Skin Structure and Health Quiz

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Questions and Answers

What are the main components of the skin's structure?

Hypodermis and subcutaneous tissue

Epidermis and dermis (correct)

Epidermis and muscle layer

Dermis and adipose tissue

Which cells in the epidermis are responsible for skin color?

Keratinocytes

Melanocytes (correct)

Langerhans cells

Fibroblasts

What is the primary function of the stratum corneum?

Cell growth and division

Nutrient absorption

Melanin production

Protection from external elements (correct)

Which layer of the skin contains blood vessels?

Dermis Signup and view all the answers

What is a common effect of aging on the skin barrier?

Decreased elasticity and moisture Signup and view all the answers

Which term describes raised, fluid-filled lesions on the skin?

Vesicles Signup and view all the answers

What is a key nursing responsibility when caring for patients with skin disorders?

Performing skin assessments and promoting self-care Signup and view all the answers

What should be a primary focus in teaching adolescents about skin health?

Preventing skin cancer through protection from UV rays Signup and view all the answers

What is the recommended time frame for reapplying sunscreen while exposed to the sun?

Every 2 hours Signup and view all the answers

What factor increases the risk of developing a skin tear in older adults?

Dry skin with dehydration Signup and view all the answers

Which time period is considered to have the most hazardous sun exposure?

10 A.M. to 2 P.M. Signup and view all the answers

Which clothing style might not provide adequate protection from the sun's rays?

Light, loosely woven clothing Signup and view all the answers

What is a common misconception regarding vitamin D production during sun exposure?

Limited sun exposure can lead to vitamin D deficiency. Signup and view all the answers

How long does it take for sunburn to become painful after exposure?

6 to 8 hours Signup and view all the answers

What is the effect of using tanning booths on individuals under 36 years old?

Eightfold increased risk of developing melanoma Signup and view all the answers

What role does the fern extract Polypodium leucotomos play concerning UV protection?

It offers natural antioxidant properties. Signup and view all the answers

What should you do to facilitate adequate protection for patients with fragile skin?

Lubricate the skin with cream or lotion twice a day. Signup and view all the answers

What is the consequence of the ingredients in sunscreen being absorbed into the systemic circulation?

They are depleted within a certain time frame. Signup and view all the answers

To prevent skin tears, what should be avoided during patient transfers?

Transfer techniques that cause friction or shear Signup and view all the answers

Which external factor can exacerbate sun exposure effects, leading to sunburn?

Reflective surfaces like snow and sand Signup and view all the answers

Which practice is not recommended for sunscreen application?

Applying sunscreen just before going indoors Signup and view all the answers

What indicates poor skin turgor when assessing skin elasticity?

Skin remains tented for more than 2 seconds Signup and view all the answers

Which area is recommended for assessing skin turgor in older adults?

Upper chest Signup and view all the answers

What is a common characteristic of senile purpura in older adults?

They are deep red areas from minor injuries Signup and view all the answers

How often should individuals examine their skin for changes?

Every few months Signup and view all the answers

Which of the following is NOT one of the ABCDs for assessing melanoma?

Blanching Signup and view all the answers

What should be done when a reddened area is detected on the skin?

Assess for blanching by applying gentle pressure Signup and view all the answers

What is the main focus when performing a physical examination of the skin?

Evaluate areas between skin folds Signup and view all the answers

What is signified by skin that remains tented after being pinched?

Severe dehydration Signup and view all the answers

When is total skin assessment recommended to be done?

During every shift for immobile patients Signup and view all the answers

What characteristic of lesions should be documented accurately?

Location, size, appearance, and characteristics Signup and view all the answers

Which of the following is a primary nursing goal for patients with skin disorders?

Restore skin to normal Signup and view all the answers

What assessment is critical when a patient is admitted to a facility?

Skin assessment for signs of breakdown Signup and view all the answers

How should lesions be measured during assessment?

With a ruler for accurate measurement Signup and view all the answers

What general guideline should be followed in caring for patients with skin diseases?

Bathing with soap is usually contraindicated in inflammatory conditions Signup and view all the answers

What is the primary risk associated with improper bathing practices in hospitalized patients?

Skin breakdown Signup and view all the answers

What is the recommended solution to reduce contamination from traditional bath basins in health care settings?

Employing disposable cleansing cloths Signup and view all the answers

Which substance was found to significantly decrease health care−acquired infections but was later abandoned due to patient intolerance?

2% chlorhexidine gluconate (CHG) Signup and view all the answers

What skin condition is more likely to affect individuals with fair skin, especially those who freckle?

Malignant changes Signup and view all the answers

How often should older adults with dry skin ideally bathe to maintain skin health?

1-2 times per week with mild soap Signup and view all the answers

Which factor is NOT mentioned as a risk for skin health when considering environmental impacts?

Use of moisturizing lotions Signup and view all the answers

What type of skin care product should be applied to older adults’ skin immediately after bathing?

Moisturizing lotion or cream Signup and view all the answers

What is a common misconception about tanning and sun exposure?

A healthy tan protects against sunburn Signup and view all the answers

Which demographic group requires special skin care due to delicate skin characteristics?

Blondes and redheads with fair complexion Signup and view all the answers

Which condition is associated with both skin aging and inadequate skin care?

Skin irritation and breakdown Signup and view all the answers

What is the correct classification for a skin tear that has complete tissue loss and no epidermal flap?

Category III Signup and view all the answers

Which recommendation should be given regarding the use of soap for people with oily skin?

Clean skin frequently with a liberal amount of soap Signup and view all the answers

Which step should be taken first when managing a skin tear?

Gently cleanse the skin tear with saline Signup and view all the answers

Which type of dressing is preferred when a skin tear flap is viable?

Silicone-coated net dressing Signup and view all the answers

What is a vital consideration when bathing those with skin disorders?

Assessing and accommodating skin type Signup and view all the answers

What is the effect of dehydration on the skin?

Decreases skin turgor and predisposes to pressure ulcers Signup and view all the answers

What is the recommended interval for removing sutures from an excisional biopsy on the scalp?

7 to 10 days Signup and view all the answers

Which age-related change impacts the skin's health?

Decreased activity of oil and sweat glands Signup and view all the answers

What aspect of skin tear management should not be applied for about 5 days?

Disturbing the skin flap Signup and view all the answers

Which method is NOT a type of biopsy mentioned in the content?

Incisional biopsy Signup and view all the answers

What should be done after a culture and sensitivity test is performed?

Send the specimen to the lab for culturing Signup and view all the answers

What is a specific indication for using a Wood light in dermatological examination?

To diagnose fungal infections Signup and view all the answers

What is one of the primary purposes of a skin biopsy?

To differentiate benign from malignant lesions Signup and view all the answers

What is the purpose of the diascopy method in skin examination?

To reveal underlying lesion shapes Signup and view all the answers

Which of the following is NOT a sign that a wound may be infected?

Regular cleansing of the wound site Signup and view all the answers

What should be the focus of dressing for a skin tear?

Continuously cleanse the wound and keep it moist Signup and view all the answers

What is a primary concern when handling specimens for culture and sensitivity testing?

Avoiding contamination of the specimen Signup and view all the answers

What is the primary structural component providing strength and elasticity in the dermis?

Collagenous fibers Signup and view all the answers

Which glands are responsible for producing sebum?

Sebaceous glands Signup and view all the answers

How does the skin primarily help regulate body temperature?

By dilating and constricting blood vessels Signup and view all the answers

What effect does aging have on the collagen fibers in the dermis?

They decrease in number Signup and view all the answers

What is the primary role of melanin in the skin?

To absorb light and protect tissue from UV light Signup and view all the answers

Which of the following changes occur due to reduced activity of sebaceous glands as one ages?

Dry skin that may itch Signup and view all the answers

What is the primary structural component of nails?

Keratinized epidermal cells Signup and view all the answers

Which part of the nail is known as the free edge?

The visible part extending beyond the fingertip Signup and view all the answers

What is a common psychological impact of skin disorders?

Threatened self-image and damaged self-esteem Signup and view all the answers

What is the correct description of a macule?

