing cosmetic surgery; appearance is an important part of confidence and self-assurance. Acne scars, pigmentation problems, and wrinkling can be treated with cosmetic surgery but the surgery does not prevent the skin changes associated with aging.

Which skin condition occurs as an allergic reaction to mite eggs? a. Scabies b. Impetigo c. Folliculitis d. Pediculosis

ans: a. In scabies mites penetrate the skin and deposits eggs. An allergic reaction can result from the presence of eggs, feces, and mite parts. Impetigo involves vesiculopustular lesions that develop a thick, honey-colored crust surrounded by erythema. Folliculitis is a small pustule at the hair follicle opening with minimal erythema. Pediculosis is lice

A nurse caring for a disheveled patient with poor hygiene observes that the patient has small red lesions flush with the skin on the head and body. The patient complains of severe itching at the sites. For what should the nurse further assess the patient? a. Nits on the shafts of his head hair b. A history of sexually transmitted diseases c. The presence of ticks attached to the scalp d. The presence of burrows in the interdigital webs

ans: a. Pediculosis (head lice and body lice) causes very small, red, noninflammatory lesions that progress to papular wheal-like lesions and cause severe itching. Lice live on the body as nits (tiny white eggs) that are firmly attached to hair shafts on the head and body. Burrows, especially in interdigital webs, are found with scabies.

What is a skin graft that is used to transfer skin and subcutaneous tissue to large areas of deep tissue destruction called? a. Skin flap b. Free graft c. Soft tissue extension d. Free graft with vascular anastomoses

ans: a. Skin flaps as grafts include moving skin and subcutaneous tissue to another part of the body and are used to cover wounds with poor vascular beds, add padding, and cover wounds over cartilage and bone. Both types of free grafts include just skin and soft tissue extension involves placement of an expander under the skin, which stretches the skin over time to provide extra skin to cover the desired area.

The nurse plans care for a patient with a newly diagnosed malignant melanoma based on the knowledge that initial treatment may involve (select all that apply) a. shave biopsy. b. Mohs' surgery. c. surgical excision. e. localized radiation. g. topical nitrogen mustard. f. fluorouracil (5-FU).

ans: b, c. In the early stages, surgical excision with a margin of normal skin is the initial treatment for malignant melanoma. Mohs' surgery can also be used to treat malignant melanoma. Radiation may be used after excision for malignant melanoma, depending on staging of the disease. Topical nitrogen mustard may be used for treatment of cutaneous T-cell lymphoma.

Which description characterizes seborrheic keratosis? a. White patchy yeast infection b. Warty, irregular papules or plaques c. Excessive turnover of epithelial cells d. Deep inflammation of subcutaneous tissue

ans: b. Seborrheic keratoses are irregularly round or oval shaped and are often verrucous papules or plaques. Candidiasis is a white patchy yeast infection. Cellulitis is a deep inflammation of subcutaneous tissue. Psoriasis is an excessive turnover of epithelial cells. .

What should the nurse include in the instructions for a patient with urticaria? a. Apply topical benzene hexachloride. b. Avoid contact with the causative agent. c. Gradually expose the area to increasing amounts of sunlight. d. Use over-the-counter antihistamines routinely to prevent the condition.

ans: b. Urticaria is inflammation and edema in the upper dermis, most commonly caused by histamine released during an antibody-allergen reaction. The best treatment for all types of allergic dermatitis is avoidance of the allergen. Sunlight and warmth would increase the edema and inflammation. Antihistamines may be used for an acute outbreak but not to prevent the dermatitis. Topical benzene hexachloride is used to treat pediculosis.

Which skin conditions are more common in immunosuppressed patients (select all that apply)? a. Acne b. Lentigo c. Candidiasis d. Herpes zoster e. Herpes simplex 1 f. Kaposi sarcoma

ans: c, e, f. increased risk for candidiasis (a fungal infection), herpes simplex 1 (caused by a virus), and Kaposi sarcoma (vascular lesions on the skin, mucous membranes, and viscera with wide range of presentation). The other options are not at increased risk with immunosuppression. Acne is caused by inflammation of sebaceous glands. Lentigo (also called "liver spots" or "age spots") is caused by an increased number of normal melanocytes in the basal layer of epidermis. Herpes zoster, which is caused by an activation of the varicella- zoster virus, is a group of vesicles and pustules resembling chickenpox located in a linear distribution along a dermatome

A patient with a contact dermatitis is treated with calamine lotion. What is the rationale for using this base for a topical preparation? a. A suspension of oil and water to lubricate and prevent drying b. An emulsion of oil and water used for lubrication and protection c. Insoluble powders suspended in water that leave a residual powder on the skin d. A mixture of a powder and ointment that causes drying when moisture is absorbed

ans: c. A lotion is a suspension of insoluble powders in water, which has cooling and drying properties, useful when itching is present. Creams and ointments have an oil and water base that lubricates and protects skin whereas a paste is a mixture of powder and ointment.

Which skin condition would be treated with laser surgery? a. Preauricular lesion b. Redundant soft tissue conditions c. Obesity with subcutaneous fat accumulation d. Fine wrinkle reduction or facial lesion removal

ans: d. A facelift is used for preauricular lesions and redundant soft tissue reduction. Liposuction is used for obesity with subcutaneous fat accumulation.

What characteristic is commonly seen with dysplastic nevus syndrome? a. Associated with sun exposure b. Precursor of squamous cell carcinoma c. Slow-growing tumor with rare metastasis d. Lesion has irregular color and asymmetric shape

ans: d. Dysplastic nevus syndrome involves atypical moles with irregular borders and various shades of color.

A patient with psoriasis is being treated with psoralen plus UVA light (PUVA) phototherapy. During the course of therapy, for what duration should the nurse teach the patient to wear protective eyewear that blocks all UV rays? a. Continuously for 6 hours after taking the medication b. Until the pupils are able to constrict on exposure to light c. For 12 hours following treatment to prevent retinal damage d. For 24 hours following treatment when outdoors or when indoors near a bright window

ans: d. Psoralen is absorbed by the lens of the eye and eyewear that blocks 100% of UV light must be used for 24 hours after taking the medication. Because UVA penetrates glass, the eyewear must also be worn indoors when near a bright window. Psoralen does not affect the accommodative ability of the eye.

What skin condition has keratotic and firm lesions, is a precursor of squamous cell carcinoma, and is treated with topical fluorouracil (5-FU)? a. Actinic keratosis b. Basal cell carcinoma c. Malignant melanoma d. Squamous cell carcinoma

ans:a. Basal cell carcinoma is noduloulcerative with pearly borders. Malignant melanoma tumors arise in melanocytes. Malignant melanoma is the deadliest skin cancer and has an increased risk in people with dysplastic nevus syndrome. Squamous cell carcinoma is a malignant neoplasm of keratinizing epidermal cells.

Which statements characterize malignant melanomas (select all that apply)? a. Lesion is keratotic and firm b. Neoplastic growth of melanocytes c. Skin cancer with highest mortality rate d. Irregular color and asymmetric shape e. Frequently occurs on previously damaged skin

ans:b, c, d. Actinic and firm lesions are actinic keratosis and squamous cell carcinoma. Squamous cell carcinoma frequently occurs in previously damaged skin.

Normal nail

approximately 160 degree angle between nail plate and nail

Tendinous xanthomas

are firm nodules that develop subcutaneously in fasciae, ligaments, and tendons, often in extensor surfaces.1

Xanthomas

are nontender lesions consisting of abnormal lipid deposition and foam cells.1 The yellow to red hue. Morphology can vary from macules and papules to plaques and nodules.3 They can develop on the skin and tendons.

Cherry (senile) angiomas

are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old.

Planar xanthomas

are yellow macules, papules, or plaques on the upper eyelids, wrists, palms, and intertriginous areas.

Eruptive xanthomas

are yellow-red papules that appear suddenly in crops on extensor surfaces of the extremities and the buttocks.

What is the most common skin cancer and has pearly borders? a. Actinic keratosis b. Basal cell carcinoma c. Malignant melanoma d. Squamous cell carcinoma

b. Actinic keratosis is an irregularly shaped, flat, slightly erythematous papule with indistinct borders and an overlying hard keratotic scale or horn. Malignant melanoma tumors arise in melanocytes. Malignant melanoma is the deadliest skin cancer and has an increased risk in people with dysplastic nevus syndrome. Squamous cell carcinoma is a malignant neoplasm of keratinizing epidermal cells.