Circumscribed, flat area with a change in skin color, 0.5 cm in diameter Signup and view all the answers

What type of lesion is characterized by being filled with purulent fluid?

Pustule Signup and view all the answers

How can extensive skin damage affect the body’s fluid balance?

It disturbs fluid and electrolyte balance Signup and view all the answers

Which of the following is not a function of the skin?

Production of hormones Signup and view all the answers

Which intervention is appropriate for a patient with disrupted sleep patterns due to pain?

Administer medication to relieve itching Signup and view all the answers

What leads to an increased risk of sunburn in older adults?

Decreased melanocyte activity Signup and view all the answers

What nursing intervention is aimed at reducing the potential for infection in skin lesions?

Encourage the patient to keep hands off affected areas Signup and view all the answers

What is a characteristic of a wheal?

Firm, edematous, irregularly shaped area with variable diameter Signup and view all the answers

Which condition is most likely to worsen due to decreased nail growth in older adults?

Higher susceptibility to fungal infections Signup and view all the answers

What is the main concern associated with self-care measures for skin disorders?

Aggravation of the condition or temporary relief Signup and view all the answers

What is a critical expected outcome for patients within 2 weeks with altered skin integrity?

Patient’s skin will be intact Signup and view all the answers

Which lesion type is an example of a wart?

Papule Signup and view all the answers

Which strategy is useful in helping a patient deal with anxiety related to a skin disorder?

Providing an atmosphere of acceptance Signup and view all the answers

What is a common nursing intervention for managing pain in patients with skin lesions?

Provide distraction activities Signup and view all the answers

What is an appropriate goal for a patient with decreased self-esteem due to skin lesions?

Patient will socialize with others within 3 weeks Signup and view all the answers

What describes a vesicle?

Circumscribed superficial collection of serous fluid Signup and view all the answers

What outcome indicates effective education regarding a skin disorder?

Patient recognizes medication side effects and self-care techniques Signup and view all the answers

What type of lesion has a diameter of 0.5 cm and is an elevated solid lesion?

Papule Signup and view all the answers

Which nursing intervention addresses potential social isolation during lengthy treatment?

Encourage family and friends to communicate regularly with patient Signup and view all the answers

Which physiologic change in aging contributes to an increased risk of skin breakdown?

Loss of collagen Signup and view all the answers

What is the best intervention to protect fragile skin when applying a dressing?

Applying a sterile transparent dressing gently Signup and view all the answers

Which action by a nursing assistant suggests a need for further training regarding skin care for older adults?

Using hot water and soap daily for bathing Signup and view all the answers

When observing a graduate nurse assessing a patient with skin lesions, which action would warrant intervention?

Removing scales and scabs from the lesions Signup and view all the answers

What is the purpose of the prick testing method in allergy diagnostics?

To introduce test chemicals to unaffected skin Signup and view all the answers

What measures should be taken to prevent skin tears in a patient who is immobile?

Pad areas where limbs may come into contact with furniture Signup and view all the answers

What is the expected recommendation for a patient with superficial vesicles filled with serous fluid?

Isolation precautions for herpes zoster Signup and view all the answers

Why is it important to check for allergies before surgery?

To prevent complications from anesthetics Signup and view all the answers

Which instruction is crucial for a patient undergoing patch testing for allergies?

Do not shower while the strips are applied Signup and view all the answers

What symptoms can indicate that a skin disorder may be allergy-related?

Shortness of breath and cough Signup and view all the answers

Which nursing action should be indicated for a patient admitted with dry skin and bilateral pitting edema?

Encourage hydration with electrolyte drinks Signup and view all the answers

What should be included in a focused assessment for diagnosing skin disorders?

Inquiries about recent travels and exposures Signup and view all the answers

What should be avoided when providing care to prevent skin tears in older adults?

Using a lift sheet to move the patient Signup and view all the answers

What is the expected duration for the allergen to be applied and left during patch testing?

2 days Signup and view all the answers

What does not contribute to skin breakdown in older adults?

Increased elastic fibers Signup and view all the answers

How can a healthcare provider differentiate between a macule and a papule?

Using a flashlight to check for shadows Signup and view all the answers

What is a common characteristic of seborrheic keratoses?

They appear as wartlike, greasy lesions Signup and view all the answers

Why is proper labeling of specimens important in nursing care for diagnostic tests?

To ensure accurate test results Signup and view all the answers

What cultural practice is described in the content that involves drawing illness out of the body?

Coin rubbing Signup and view all the answers

What is a characteristic of a keloid scar?

It stands up from the surrounding skin Signup and view all the answers

What type of skin lesions might indicate a drug allergy or reaction?

Rash or lesions that are similar to those in various diseases Signup and view all the answers

What might exacerbate the symptoms of winter itch in patients?

Severe cold and dryness Signup and view all the answers

When examining a dark-skinned patient for pallor, what observation indicates pallor?

An ashen-gray tone to the skin Signup and view all the answers

What effect can excessive application of topical antifungal agents have on the skin?

Delays healing due to chemical irritation Signup and view all the answers

What should be suspected if a patient develops eczema after applying a topical medication?

Allergic contact dermatitis Signup and view all the answers

What condition can result from maceration near a wound due to constant moisture?

Enlarged wound size Signup and view all the answers

Why is teaching self-examination of the skin important?

To identify skin changes early Signup and view all the answers

What is the primary function of topical therapy?

To deliver medication directly to affected skin areas Signup and view all the answers

What does the ABCD rule in self-skin examination stand for?

Asymmetry, Border irregularity, Color variation, Diameter Signup and view all the answers

Which of the following is a recommended precaution for applying topical medications?

Inspect skin for maceration before changing dressings Signup and view all the answers

What dietary factor can help in preventing skin disorders?

Increasing vitamin intake Signup and view all the answers

What role does the dermis play in skin healing?

It contains new cells essential for healing Signup and view all the answers

In relation to skin lesions, what is critical to assess during a patient history?

Any recent medications used Signup and view all the answers

What risk is associated with aging skin?

Thinning and fragility Signup and view all the answers

What is the impact of applying sunscreen with a low SPF?

Higher chance of sunburn Signup and view all the answers

How long might it take for a simple fungal infection to show improvement with topical treatment?

7 to 14 days Signup and view all the answers

What factor can increase the risk of skin disorders as people age?

Decreased skin hydration Signup and view all the answers

What is one primary reason to encourage patients to return to community activities after skin treatment?

To help with emotional reintegration and support Signup and view all the answers

Which of these actions should be avoided when caring for skin lesions?

Using lotion without provider approval Signup and view all the answers

Why should a nonslip bath mat be used during medicated baths?

To prevent slips and falls due to slippery substances Signup and view all the answers

What should be done with bed linens used by a patient with severe skin conditions?

They may require special laundering to eliminate soap traces Signup and view all the answers

What is the recommended application method for ointments on the skin?

Gently massage a small amount into a thin film Signup and view all the answers

Which of the following statements about wet dressings is false?

Open compresses can be left on for extended periods Signup and view all the answers

How should powders be applied to the skin?

After thoroughly drying the area to prevent caking Signup and view all the answers

What is a key consideration when preparing an oatmeal bath?

The patient should be protected from chilling during the bath Signup and view all the answers

Which type of dressing is characterized by being open and continuous without drying?

Open compress Signup and view all the answers

For what purpose is sodium bicarbonate often added to bath water?

To soothe and alleviate skin irritation Signup and view all the answers

What is the primary benefit of giving medicated baths?

They soothe and relieve itching and burning Signup and view all the answers

When is it appropriate to apply medication after a bath?

As soon as the bath is completed after patting dry Signup and view all the answers

What laundry practice is recommended for washing new clothes for sensitive skin patients?

Washing new clothes before wearing to remove chemicals Signup and view all the answers

Why is it important to avoid excessive handling of the skin on admission?

To reduce the risk of spreading infection Signup and view all the answers

Which of the following substances is NOT typically added to medicated baths?

Vinegar Signup and view all the answers

Study Notes

Integumentary System Overview

The integumentary system comprises the skin, hair, and nails, acting as a protective barrier and regulating body temperature.
Skin structure: Two main layers—epidermis (outer, squamous epithelium, no blood vessels) and dermis (thicker, dense connective tissue with blood vessels, nerves, hair follicles, and glands). Subcutaneous tissue connects skin to underlying structures.
Epidermal cell growth pushes cells upward, eventually sloughing off or washing off the outer stratum corneum. Melanocytes in the epidermis produce melanin for skin color.
Hair consists of shaft and root; follicles are embedded in the dermis. Sebaceous glands secrete sebum for hair and skin lubrication and bacterial growth inhibition.
Sweat glands excrete water and salt, regulating body temperature. Underarm and genital sweat glands, active at puberty, secrete more complex substances.
Nails are hard keratinized cells covering fingertips and toes, containing free edge, body, & root.

Decreased elastic and collagen fibers lead to wrinkling, sagging, and increased skin fragility.
Thinner, more transparent skin, dry skin, reduced temperature regulation.
Decreased sebaceous gland activity leads to drier skin, increased risk of cold intolerance and heat exhaustion.
Diminished melanocyte activity raises sunburn and skin cancer risks.
Hair follicle decrease, slower hair growth, and gradual hair color loss.
Nail growth decrease, development of ridges, and thickening. Increased susceptibility to fungal infections.
Increased melanin production in some areas can result in "age spots".

Skin Disorders and Causes

Thousands of skin disorders exist, some tied to systemic diseases.
Many arise from skin pathologies, or from immunologic, inflammatory, proliferative/neoplastic, metabolic/endocrine issues, or nutritional problems.
Physical, chemical, and microbiological factors can damage skin.

Integumentary System Protection and Hygiene

Skin is a primary defense against pathogens. Skin damage compromises this defense and increases infection risk.
Large skin damage (burns) disrupts fluid/electrolyte balance; loses protein & body heat.
Skin reflects systemic conditions; the physical impact of a disorder can negatively impact a patient’s mental health.
Daily bathing is not imperative for all, but maintaining appropriate cleanliness is critical for patients with skin issues, particularly those with specific skin conditions.

Skin Tear Prevention

Skin tears are common among older adults, resulting from age-related skin thinning, handling, friction, or shearing.
Risk factors include dry skin, dehydration, ecchymosis, friction/shearing/pressure, sensory/mobility impairments, certain medications (e.g., corticosteroids), renal/heart/stroke conditions and improper dressing removal.
Prevention measures include dressing in long-sleeved clothing/stockinettes, adequate lighting, nutrition/hydration, frequent lubrication with lotions/oils, gentle cleansing, transfer techniques to minimize friction & shear, padding for bed rails/equipment.
Utilizing non-adherent dressings and gentle dressing/tape removal for healing.

Nursing Management and Assessment

Skin assessment is essential, including history-taking to identify potential causes.
Focused physical assessment using good lighting assesses skin texture, elasticity, lesions, temperature, and turgor (checking how quickly skin returns to place after being picked up), and edema.
Lesions measured/documented; blanching is an indicator of temporary redness.
Observe patient for scratching or rubbing; inspect hair and nails; perform skin assessments on those prone to breakdown.

Integumentary Diagnostic Tests

Skin Biopsy: Tissue sample for differentiation of benign/malignant lesions and identifying disease-causing organisms.
Culture Sensitivity Tests: A specimen of exudate/drainage to detect pathogens and optimize treatment selection.
Microscopic Tests: Various stains, scrapings for fungus, bacteria or viral detection.
Special Light Inspections: Wood lights for fungal/erythrasma detection. Diascropy for revealing underlying lesions, or allergy assessment through scratching or topical testing, or intradermal injections.

Nursing Considerations for Diagnostic Tests

Obtain informed consent and ensure patient comprehension.
Assess any allergies, label specimens, and follow-post-operative care instructions to the patient.

Patient Teaching

Encourage skin self-exams, particularly for moles/warts or areas with unusual coloration. Examine new skin lesions every month, noting ABCDs (A=asymmetric; B=irregular border; C=color change; D=diameter of ¼ inch).
Teach general skin hygiene, sun precaution and risk factors.

Skin Disease Treatments

Topical therapy (lotions/creams/ointments), medicated baths, compresses, and dressings.

Nursing Interventions and Patient Education

Promote healing, reduce pain/itching, and prevent further damage/infection and scarring.
Emphasize gentle skin care, protection from environmental factors such as sun exposure, heat & cold; and diligent hygiene.
Provide comprehensive discharge instructions for patients.

42: The Integumentary System

OBJECTIVES

Theory

1. Describe the structure and functions of the skin.

2. Compare and contrast the various causes of integumentary disorders.

3. Analyze important factors in the prevention of skin disease.

4. Plan specific measures to prevent skin tears.

5. Interpret laboratory and diagnostic test results for skin disorders.

6. State nursing responsibilities in the care of patients with skin disorders.

7. Write outcome objectives for a patient with a problem of altered skin integrity.

Clinical Practice

8. Teach three patients to perform a self-assessment of the skin.

9. Analyze the changes that have occurred with aging that affect the skin barrier for one of your older adult patients.

10. Perform a focused integumentary assessment on a patient.

11. Provide skin care for an older adult with dry skin.

12. Implement a teaching plan appropriate for adolescents and young adults for the prevention of skin cancer.

KEY TERMS

biopsy (BĪ-ŏp-sē, p. 986)

erythrasma (ĕ-rĭth-RĂZ-mă, p. 986)

exudate (ĔKS-ū-dāt, p. 986)

keloid (KĒ-loid, p. 987)

keratoses (kĕr-ă-TŌ-sēs, p. 987)

macule (MĂK-ūl, p. 987)

papule (PĂP-ūl, p. 987)

plaque (plăk, p. 989)

pustule (PŬS-tūl, p. 989)

senile lentigines (SĒ-nīl lĕn-TĪJ-ĭ-nēz, p. 983)

senile purpura (SĒ-nīl PŬR-pū-ră, p. 988)

vesicle (VĔS-ĭ-kŭl, p. 989)

wheal (WĒL, p. 987)

http://evolve.elsevier.com/Stromberg/medsurg

Concepts Covered in This Chapter

• Self-Management

• Fluid and Electrolytes

• Cellular Regulation

• Nutrition

• Immunity

• Inflammation

• Infection

• Tissue Integrity

• Coping

• Health Promotion

Anatomy and Physiology of the Integumentary System

Structure of the Skin, Hair, and Nails

• The skin consists of two layers of tissue, the epidermis and the dermis (Fig. 42.1).

• The skin is attached to underlying structures by subcutaneous tissue.

• The epidermis consists of squamous epithelium and contains no blood vessels; cells receive nutrients by diffusion from vessels in the underlying tissue.

• Cell growth occurs from the bottom of the epidermis and pushes cells above to the surface, where they eventually die and slough off or are washed off. This layer is called the stratum corneum.

• The bottom layer of the epidermis contains melanocytes that contribute color to the skin.

• The dermis, also called the corium, is thicker than the epidermis and consists of dense connective tissue.

• The dermis contains both elastic and collagenous fibers that give it strength and elasticity.

• The dermis contains blood vessels and nerves, as well as the base of hair follicles, glands, and nails that are derived from the epidermis.

• A hair consists of a shaft and a root made up of dead keratinized epithelial cells.

• The hair root is below the surface of the epidermis and is enclosed in a hair follicle that is embedded in the dermis.

FIG. 42.1 Structure of the skin.

From Harding MM, Kwong J, Roberts D, et al.: Lewis’s medical-surgical nursing: assessment and management of clinical problems, ed 11, St. Louis, 2020, Elsevier.

• Fibroblasts that produce new cells to heal the skin are contained in the dermis.

• Glands contained in the skin are sebaceous (sweat producing) or ceruminous (wax producing).

• Nails are composed of tightly packed, hard, keratinized epidermal cells.

Functions of the Skin and its Structures

• The skin acts as a protective covering over the entire surface of the body.

• The keratin in the skin makes it waterproof, preventing water loss from the underlying tissues and too much water absorption during swimming and bathing.

• Skin provides a barrier to bacteria and other invading organisms.