Vitamin C deficiency

can lead to scurvy. Signs and symptoms of this rare disease include bleeding under the skin and around the gums. Vitamin C deficiency can develop if you don't get enough vitamin C from the foods you eat. Vitamin C deficiency is also possible if something impairs your ability to absorb vitamin C from food. For instance, smoking impairs your body's ability to absorb vitamin C. Certain chronic illnesses, such as cancer or chronic kidney disease, also increase your risk of vitamin C deficiency anemia by affecting the absorption of vitamin C. Foods rich in vitamin C include: Broccoli Citrus fruits and juices Strawberries Green peppers Tomatoes

Tuberoeruptive Xanthomas

can occur with hypercholesterolemic states such as dysbetalipoproteinemia (Frederickson type III) and familial hypercholesterolemia (Frederickson type II) They often present as pink-yellow papules or nodules on extensor surfaces, specifically the elbows and knees. Tuberous lesions are the larger of the two, exceeding 3 cm in diameter.

Clubbing

change in angle between nail and nail base (eventually larger than 180 degrees); nail bed softening, with nail flattening; often enlargement of fingertips

Lice

coming into contact with either lice or their eggs. Lice can't jump or fly. They spread through: •Head-to-head or body-to-body contact. This may occur as children or family members play or interact closely. •Proximity of stored belongings. Storing infested clothing in closets, lockers or on side-by-side hooks at school, or storing personal items such as pillows, blankets, combs and stuffed toys in proximity at home can permit lice to spread. •Items shared among friends or family members. These may include clothing, headphones, brushes, combs, hair decorations, towels, blankets, pillows and stuffed toys. •Contact with contaminated furniture. Lying on a bed or sitting in overstuffed, cloth-covered furniture recently used by someone with lice can spread them. Lice can live for one to two days off the body. •Sexual contact. Pubic lice usually spread through sexual contact and most commonly affect adults. Pubic lice found on children may be a sign of sexual exposure or abuse.

Defining characteristics for body image problems

include verbalization of self-disgust and reluctance to look at lesions, as evidenced in this patient. Social isolation is indicated only if there is evidence of decreased social activities and of anxiety by verbalization of anxiety or frustration. Ineffective self-health management is indicated by evidence of a lack of self-care or understanding of the disease process.

rash distribution

includes allergic contact dermatitis, irritant contact dermatitis, pseudophytophotodermatitis, and chemical burn.

Squamous cell carcinoma

is a malignant neoplasm of keratinizing epidermal cells. • an invasive malignant tumor of the surface epithelium• like basal cell carcinoma, it occurs most often on sun-exposed skin • lesion presents as a flat plaque; a small, persistent ulcer; or a slightly elevated, keratotic plaque; • histologically, squamous cell carcinoma of the skin is indistinguishable from squamous cell carcinoma in other sites.

Afelon

is an abscess of the distal pulp of the fingertip. An early felon may be amenable to elevation, oral antibiotics, and warm water or saline soaks. Amore advanced felon requires incision and drainage

Erythema multiforme

is an acute, recurring, inflammatory disorder of the skin and mucous membranes. It is associated with allergic or immunologic reactions to drugs or microorganisms. Immune complex formation and deposition of C3, IgM, and fibrinogen around the superficial dermal blood vessels, basement membrane, and keratinocytes can be observed in most individuals with erythema multiforme. The characteristic "bull's eye" lesion occurs on the skin surface, consisting of a central erythematous region surrounded by concentric rings or alternating edema and inflammation. A vesiculobullous form is characterized by mucous membrane lesions and erythematous plaques on the extensor surfaces of the extremities.

Anasarca

is bilateral or generalized edema all over the body.

Wilson's disease

is inherited as an autosomal recessive trait present at birth, but signs and symptoms don't appear until the copper builds up in the brain, liver or other organ. Signs and symptoms vary depending on the parts of your body affected by the disease. They can include: Fatigue, lack of appetite or abdominal pain A yellowing of the skin and the whites of the eye (jaundice) Golden-brown eye discoloration (Kayser-Fleischer rings) Fluid buildup in the legs or abdomen Problems with speech, swallowing or physical coordination Uncontrolled movements or muscle stiffness

Basal cell carcinoma

is noduloulcerative with pearly borders. • most common malignant skin tumor of epithelial origin • low-grade malignant tumor that does not metastasize and rarely, if ever, causes death; • tumor presents as a slightly elevated nodule with a central depression that becomes increasingly prominent as the tumor grows

Pedal erythema

is redness of the feet

Xerosis

is the term used to describe skin that is excessively dry.

Scleroderma

is tight, "hard" skin that causes problems with mobility.