• Skin protects underlying tissues from thermal, chemical, and mechanical injury.

• The skin helps regulate body temperature by dilating and constricting blood vessels and by activating or inactivating sweat glands.

• When the skin is exposed to ultraviolet (UV) light, molecules in the cells convert the rays to vitamin D.

• Melanin pigment absorbs light and acts to protect tissue from UV light.

• The nerve receptors in the dermis transmit feelings of heat, cold, pain, touch, and pressure.

• Hair follicles contained in the skin produce hair.

• Sebaceous glands secrete sebum that functions to keep hair and skin soft and pliable. Sebum also inhibits bacterial growth on the surface of the skin and, because of its oily nature, helps prevent water loss from the skin.

• Sweat glands act to excrete water and salt when the body temperature increases; sweat evaporates, producing a cooling effect.

• Sweat glands in the axillae and external genitalia secrete fatty acids and proteins as well as water and salts. They become active at puberty and are stimulated by the nervous system in response to sexual arousal, emotional stress, and pain.

• Hair color is produced by melanocytes in the skin and depends on the type of melanin produced.

• The shape of the hair shaft determines whether hair is straight or curly.

• Hair assists the body to retain heat.

• Nails cover the distal ends of the fingers and toes.

• Each nail has a free edge, a nail body, and a nail root that is covered by skin.

• The cuticle of each nail is a fold of stratum corneum.

Aging-Related Changes in the Skin and its Structures

• The number of elastic fibers decreases, and adipose tissue diminishes in the dermis and subcutaneous layers, causing skin to wrinkle and sag.

FIG. 42.2 Senile lentigines (age spots or liver spots).

• Loss of collagen fibers in the dermis makes the skin increasingly fragile and slower to heal.

• The skin becomes thinner and more transparent.

• Reduced sebaceous gland activity causes dry skin that may itch.

• Thinned skin and decreased sebaceous gland activity reduce temperature control and lead to an intolerance of cold and a susceptibility to heat exhaustion.

• A reduction in melanocyte activity increases the risk of sunburn and skin cancer.

• The number of hair follicles decreases, and the growth rate of hair declines; the hair thins.

• A decrease in the numbers of melanocytes at the hair follicle causes gradual loss of hair color.

• Nail growth decreases, longitudinal ridges appear, and the nails thicken; nails become more susceptible to fungal infections.

• Some areas of melanocytes increase in production, producing brown “age spots” or “liver spots,” properly named senile lentigines (Fig. 42.2).

The Integumentary System

The skin is the first line of defense against invasion by pathogenic bacteria living in the environment. When an area of the skin is destroyed by disease or trauma, its protective functions are immediately impaired. This impairment makes the body susceptible to infection. If very large areas of skin are destroyed, as in an extensive burn, fluid and electrolyte balance is disturbed. Protein and body heat are lost from burned areas. Skin diseases are common; they are often difficult to diagnose and cure and tend to recur. The physical effects of skin diseases are not often serious. However, when the disorder renders the patient unattractive, there is a psychological impact that threatens self-image and damages self-esteem. The skin also reflects systemic diseases.

Disorders of the Integumentary System

Causes

More than 3000 disorders of the skin have been officially named, and many more are not included in any official nomenclature. Most of the recognized and named skin disorders arise from some pathology in the skin itself. The remainder are manifestations of systemic disease. Skin disorders may occur from immunologic and inflammatory disorders, proliferative and neoplastic disorders, metabolic and endocrine disorders, and nutritional problems. Physical, chemical, and microbiological factors also can damage the skin.

Many patients with dermatologic disease are not hospitalized and are seen only in health care providers’ offices and outpatient clinics. Others do not seek medical attention but treat their skin disorder themselves with home remedies and over-the-counter drugs. In some cases self-care measures are successful, but they also have the potential to aggravate the condition or only temporarily relieve more severe symptoms. This can lead to delay in treatment and allow the disease to progress to a chronic and sometimes untreatable state.

Prevention

Hygiene

The ritual of the daily bath is almost an obsession with the average American. Experts do not agree on what frequency of bathing is best for health, but most agree it does not need to be daily. People with healthy skin can usually bathe daily without damaging the protective layers of the skin, but those with skin disorders need to be careful not to worsen their condition.

Hospitalized patients may be at risk for skin breakdown due to multiple factors. Keeping skin clean and dry is an important nursing intervention. Cleansing of skin can put patients at risk. Multiple studies have cultured Escherichia coli and methicillin-resistant Staphylococcus aureus (MRSA) from plastic bath basins routinely used in health care facilities. Plastic bath basins are no longer recommended for use in health care settings. Some facilities are using a disposable basin liner to combat this problem (Muro et al., 2018). Other facilities have adopted disposable cleansing cloths to replace the individual bathing basin. Using a 2% chlorhexidine gluconate (CHG) was found to significantly decrease the incidence of health care−acquired infections (HAIs), but many patients could not tolerate the CHG, and it has been abandoned as a long-term solution. a U.S. Food and Drug Administration (FDA)-approved product made with silver-ion technology consists of a reusable basin with a liner. Both are embedded with silver ions, which have proven to be 99% effective against common pathogens (Spencer & Kelly, 2019).

Soap and water continue to have a place in hygiene, but beyond infection control, astute nurses assess for and consider skin type. Blondes and redheads with a fair complexion usually have very delicate skin that requires special care to prevent drying and irritation. If the skin appears dry and scaly, frequent bathing with soap and hot water only aggravates the condition. Oils and creams that cleanse the skin quite effectively and help replace the natural oils at the same time are available. On the other hand, people with dark hair usually have skin that is oilier and less susceptible to excessive drying and irritation. People with oily skin will need to clean the skin frequently with a liberal amount of soap and water and will need to apply fewer or no additional oils to the skin. When full bathing is not possible or impractical, cleaning of the axilla and perineal areas will prevent odors and irritation.

Think Critically

You assist an older adult with a bath and notice that they have very dry skin. What interventions would you use?

Clinical Cues

Remember to dry areas where two skin surfaces touch, such as the axilla and under the breasts.

Diet

Even borderline deficiencies of vitamins and minerals will cause the skin to take on a sallow and dull appearance. Severe nutritional deficiencies lead to skin breakdown and the development of sores and ulcers. Dehydration causes loss of skin turgor and predisposes to pressure ulcers. People can be so concerned about their physical appearance that they refuse to eat properly for fear of gaining weight; however, a well-balanced diet will enhance appearance.

Age

Young people are not the only ones who should be concerned with the care of their skin. As we grow older, our skin undergoes certain changes that easily lead to irritation and breakdown if proper care is not given. The oil and sweat glands become less active, and the skin tends to become dry and scaly. It also loses some of its tone, becoming less elastic and more fragile. Frequent cleansing of the skin becomes unnecessary as the skin ages, and alcohol and other drying agents must be used sparingly, if at all. Assist older adult patients to establish a regular routine of massaging oil, cream, or oily lotion into the skin.

Older Adult Care Points

Older adults who have dry skin do not need a full bath every day; cleansing the axillae and genital-rectal area between bathing days should be sufficient. Older adults should use a mild lotion-based soap or body wash for bathing. After showering or bathing, a lotion or cream that helps seal in moisture should be applied while the skin is still damp. Moisturizing lotion or cream should be reapplied at bedtime.

Environment

Several environmental factors can have a direct effect on the health of the skin. These include prolonged exposure to chemicals, excessive drying from repeated immersions in water, very cold temperatures, and prolonged exposure to sunlight. Some of these are occupational hazards. A change of jobs may be necessary to eliminate contact with a factor that is causing a skin disorder. One of the Healthy People 2030 objectives is to reduce occupational skin diseases or disorders among full-time workers.

Overexposure to the UV rays of the sun can seriously and permanently damage the superficial and deeper layers of the skin. The damage results in severe wrinkling and furrowing, as well as loss of elasticity, and the skin assumes a tissue-paper transparency. In addition to the potential for premature aging and degenerative changes, solar damage also can result in malignant changes. Ultraviolet rays from the sun have long been known to be carcinogenic. This is especially true for fair-skinned people who have subjected their skin to prolonged exposure to sunshine. Although sunburns are particularly harmful, it is the normal daily exposure of unprotected fair skin to sun that causes long-term damage.