Celiac disease

more than half the adults with celiac disease have signs and symptoms unrelated to the digestive system, including Itchy, blistery skin rash (dermatitis herpetiformis) Mouth ulcers

Vitiligo

occurs when pigment-producing cells (melanocytes) die or stop producing melanin — the pigment that gives your skin, hair and eyes color.The discolored areas usually get bigger with time.

Excision

process of cutting out, surgical removal Malignant melanoma, Common and genital warts, Basal and squamous cell carcinomas

Varicella-Zoster Virus (VZV)

rash appears, it goes through three phases: Raised pink or red bumps (papules), which break out over several days Small fluid-filled blisters (vesicles), which form in about one day and then break and leak Crusts and scabs, which cover the broken blisters and take several more days to heal •The onset of chickenpox is rapid with mild fever and aches •Chickenpox rash is present from manifestation onset and is primarily on the trunk •Chickenpox lesions appear in various stages of development and are superficial. Vesicles collapse when punctured •Chickenpox is normally a mild disease. But it can be serious and can lead to complications including: Bacterial infections of the skin, soft tissues, bones, joints or bloodstream (sepsis) Dehydration Pneumonia Inflammation of the brain (encephalitis) Toxic shock syndrome Reye's syndrome in children and teenagers who take aspirin during chickenpox Death

Phytophotodermatitis

rash caused by exposure to certain plants and then to sunlight Psoralen, a substance responsible for inducing photosensitization, is found in lemons, limes, bergamot, figs, dill, mustard, parsnip, and garden and wild carrot.1 Lesions develop hours to days after exposure. Areas of erythema, vesicles, or hyperpigmented plaques develop, often in the form of finger marks or streaks corresponding to sites of plant contact with the skin.2 Hyperpigmentation resolves over a period of weeks to months.3

Splinter hemorrhages

red or brown linear streaks in nail beds signs of minor trauma, subacute bacterial endocarditis, trichinosis

seborrhea

refers to oily skin.

Lentigo

small brown nonfading macules, Age spots are very common in adults older than 50, but younger people can get them if they spend time in the sun. Age spots can look like cancerous growths. removed. You can help prevent age spots by regularly using sunscreen and avoiding the sun.

Beau's lines

transverse depressions that appear as white lines across the fingernails indicating temporary disturbance of nail growth (nail grows out over several months) as a sign of an acute severe illness such as malnutrition, systemic disease, thyroid dysfunction, trauma, or coronary occulsion

Warm oatmeal baths

used for pruritus

Cool sodium bicarbonate baths

used for pruritus.

Kaposi Sarcoma (HHV-8)

vascular lesions on the skin, mucous membranes, and viscera with wide range of presentation • dermal tumor composed of blood vessels and perivascular connective tissue cells • red in color and present as hemorrhagic nodules, which are often multiple and confluent • most prevalent malignant lesion in patients with AIDS • believed the state of immunosuppression associated with AIDS somehow facilitates the proliferation of blood vessel-forming cells in the dermis and in other sites; recently, herpesvirus type 8 has been isolated from Kaposi's sarcoma cells. It has been proposed that the virus may cause tumors in immunosuppressed hosts

vitamin B-12 deficiency

vitamin B-12 deficiency can lead to neurological problems, such as persistent tingling in your hands and feet or problems with balance. Eggs Fortified foods, such as breakfast cereals Milk, cheese and yogurt Meat and shellfish Vitamin B-12 deficiency can result from a diet lacking in vitamin B-12, which is found mainly in meat, eggs and milk. However, the most common cause of vitamin B-12 deficiency anemia is a lack of a substance called intrinsic factor, which can be caused when your immune system mistakenly attacks the stomach cells that produce this substance. This type of anemia is called pernicious anemia. Intrinsic factor is a protein secreted by the stomach that joins vitamin B-12 in the stomach and moves it through the small intestine to be absorbed by your bloodstream. Without intrinsic factor, vitamin B-12 can't be absorbed and leaves your body as waste. People with endocrine-related autoimmune disorders, such as diabetes or thyroid disease, may have an increased risk of developing pernicious anemia. Vitamin B-12 deficiency anemia can also occur if your small intestine can't absorb vitamin B-12 for reasons other than a lack of intrinsic factor. This may happen if: You've had surgery to your stomach or small intestine, such as gastric bypass surgery You have abnormal bacterial growth in your small intestine You have an intestinal disease, such as Crohn's disease or celiac disease, that interferes with absorption of the vitamin You've ingested a tapeworm from eating contaminated fish. The tapeworm saps nutrients from your body.

Seborrheic Keratosis

• also known as senile warts• most common benign epidermal tumor, presenting in the form of a brownish, solitary or multiple, mulberry-shaped, wart-like, exophytic, flat-topped lesion with a corrugated, furrowed surface • Histologically, the lesion consists of papillae lined with a uniform population of basaloid cells• innocuous and should not be considered premalignant • some lesions that are very pigmented may be mistaken for malignant melanoma. • In contrast to melanoma, senile warts are friable and easily removed.

Kaposi's sarcoma .

• dermal tumor composed of blood vessels and perivascular connective tissue cells• red in color and present as hemorrhagic nodules, which are often multiple and confluent• most prevalent malignant lesion in patients with AIDS• believed the state of immunosuppression associated with AIDS somehow facilitates the proliferation of blood vessel-forming cells in the dermis and in other sites; recently, herpesvirus type 8 has been isolated from Kaposi's sarcoma cells. It has been proposed that the virus may cause tumors in immunosuppressed hosts

Psoriasis

• generalized papulosquamous disease •Incurable • presents with slightly elevated papules and patches covered with silvery scales, reflecting the parakeratotic surface layer • lesions most often appear on the extensor surface of the extremities, such as the knees and elbows.

Alopecia

• loss of hair from the scalp is called baldness • may be focal (alopecia areata/patchy), diffuse, or universal

Nevus

• mole • developmental abnormality of the skin characterized by an accumulation of melanocytes; •may be located in the dermis (dermal nevus) or at the dermoepidermal junction (junctional nevus), or they may be both junctional and dermal (compound nevus)

Freckle (ephelis)

• patch of skin in which the melanocytes show a hyper-reactivity to ultraviolet stimulation → if exposed to sunlight, such spots become darker brown

Malignant melanoma

• tumor originating from melanocytes • ∼ ½ of malignant melanomas originate from intact skin; the other half arise from freckles and preexisting nevi • At least ¹/₃ to ¹/₂ of all malignant melanomas originate in preexisting lentigines or acquired and dysplastic nevi. surgical interventions: Excision

Seborrheic Dermatitis (Cradle Cap)

• widespread chronic disease• multifactorial disorder • reddening, scaling, and itching of the skin, especially on the nasolabial folds, the eyebrows, and the upper chest• Lead to formation of abundant dandruff • topical steroids, special shampoos and soaps containing sulfur also can be used.

Minor skin disorders

•Basal cell carcinoma •Candidasis (moniliasis) •Herpes simples virus •skin cancer

Tinea pedis:

•CHARACTERISTICS Athlete's foot is fungal infection of foot; scaliness and cracking of skin occur between the toes and on the soles of the feet. Small blisters containing fluid appear. •IMPLICATIONS Athlete's foot spreads to other body parts, especially hands. It is contagious and frequently recurs •INTERVENTIONS Make sure that feet are well ventilated. Drying feet well after bathing and applying powder help prevent infection. Wearing clean socks or stockings reduces incidence. Health care provider orders application of griseofulvin, miconazole, or tolnaftate.

Dry skin:

•CHARACTERISTICS Flaky, rough texture on exposed areas such as hands, arms, legs, or face •IMPLICATIONS Skin becomes infected if epidermal layer cracks. •INTERVENTIONS Bathe less frequently and rinse the body of all soap because residue left on the skin can cause irritation and breakdown. Add moisture to the air through the use of a humidifier. Increase fluid intake when the skin is dry. Use moisturizing cream to aid healing. (Cream forms protective barrier and helps maintain fluid within skin.) Use cream such as Eucerin. Use creams to clean skin that is dry or allergic to soaps and detergents.

Foot odors:

•CHARACTERISTICS Foot odors are the result of excess perspiration that promotes microorganism growth. •IMPLICATIONS Condition causes discomfort because of excess perspiration. •INTERVENTIONS Frequent washing, use of foot deodorants and powders, and wearing clean footwear prevent or reduce problem.

Corns:

•CHARACTERISTICS Friction and pressure from ill-fitting or loose shoes cause keratosis. Corns are seen mainly on or between toes over bony prominences. Corns are usually cone shaped, round, and raised. Soft corns are macerated. •IMPLICATIONS Compresses the underlying dermis, making it thin and tender. Pain is aggravated when wearing tight shoes. Tissue becomes attached to bone if allowed to grow. Patient suffers alteration in gait resulting from pain. •INTERVENTIONS Surgical removal is necessary, depending on severity of pain and size of corn. Avoid use of oval corn pads, which increase pressure on toes and reduce circulation. Warm water soaks soften corns before gentle rubbing with a callus file or pumice stone (consult with health care provider). Wider and softer shoes, especially shoes with a wider toe box, are helpful.