Health Promotion

Sun Exposure Precautions

Health teaching to inform the public about the dangers of solar UV radiation should include the following information:

• Although fair-skinned people who freckle easily are more likely to suffer sun-damaged skin, people of all complexions and races can and do burn if exposed to sufficient sunlight.

• Although a good tan may be considered by many to be desirable, dermatologists say that there is no such thing as a “healthy tan.” Tanning causes damage to the skin. For those who insist on lying out in the sun, the initial exposure should be slow and gradual, and an adequate sunscreen with a sun protection factor (SPF) of at least 30, as well as ultraviolet A (UVA) and ultraviolet B (UVB) protection, should always be used. Too much sun too quickly only leads to blistering and peeling.

• Select a sunscreen preparation based on skin type and ability to tan, as well as its active ingredients and the amount of time to be spent in the sun. Remember that the sunscreen can be washed off by water or perspiration or rubbed off on sand and towels and must be reapplied periodically. Apply sunscreen liberally 15 to 30 minutes before sun exposure (U.S. Food and Drug Administration [FDA], 2020). Reapply every 2 hours. The ingredients in the sunscreen are used by the body and depleted within these 2 hours, so a higher SPF sunscreen will not last longer.

• The ingredients in sunscreen may be absorbed through the skin into the systemic circulation. Read the label carefully.

• Avoid exposure to the sun during the time its rays are most hazardous—that is, between 10 A.M. and 2 P.M. standard time or 11 A.M. and 3 P.M. during daylight saving time.

• You can become sunburned on a cloudy or overcast day.

• Light, loosely woven clothing will not give adequate protection from the sun’s rays.

• Remember that snow, water, and sand can reflect the sun’s rays and increase the intensity of exposure.

• Do not try to gauge how much you are being burned while in the sun. It may be 6 to 8 hours before a painful burn becomes obvious.

• Wear sunglasses and a hat when you go out in the sun, and when possible wear protective clothing.

• Never use a tanning booth; there is an eightfold increased risk of developing melanoma for persons under age 36 years who use tanning booths (Centers for Disease Control and Prevention [CDC], 2021).

Complementary and Alternative Therapies

Ultraviolet Radiation Protection

An oral form of fern plant extract may help protect the skin from UV radiation. The fern extract is from Polypodium leucotomos and is a natural antioxidant with tumor inhibition properties. Initial studies showed that volunteer subjects could tolerate threefold to sevenfold longer sun exposure time.

Clinical Cues

It is estimated that 90% of people between 50 and 71 years of age are not getting adequate vitamin D. Adults with limited sun exposure are at especially increased risk of vitamin D deficiency, if their skin is dark. During spring, summer, and autumn, 5 to 15 minutes of sun exposure without sunscreen twice per week to the face, arms, hands, and back is sufficient for adequate vitamin D production (Drezner, 2020).

Think Critically

You are talking to a young woman who works as a ski instructor. She is fair-skinned and says that “on really sunny days, my hat is in my pocket and I never use sunscreen.” Discuss some issues related to this woman’s integumentary health.

Box 42.1 Risk Factors for Skin Tears in Older Adults

Assess the patient for the following factors:

• Dry skin with dehydration

• Areas of ecchymosis

• Presence of friction, shearing, or pressure from bed or chair

• Impaired sensory perception

• Impaired mobility

• Taking multiple medications

• Prolonged use of corticosteroids

• Presence of renal disease, congestive heart failure, or stroke impairment

• Incorrect removal of adhesive dressings

• Rough handling when being bathed, dressed, transferred, or repositioned

Integrity of Skin

Good nursing care includes protection of the skin and prevention of skin tears. A skin tear is a potentially preventable, traumatic wound that occurs primarily on the extremities of older adults because of age and debility. The wound occurs as a result of lack of caution when handling, friction alone, or shearing and friction forces that separate the epidermis from the dermis or separate both structures from the underlying tissue. Up to 90% of older adults in health care facilities sustain a skin tear injury each year (LeBlanc et al., 2018). The epidermis thins and becomes less elastic with age, making it susceptible to tearing with little trauma. Those individuals who require total care are at the highest risk. Risk factors for skin tears, other than age older than 65 years, are presented in Box 42.1.

Box 42.2 Measures to Prevent Skin Tears and Protect Fragile Skin

• Have patients wear long sleeves and long pants to protect the extremities or protect the fragile skin on extremities with stockinettes.

• Provide adequate lighting to reduce the risk of bumping into furniture or equipment.

• Maintain the patient’s nutrition and hydration; offer fluids between meals.

• Lubricate the skin with cream or lotion twice a day, paying special attention to the arms and legs.

• Use an emollient soap for bathing and do not use soap every day on extremities if no soiling has occurred.

• Use a lift sheet to move and turn patients.

• Avoid wearing rings or bracelets that could snag the skin.

• Use transfer techniques that prevent friction or shear.

• Pad bed rails, wheelchair arms, leg supports, or other equipment where the patient might bump an extremity.

• Support dangling arms and legs with pillows or blankets.

• Use nonadherent dressings on fragile skin. Use gauze wraps or stockinettes to secure dressing. If tape must be used, use a paper or nonallergenic tape and apply it without tension.

• Mark the dressing with an arrow showing the direction in which it should be removed.

• Remove tape and dressing with extreme caution:

• Use a solvent or saline to loosen the adhesive bond.

• Slowly pull the skin away from the tape rather that peeling the tape off of the skin.

• If a thin hydrocolloid or solid wafer skin barrier is used as a protective barrier between the skin and the dressing, allow it to fall off naturally.

The Payne-Martin, STAR Skin Care, and International Skin Tear Advisory Panel (ISTAP) classification systems identify skin tears as (LeBlanc et al., 2018):

• Category I: A skin tear without tissue loss in which the edges can be realigned

• Category II: A skin tear with partial tissue loss in which the edges cannot be realigned

• Category III: A skin tear with complete tissue loss in which the epidermal flap is missing

Nursing Management

Rigorous nursing care (Box 42.2) to prevent skin tears is obviously preferable to treating skin tears that could have been prevented. However, when a skin tear is discovered, steps for its management are as follows:

• Gently cleanse the skin tear with saline.

• Allow the area to air-dry or pat dry gently and carefully.

• If the skin tear flap has dried, remove it using scissors and sterile technique.

• If the skin tear flap is viable, gently roll the flap back into place using a moistened cotton-tipped applicator.

• If bleeding has stopped, silicone-coated net dressings are preferred; petroleum-based protective ointments are also used. Cyanoacrylate skin protectants are in a liquid form that creates a barrier to protect damaged skin. The substance does not need to be removed because it will shed in approximately 1 week (LeBlanc et al., 2018).

• If bleeding continues, apply pressure and then dress with alginate and a secondary dressing.

• Manage in the same way as a skin graft. The flap should not be disturbed for about 5 days to allow the skin flap to adhere.

• Assess and measure the size of the skin tear.

• Document assessment and treatment.

A skin tear comprehensive assessment is essential to ensure that adequate attention is given to the wound. The dressing should (1) continuously cleanse the wound, (2) conform to the wound, (3) absorb exudates, and (4) keep the wound bed moist and reduce pain and discomfort. The wound must be watched for signs of infection. Extra padding for the involved extremity will help prevent additional injuries.

Clinical Cues

Best practice recommendations from ISTAP do not recommend use of transparent adhesive dressings for skin tears (LeBlanc et al., 2018).

Diagnostic Tests and Procedures

Skin biopsy

Removing a sample of tissue (biopsy) from a skin lesion usually is performed with a local anesthetic. It can be done by shaving a top layer off a lesion that rises above the skin line (shave biopsy), by removing a core from the center of the lesion (punch biopsy), or by excising the entire lesion (excisional biopsy).

Skin biopsy is used to differentiate benign from malignant lesions and to help identify the causative organism in bacterial and fungal infections. No special patient preparation is necessary beyond a simple explanation of the procedure and its purpose. If a local anesthetic is to be used, the patient is asked about any personal or family history of allergies. After the procedure, the patient is given instructions for the care of the biopsy site. After 12 to 24 hours the bandage is removed, the incision site is cleaned with soap and water twice daily, and a bandage is reapplied after each cleansing. The site may or may not be treated with a topical antibiotic solution or ointment. Sutures from an excisional biopsy will need to be removed in 3 to 5 days for the face; in 7 to 10 days for the scalp, chest, abdomen, and arms; and in 12 to 20 days for the back and legs (Alguire & Mathes, 2020).

Culture and sensitivity tests

When a bacterial, viral, or fungal infection of the skin is suspected, culture and sensitivity tests can be used to identify the causative organism and the drug most appropriate for treating the specific infection. A sampling of exudate (drainage) is taken from the lesion and sent to the laboratory for culturing. Once the organism has been cultured, colonies can be tested for sensitivity to certain antiinfective agents. Care must be taken when handling the specimen and its container to avoid contaminating people who will later be handling the specimen.

Safety Alert

Skin Drainage or Weeping

Whenever there is a question of a pathogenic process, weeping or drainage from skin lesions, or the suspicion of scabies, Standard Precautions should be used when touching the patient’s skin to prevent self-contamination or transmission of an organism.

Microscopic tests

Various stains and solutions are used to prepare skin, hair, scales, or nail material for study. These tests can identify fungal, bacterial, and viral organisms. To check for organism infestations, scrapings are suspended in mineral oil and examined under the microscope.

Special light inspection

Inspection of the skin is one of the principal means by which skin lesions are diagnosed. To facilitate the diagnosis of certain kinds of skin disorders, special lights may be used by the examiner. A cold light is one in which the light is transmitted through a quartz or plastic structure to dissipate the heat. Because there is no danger of burning the skin, the cold light can be applied directly to the skin to illuminate its layers for visualization of malignant changes.

A Wood light is a specially designed UV light. The nickel oxide filter holds back all but a few violet rays of the visible spectrum. This special light is especially useful to diagnose fungal infections of the scalp and chronic bacterial infection of the major folds of the skin (erythrasma). Under a Wood light, fungal lesions and erythrasma are fluorescent. Erythrasma usually is seen on the inner thighs, scrotum, and axilla; under the breasts; and in the area between the toes.

Diascopy

Diascopy uses a glass slide or lens pressed down over the area to be examined, blanching the skin and thereby reducing the erythema caused by increasing blood flow to the area. The shape of the underlying lesion is then revealed.

Allergy testing

When a rash is suspected to be of an allergic nature, one of three methods is used to identify the responsible allergen. Test chemicals or substances are introduced to unaffected skin, usually on the forearm or back, by superficial scratches or pricks in the prick testing. In patch testing, the allergen is applied to the skin in the form of an adhesive patch and left for 2 days. The allergen can also be introduced by intradermal injection. If a localized reaction producing a wheal (smooth, slightly elevated area that is pale or reddened) occurs, the test is positive.

Nursing care for diagnostic tests

Check to see that the patient has signed an informed consent for any invasive procedure such as a biopsy. Reinforce what the health care provider has told the patient about the procedure and assess whether the patient understands or has additional questions. Check for allergies to the anesthetic or skin preparation solution. Properly label any specimens and send them to the laboratory. Apply a dressing and give both verbal and written postoperative instructions to the patient. Tell the patient approximately when the results will be back and that they will be notified of the results. Advise whether a follow-up visit is necessary.

Nursing Management

Assessment (Data Collection)

History Taking

Diagnosing skin disorders requires a thorough history to identify factors that predispose a patient to skin disease or factors that cause some types of skin disease.

Focused Assessment

Data Collection for Skin Disorders

The following questions should be asked when seeking data on a skin disorder:

• When did the rash or lesion first appear?

• Can you think of any event or different food you ate or substance you were using just before it appeared?

• What is your usual dietary pattern? What do you eat and drink?

• Have you noticed if anything makes it worse?

• What seems to make it better?

• Have you been using any chemicals lately for household cleaning or in pursuit of your hobbies?

• Have you been out in rural areas or in the woods lately?

• Have you been traveling? Did you visit a tropical area?

• Have you had any recent exposure to animals?

• What drugs are you taking? Do you take any over-the-counter medications?

• Are you using any street drugs? What route of administration?

• Have you ever had a drug reaction?

• Have you ever had radiation therapy?

• Do you have a history of any skin disorders in your family?

• Does anyone in the family currently have similar symptoms, such as a rash?

• Do you have any allergies?

• Are you experiencing itching? Pain? Fever?

• Have you had any gastrointestinal problems that began about the same time that the rash or lesion appeared? What about a runny or stuffed-up nose? Cough?

• Has the skin condition affected your social life or work?

Scabies, lice, and other parasites can be transmitted through close personal contact with infected persons at work, recreation, home, or school. It is important to know whether exposure has occurred, so that others can be notified and treated.

Many drugs can produce skin eruptions in certain individuals. Drug allergy or reaction can produce lesions and rashes that imitate those found in a long list of diseases, including measles, chickenpox, fungal infections, skin cancers, and psoriasis.

Itching and pain are the most common complaints. If the patient has recently been exposed to severe cold, their skin may be drier than usual, and they may complain of severe itching (winter itch). If the disorder is caused by an allergy, the patient also may complain of shortness of breath, cough, or some gastrointestinal symptoms. The patient also may be able to relate what other factors, such as stress or excitement, could be related to the appearance of the skin lesions.

Physical Assessment

A thorough inspection of the skin under good lighting is essential. Provide privacy and have the room at a moderate temperature so that the patient does not become chilled. The patient should don a gown that allows access to all areas of the skin.

Cultural Considerations

Coin Rubbing

Coin rubbing is a Southeast Asian folk remedy that is intended to draw illness out of the body. An oiled coin is rubbed over the skin surface and creates bruiselike marks or patterns of red lines or welts on the skin. The redness is interpreted as a sign that the remedy is bringing the illness to the surface (Wong et al., 2020).

Seborrheic keratoses are common in older adults. They appear as wartlike, greasy lesions on the trunk, arms, scalp, and sometimes the face. They are not a cause for concern.

Darkly pigmented people will have areas that are darker than other parts of the skin. This is caused by hormonal influences. The darker areas are the nipples, areola, scrotum, and labia minora. This is true among both African Americans and Asians. When the skin of a darkly pigmented person is damaged, scar tissue may hypertrophy, forming a keloid (a thick ridge of scar tissue that stands up from the surrounding skin) (Fig. 42.3).

The hair of African Americans differs in texture. It varies from being long and straight to being short, thick, and tightly curled. It is very dry and fragile and requires daily grooming with oil. Asians tend to have straight hair. If an African American child has malnutrition, sometimes the hair will turn a coppery red.

Clinical Cues

When trying to differentiate between a macule and a papule, shine a flashlight at a right angle to the lesion. A papule will cast a shadow. If there is no shadow, the lesion is a macule. To determine whether there is fluid in a lesion, place the tip of a penlight against the side of the lesion. If the light illuminates it with a red glow, it is fluid filled. If there is no light illumination, the lesion is solid.

FIG. 42.3 A keloid scar.

From Damjanov I, Perry A, Perry K: Pathology for the health professions, ed 6, St. Louis, 2021, Elsevier.

Clinical Cues

Pallor in a dark-skinned person presents as an ashen-gray tone to the skin. In a brown-skinned person, pallor gives the skin a yellow-brown color.

The skin should be lightly palpated to detect changes in texture and surface elevations. Palpation also is used to detect pain, areas of increased warmth, and tenderness. When checking the temperature of the skin, the back of the hand should be used. Skin turgor is assessed by lifting a fold of skin on the forearm, chest, or abdomen between two fingers and seeing how fast it falls back into place. Skin that takes longer than 1 to 2 seconds to return to place is called “poor skin turgor” and indicates dehydration.

Table 42.1 shows characteristics of various types of skin lesions. As you are performing your assessment you can simultaneously teach the patient about self-examination of the skin.