Plantar warts:

•CHARACTERISTICS Fungating lesion appears on sole of foot and is caused by the papilloma virus. •IMPLICATIONS Some warts are contagious. They are painful and make walking difficult •INTERVENTIONS Treatment ordered by health care provider often includes applications of salicylic acid, electrodessication (burning with electrical spark), or freezing with solid carbon dioxide.

Contact Dermatitis:

•CHARACTERISTICS Inflammation of skin characterized by abrupt onset with erythema; pruritus; pain; and appearance of scaly, oozing lesions (seen on face, neck, hands, forearms, and genitalia) •IMPLICATIONS often difficult to eliminate because person is usually in continual contact with substance causing skin reaction. Substance is often hard to identify •INTERVENTIONS Avoid causative agents (e.g., cleansers and soaps).

Acne:

•CHARACTERISTICS Inflammatory, papulopustular skin eruption, usually involving bacterial breakdown of sebum; appears on face, neck, shoulders, and back •IMPLICATIONS infected material within pustule spreads if area is squeezed or picked. Permanent scarring can result. •INTERVENTIONS Wash hair and skin thoroughly each day with warm water and soap to remove oil. Use cosmetics sparingly because oily cosmetics or creams accumulate in pores and tend to make condition worse. Implement dietary restrictions if necessary. (Eliminate foods that aggravate condition from diet.) Use prescribed topical antibiotics for severe forms of acne.

Pediculosis:

•CHARACTERISTICS Lice; tiny, grayish-white parasitic insects that infest mammals

Pediculosis capitis:

•CHARACTERISTICS Parasite is on scalp attached to hair strands. Eggs look like oval particles similar to dandruff. Bites or pustules may be observed behind the ears and at the hairline. •IMPLICATIONS Head lice are difficult to remove and spread to furniture and other people if not treated. They do not carry disease, cannot fly or jump, and are carried by animals.

Pediculosis pubis:

•CHARACTERISTICS Parasites are in pubic hair. Crab lice are grayish white with red legs. •IMPLICATIONS Lice spread through bed linen, clothing, or furniture or between people via sexual contact

Pediculosis corporis:

•CHARACTERISTICS Parasites tend to cling to clothing, so they are not always easy to see. Body lice suck blood and lay eggs on clothing and furniture. •IMPLICATIONS Patient itches constantly. Scratches seen on skin become infected. Hemorrhagic spots appear on skin where lice are sucking blood.

Abrasion:

•CHARACTERISTICS Scraping or rubbing away of epidermis that results in localized bleeding and later weeping of serous fluid •IMPLICATIONS Infection occurs easily because of loss of protective skin layer •INTERVENTIONS Be careful not to scratch patient with jewelry or fingernails. Wash abrasions with mild soap and water; dry thoroughly and gently. Observe dressing or bandage for retained moisture because it increases risk of infection.

Skin Rashes

•CHARACTERISTICS Skin eruptions that result from overexposure to sun or moisture or from allergic reaction (flat or raised, localized or systemic, pruritic or nonpruritic) •IMPLICATIONS If skin is continually scratched, inflammation and infection may occur. Rashes also cause discomfort. •INTERVENTIONS Wash area thoroughly and apply antiseptic spray or lotion to prevent further itching and aid in healing process. Apply warm or cold soaks to relieve inflammation if indicated

Ingrown nails:

•CHARACTERISTICS The toenail or fingernail grows inward into soft tissue around the nail. Ingrown nails often result from improper nail trimming. •IMPLICATIONS Ingrown nails cause localized pain when pressure is applied. •INTERVENTIONS Treatment is frequent hot soaks in antiseptic solution and removal of part of nail that has grown into skin. Instruct patient in proper nail-trimming techniques and refer to podiatrist.