Older Adult Care Points

When checking skin turgor on an older adult, test the upper chest because the skin of the arms and hands of older adults may lose elasticity and is not a reliable index. Gently pinch a small amount of skin, lift it up, and let go. Note the time It takes for the skin to move back to Its normal position. If the skin quickly returns to normal position, then the patient has less than 5% body water loss. If skin is delayed in returning to normal position (taking 1 to 2 seconds), then a 5% to 9% body water deficit is assumed. Skin that stays tented indicates severe dehydration. Older adults bruise more easily as the skin becomes thinner and collagen is lost. Patches of senile purpura, deep red areas, may occur even from minor injuries, so be gentle when testing skin turgor.

Focused Assessment

Physical Assessment of Skin

Perform a physical examination of the entire skin surface. Proceed from head to toe. Compare one side of the body to the other. Use the metric system when measuring lesions, and document all findings. Check the patient for the following:

• General appearance of skin surface: texture, elasticity, thickness

• Condition of areas between skin folds

• Type of lesions and distribution, size, and appearance; photograph or measure and document measurements

• Appearance of skin adjacent to lesions; note whether reddened areas blanch when mild pressure is applied

• Localized or generalized skin edema

• Characteristics of secretions: color, viscosity, amount

• Odor: description of odor; strong or faint; source—local or generalized

• Temperature changes: location of hot spots or cold areas of the skin

In addition:

• Check the back and the soles of the feet, including between the toes

• Observe patient for scratching, rubbing, or picking at lesions

• Observe patient for scratching of the scalp or pubic areas

• Inspect the hair for texture, brittleness, thinning, and cleanliness

• Inspect the nails for chipping, splitting, discoloration, and ragged or inflamed cuticles

Patient Teaching

Self-Assessment of the Skin

Teach the patient that the skin should be examined every few months. For the back or other areas, suggest that a family member or close friend examine that area of skin. If any changes have occurred, the patient should consult the health care provider right away. Advise that warts, moles, or discolorations of the skin should be checked each month for:

• Darkening or spreading of color or increasing unevenness of color

• Increase in size or diameter

• Change in shape; that is, has the lesion become elevated, or have its formerly regular edges become irregular?

• Redness or swelling of surrounding skin or any other noticeable change around the lesion

• Itching, tenderness, or other change in sensation

• Crusting, scaling, oozing, ulceration, or other change in the surface of the lesion

• When assessing for melanoma, check for the ABCDs: A = asymmetric, B = irregular border, C = color change, D = diameter change greater than ¼ inch

Assessing the Skin for Signs of Breakdown

Skin should be thoroughly assessed when the patient is admitted to your facility. Skin assessment is performed during every shift on immobile patients, noting the condition of skin over bony prominences. Findings must be documented accurately.

Legal and Ethical Considerations

Skin Lesion Documentation

All data gathered when assessing the skin and any lesions should be documented accurately, Including location, size, appearance, and characteristics. Measure lesions using a ruler and note the measurements in the chart. For pressure ulcers, many facilities take photos and enter those in the chart so that healing progress can be demonstrated.

Once every 24 hours, usually during the bath, the skin is totally assessed. When a reddened area is found, it is checked for blanching by pressing gently in the center of the area to see if it turns from red to white or to a paler color on darker skin. Blanching usually indicates that the redness is temporary and will resolve when pressure on the area is relieved. (See Chapter 43 for additional information on pressure injury.)

Assignment Considerations

Observation While Bathing

Unlicensed assistive personnel are generally assisting with hygiene, and you should give specific Instructions to report reddening, bruising, breaks In the skin, or new lesions. Remember that total skin assessment cannot be delegated; this is your responsibility.

Problem Statement/Nursing Diagnosis and Planning

Problem statements are based on the analysis of the data gathered from assessment. Problem statements commonly associated with skin disorders are presented in Table 42.2.

Nursing goals for patients with skin disorders are to:

• Restore the skin to normal

• Decrease pain and itching

• Protect the skin from further damage

• Prevent infection

• Prevent scarring as much as possible

Planning of the daily work schedule should include consideration of time necessary for dressing changes, soaks, special baths, and other skin treatments.

Implementation

Some general rules when caring for patients with a skin disease may be helpful as a guide until specific orders are obtained:

• Bathing with soap is usually contraindicated in all inflammatory conditions of the skin.

• Dressings covering the skin lesions that have been applied by a health care provider should not be removed when the patient is admitted unless there are specific orders to do so.

Table 42.1

Types of Skin Lesions

Lesion Description

Macule

Illustration of cross-section of skin layers shows a semi-circular darkened area on the top skin layer

Circumscribed, flat area with a change in skin color; <0.5 cm in diameter. If >0.5 cm in diameter, it is a patch.

Examples: Freckles, petechiae, measles, flat mole (nevus)

Papule

Illustration of cross-section of skin layers shows a semi-circular darkened and elevated area in the stratum germinativum (basal cell layer) of the skin.

Elevated, solid lesion; <0.5 cm in diameter. If >0.5 cm in diameter, it is a nodule.

Examples: Wart (verruca), elevated moles, lipoma, basal cell carcinoma

Vesicle

Illustration of cross-section of skin layers shows a convex shaped cavity filled with fluid between top layer of skin and stratum germinativum (basal cell layer) of the skin.

Circumscribed, superficial collection of serous fluid; <0.5 cm in diameterExamples: Varicella (chickenpox), herpes zoster (shingles), second-degree burn

Plaque

Illustration of cross-section of skin layers shows a semi-circular uneven, pink, and elevated area in the stratum corneum (horny cell layer) of the skin.

Circumscribed, elevated superficial, solid lesion; >0.5 cm in diameterExamples: Psoriasis, seborrheic, and actinic keratoses

Wheal

Illustration of cross-section of skin layers shows a semi-circular uneven, pink, and elevated area in the stratum corneum (horny cell layer) of the skin.

Firm, edematous, irregularly shaped area; diameter variable

Examples: insect bite, urticaria

Pustule

Illustration of cross-section of skin layers shows fluid filled in egg-shape between top layer of skin and stratum germinativum (basal cell layer) with a bump on the top skin surface.

Elevated, superficial lesion filled with purulent fluid

Examples: Acne, Impetigo

From Harding MM, Kwong J, Roberts D, et al.: Lewis’s medical-surgical nursing: assessment and management of clinical problems, ed 11, St. Louis, 2020, Elsevier. Figures from Patton KT, Thibodeau GA: The human body in health and disease, ed 8, St. Louis, 2022, Elsevier.

Table 42.2

Common Problem Statements, Expected Outcomes, and Nursing Interventions for Patients With Skin Disorders

Problem Statement Goals/Expected Outcomes Nursing Interventions

Altered skin integrity due to injury and treatment; excoriation or scaling; infectious process

Patient’s skin will be intact within 2 wk (4 mo for burns).

Number of lesions will decrease within 2 mo.

Patient will exhibit no signs of infection within 3 mo.

Cleanse skin and apply topical medications as prescribed.

Monitor for signs of adverse reaction to topical medication.

Preserve integrity of grafted areas with aseptic dressing technique and splinting.

Apply light treatments as prescribed.

Pain due to itching, soreness, or tenderness of lesions; exposure of denuded skin to air; or involvement of nerve tissue Patient’s pain will be controlled to less than 4/10 on the pain scale by medication and relaxation or distraction techniques.

Apply topical medication as prescribed.

Administer analgesia as prescribed and as needed (PRN).

Provide medicated baths as prescribed.

Teach relaxation techniques. Provide distraction activities.

Decreased self-esteem due to disrupted skin surface and lesions Patient will show increase in self-esteem by socializing with others within 3 wk.

Suggest ways to cover lesions.

Help patient list positive aspects and achievements.

Encourage socialization with others. Show acceptance and matter-of-fact attitude when dealing with patient’s lesions.

Potential for infection due to loss of intact skin barrier Patient will not experience skin infection before lesions are healed.

Cleanse skin carefully and gently.Use aseptic technique when attending to lesions.

Apply prescribed topical medications.