Calluses:

•CHARACTERISTICS Thickened portion of epidermis consists of mass of horny, keratotic cells. Calluses are usually flat and painless and are found on undersurface of foot or on palm of hand. •IMPLICATIONS Local friction or pressure causes callus formation, which causes discomfort when wearing tight shoes. •INTERVENTIONS Soft-sole shoes with insoles are recommended. Advise patient to wear gloves when using tools or objects that create friction on palmar surfaces. Advise patients, especially with callus formation, not to self-treat but seek interventions from a podiatrist

Alopecia:

•CHARACTERISTICSAlopecia occurs in all races. Balding patches are in the periphery of the hair line. Hair becomes brittle and broken. •IMPLICATIONS Patches of uneven hair growth and loss alter patient's appearance

Dandruff:

•CHARACTERISTICSScaling of scalp is accompanied by itching. In severe cases, dandruff is on the eyebrows. •IMPLICATIONS Dandruff causes person embarrassment. If it enters eyes, conjunctivitis often develops

Ticks:

•CHARACTERISTICSSmall, gray-brown parasites burrow into the skin and suck blood •IMPLICATIONS Ticks transmit several diseases to people. Most common are Rocky Mountain spotted fever, tularemia, and Lyme disease.

Candidiasis (Moniliasis)

•Candidiasis is a yeast infection, an inflammatory reaction caused by Candida fungi. Infection occurs when Candida fungi penetrate the tissue, colonize, and release toxins that cause an acute inflammatory response. The infections are also termed moniliasis, which is defined as a yeast infection of the skin and mucous membranes. Infections are common in the mouth (thrush), esophagus, pulmonary system, vagina (moniliasis), and skin (diaper rash). Most typically, Candida infections occur in moist areas of the skin such as skin folds, around fingernails, and in mucous membranes, with the most common site being the vulvovaginal area. Candida may infest wounds, catheter sites, and intravenous sites. Infections may take 6 to 8 weeks to resolve. In immunosuppressed patients, candidiasis can become disseminated by entering the blood- stream and causing serious infections in other organs; such infections are difficult to eradicate. Candida albicans is the most common fungus that causes pathology in patients with the human immunodeficiency virus (HIV), and women with persistent and severe infections should haveHIV testing. •CAUSES .The Candida fungus, which is not pathologic under normal conditions, is found normally on the skin and in the gastrointestinal (GI) tract, the mouth, and the vagina. Candida causes infection when a body change permits its sudden proliferation. The most common factor remains the side effects caused by the use of broad-spectrum antibiotics. Changes that contribute to susceptibility to candidiasis include rising glucose levels caused by diabetes mellitus, and lowered resistance caused by a disease such as carcinoma, an immunosuppressive drug such as corticosteroids, or radiation therapy. Approximately 14% of patients with immunocompromising illnesses develop systemic candidiasis. Other associated factors include aging, irritation from dentures, instrumentation (urinary or intravenous catheters, indwelling foreign bodies), surgery, peritoneal dialysis, or the use of oral contraceptives. •ASSESSMENT (1)HISTORY. Question the patient carefully to elicit a history of risk factors or a history of repeated episodes of candidiasis. Factors such as cigarette smoking, tobacco chewing, or pipe smoking are often associated with Candida infections. Take a careful medication his- tory, and pay particular attention to use of antibiotics, corticosteroids, or other immunosup- pressive drugs. A reproductive history, including current pregnancy or oral contraceptive use, is important. The patient may complain of a burning or painful sensation in the mouth or difficulty in swallowing. The patient also may report regurgitation. Patients with vaginal infections will describe itchiness, irritation, and swelling of the labia. Patients may also describe a white, cheesy vaginal discharge. (2)PHYSICAL EXAMINATION. Inspect the patient's lips for color, texture, hydration, and lesions. Assess the patient's mouth thoroughly for bleeding, edema, white patches, nodules, or cysts. Inspect the mucosa; the roof and floor of the mouth; the tongue, including under the sur- face and the lateral borders; the gums; and the throat. Palpate any lesions or nodules. Inspect the patient's nail beds for swelling, redness, darkening, purulent discharge, or separation from the nails. Inspect the patient's skin for an erythematous, macular rash. Inspect the patient's vagina for vulval rash; erythema; inflammation; cheesy exudate; or lesions of the labia, vaginal walls, or the cervix. Palpate lesions for texture and tenderness. Systemic infection causes symptoms that can include a high, spiking fever; lowered blood pressure; rashes; and chills. Pulmonary infection may produce a cough. Renal infection may produce painful or cloudy urination and blood or pus in the urine. If the infection occurs in the brain, symptoms can include headache and seizures. Eye infection can cause blurred vision, orbital or periorbital pain, scotoma (blind gap in visual field), and exudate. If the infection occurs in the endocardium, symptoms can include systolic or diastolic murmur or chest pain. ••••

Protection

•FUNCTION/DESCRIPTION Epidermis is relatively impermeable layer that prevents entrance of microorganisms. Although microorganisms reside on skin surface and in hair follicles, relative dryness of surface of skin inhibits bacterial growth. Sebum removes bacteria from hair follicles. Acidic pH of skin further retards bacterial growth. •IMPLICATIONS FOR CARE Weakening of epidermis occurs by scraping or stripping its surface (e.g., use of dry razors, tape removal, improper turning or positioning techniques). Excessive dryness causes cracks and breaks in skin and mucosa that allow bacteria to enter. Emollients soften skin and prevent moisture loss, soaking skin improves moisture retention, and hydrating mucosa prevents dryness. However, constant exposure of skin to moisture causes maceration or softening, interrupting dermal integrity and promoting ulcer formation and bacterial growth. Keep bed linen and clothing dry. Misuse of soap, detergents, cosmetics, deodorant, and depilatories cause chemical irritation. Alkaline soaps neutralize the protective acid condition of skin. Cleaning skin removes excess oil, sweat, dead skin cells, and dirt, which promote bacterial growth.

Temperature Regulation

•FUNCTION/DESCRIPTION Radiation, evaporation, conduction, and convection control body temperature. •IMPLICATIONS FOR CARE Factors that interfere with heat loss alter temperature control. Wet bed linen or gowns interfere with convection and conduction. Excess blankets or bed coverings interfere with heat loss through radiation and conduction. Coverings promote heat conservation.

Sensation

•FUNCTION/DESCRIPTION Skin contains sensory organs for touch, pain, heat, cold, and pressure. •IMPLICATIONS FOR CARE Minimize friction to avoid loss of stratum corneum, which results in development of pressure ulcers. Smoothing linen removes sources of mechanical irritation. Remove rings from fingers to prevent accidentally injuring patient's skin. Make sure that bath water is not excessively hot or cold.

Excretion and Secretion

•FUNCTION/DESCRIPTION Sweat promotes heat loss by evaporation. Sebum lubricates skin and hair •IMPLICATIONS FOR CARE Perspiration and oil harbor microorganisms. Bathing removes excess body secretions; although, if excessive, it causes dry skin.

Smallpox

•Findings include high fever, fatigue, and head and body aches •Rash begins on face and tongue; quickly spreads to the truck, arms, and legs, then feet; then turns to pusfilled lesions •Onset is a sudden fever with severe aches and possible vomiting •Rash appears 2 to 4 days after fever •Lesions are all in the same stage of development, deep vesicles, and do not collapse when punctured.

RISK FACTORS FOR SKIN IMPAIRMENT

•Immobilization •Reduced Sensation •Nutrition and Hydration Alterations Secretions and •Excretions on the Skin •Vascular Insufficiency •External Devices •Altered Cognition

Nutrition and Hydration Alterations

•Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue, which results in impaired or delayed wound healing. •Insufficient protein, carbohydrates, and vitamin C contribute to muscle wasting, insufficient subcuta- neous tissue, and weight loss • Insufficient protective cushioning of bony prominences by adequate tissue layers increases the risk of skin breakdown due to pressure. •Nursing care. a. Assess self-feeding ability; condition of oral cavity, such as lesions, stomatitis, and problems with dentures; current weight; and weight history.

texture

•Recognize that skin texture varies according to age and the area being assessed. (1) Exposed areas and elbows and knees tend to be drier and coarser that unexposed areas. (2) Skin of infants and children is softer and smoother than that of adults because of lack of exposure to the environment and extent of hydration of tissues. •Identify changes in skin texture related to impaired circulation.(1) Peripheral arterial insufficiency is associated with smooth, thin, shiny skin that has little or no hair. (2) Peripheral venous insufficiency is associated with thick, rough skin that frequently is hyperpigmented.

Major skin disorders

•Skin cancer •Melanoma skin caner •Lupus erythematosus •Herpes zoster (shingles)

temperature

•Use the back of the hand or fingers to assess skin temperature skin should feel warm to touch. •Assess extremities bilaterally and compare for symmetry. •Assess a patient with excessively warm skin further because this finding may indicate a fever; obtain body temperature to verify •Assess a patient with excessively cool skin further because it may indicate conditions such as impaired circulation, shock, or hypothyroidism

Assessment of the skin includes:

•color, •texture, •thickness, •turgor, •temperature •hydration.