Encourage patient to keep hands off affected skin areas.

Encourage hand hygiene for patient.

Anxiety due to chronic, recurring nature of skin disorder; reaction to diagnosis of cancer; slow healing

Patient will verbalize feelings within 3 wk.

Patient will explore options for treatment of cancer.

Patient will identify short-term and long-term goals that realistically match the slow healing process.

Provide atmosphere of acceptance.

Allow patient time to verbalize feelings.

Assist to recognize positive coping techniques by looking at ways patient has coped with anxiety in the past.

Provide information on treatment and prognosis for skin malignancy.

Deficient knowledge regarding cause and treatment of skin disorder

Patient will verbalize knowledge of factors related to appearance of skin disorder.

Patient will verbalize knowledge of treatment for disorder.

Patient will demonstrate self-care techniques.

Explain the cause of the skin disorder and measures to prevent possible recurrence, if any.

Instruct in various methods of treatment.

Teach the side effects of medications. Instruct in self-care techniques for medication application, dressing changes, and so on.

Obtain feedback of information and skills taught.

Disrupted sleep pattern due to itching or pain Patient will obtain at least 7 h of rest per day.

Administer medication to relieve itching.

Keep environment cool to decrease itching sensation.

Caution patient to take cool or tepid baths or showers to decrease itching.

Caution not to scratch lesions; this often makes itching worse.

Suggest ways to use distraction (e.g., card or game playing, intense concentration on learning something, or reading an absorbing book) to decrease focus on itching.

Administer hypnotic as prescribed.

Administer analgesics as prescribed.

Encourage use of meditation, relaxation, or imagery techniques to decrease pain.

Provide restful, quiet environment.

Use massage as appropriate to promote relaxation and sleep.

Allow usual bedtime rituals that help patient induce sleep.

Table Continued

Problem Statement Goals/Expected Outcomes Nursing Interventions

Potential social isolation due to long treatment process; disfigurement

Patient will maintain social contact with family and friends.

Patient will reintegrate into community within 3–24 mo.

Encourage family and friends to send cards, call, and visit.

Encourage patient to continue dialogue with family and friends.

Refer to psychologist or social worker for grief work and reintegration of new body image.

Refer to support group for expression of feelings and realization patient is not alone with such problems.

Encourage return to employment or job training.

Encourage return to church or community activities.

• Do not attempt to remove scales, crusts, or other exudates on the skin lesions until the provider has had an opportunity to examine the patient.

• Observe the skin very carefully at the time of the patient’s admission and record observations on the chart or report them to the nurse in charge.

• Avoid excessive handling or rubbing of the skin against the sheets and bedclothes when changing the bed.

• Lotions or other skin products should not be used on the skin unless the provider has approved their use.

Once the provider has determined the type of lesions present, specific treatments will be ordered to relieve the patient’s symptoms and promote healing. The two most commonly used treatments are special dermatologic baths and wet compresses or dressings. In addition, lotions, salves, or ointments may be applied locally at frequent intervals.

Although most skin diseases are not contagious, you should be careful to observe rules of cleanliness and Standard Precautions when caring for any patient with a skin eruption. Special care is needed to prevent spreading infection from the fluid in all pustules and in the vesicles of fever blisters and cold sores.

Giving Medicated Baths

Among the agents that may be added to the bath water are sodium bicarbonate, sodium chloride, cornstarch, oatmeal, medicated tars, oils, potassium permanganate, and special bath preparations.

Safety Alert

Prevent Falls

A nonslip bath mat should be used in the tub when giving medicated baths. The substances used for the bath can make the tub very slippery. Showers should have nonslip mats in them as well, especially when showering an older adult.

Patient Teaching

Easy Cleanup After an Oatmeal Bath

Put dry, uncooked oatmeal into an old sock to make an oatmeal sachet. Place the sachet in the tub and squeeze it repeatedly. After the bath is finished, discard the sachet.

During the bath, the patient must be protected from chilling because the bath usually lasts from 30 minutes to 1 hour, and most patients with skin diseases have a lowered resistance to cold. When the patient is removed from the tub, the skin is dried by patting rather than by rubbing. If medication is to be applied locally, it should be put on as soon as the bath is completed to keep pruritus (itching) at a minimum. Medication is applied in a thin layer unless otherwise ordered.

The medicated bath has a very soothing and relaxing effect on the patient and also helps relieve the itching and burning commonly associated with skin diseases. Encourage the patient to rest in bed and perhaps to take a short nap after each bath.

Laundry Requirements

The bed linens and gowns used for patients with severe skin diseases may need special laundering to eliminate all traces of soap. If the patient is to be cared for at home, vinegar may be added to the rinse water to neutralize the soap. One tablespoon of vinegar is used for each quart of water. Only detergent without perfume or other additives should be used. Dryer sheets should not be used because they contain chemicals that often cause skin problems. Residue from dryer sheets can remain in the dryer and affect laundry that has been washed separately for the individual with a skin sensitivity. New clothes should be washed before wearing when skin sensitivity is a problem. Washing removes chemical fabric-finishing products.

Application of Wet Compresses or Dressings

Wet dressings may be applied to the skin in various ways. The two general types used are open dressings and closed dressings. Open compresses must be changed repeatedly and are never allowed to dry. They usually need to be remoistened every 20 to 30 minutes. The solution used should be at room temperature or warmer. This type of dressing is used when the dermatologist wishes to have air circulating to the skin lesions. Closed dressings are thoroughly soaked with the prescribed solution and wrapped with an airtight, waterproof material. Obtain specific instructions from the dermatologist before applying wet dressings to any skin lesions.

Box 42.3 Guidelines for Applying Topical Medicationsa

Powders

• Dry the area thoroughly before applying powder to prevent caking.

• Do not apply to raw and denuded areas.

• Some powders, such as cornstarch, can serve as culture media for the growth of bacteria.

Ointment

• Use only a small amount and gently massage into the skin until a thin film covers the area. An exception is when ointment is used as an occlusive dressing, as for a burn.

• Ointments tend to leave a greasy feeling to the skin. They are best for chronic lesions because they help the skin retain moisture and natural oils.

• Avoid putting ointment on areas where the skin is creased and overlaps itself.

Gels

• A gel is a semisolid mixture that tends to liquefy when applied to the skin. It is absorbed into the skin and dries quickly, leaving a thin, nonocclusive film.

• If applied to abraded or sensitive areas, alcohol in the base can cause a burning or stinging sensation.

Lotions

• Lotions are powders suspended in water; they will leave a residue once the liquid evaporates from the skin. This residue should be washed off before a fresh dose is applied.

• Be sure that powder is uniformly dispersed in solution before applying, then use a firm stroke to distribute the medication evenly. Do not “dab” on lotions, as this can be irritating to the skin.

All Types

• Always apply topical medications sparingly and in a thin film that extends beyond the affected area by about ¼ inch. Thick layers of topical medications are wasteful, and some of these drugs, such as corticosteroids, are very expensive.

• Too much of some topical medications (e.g., antifungal agents) can chemically irritate the skin and delay healing. Thick layers also tend to soften the skin too much.

• If the skin condition appears to be getting worse after a topical agent is applied or if the patient develops eczema, suspect an allergic contact dermatitis caused by the drug.

a Allergies must be assessed before applying a topical medication.

Clinical Cues

When changing wet dressings, inspect the skin adjacent to the wound for signs of maceration from the moisture; this condition could cause the wound to enlarge.

Application of Topical Therapy

Many skin lesions are treated by directly applying medications to the surface of the affected area. This method is called topical therapy. Lotion, cream, ointment, powder, or gel may be used. The health care provider prescribes the kind of medication to be used and the way in which the drug is to be applied. Patients with skin conditions do not always consult a provider and sometimes choose to treat themselves at home. All patients should be instructed in the proper application of topical medications (Box 42.3). Occlusive dressings must not be applied over the area after application of the medication unless ordered by the health care provider (see Table 42.2 and Chapter 43).

Think Critically

If a patient has an order for a topical cream to be applied to an area of rash on the right upper thigh, how would you apply this cream?

Evaluation

Evaluation of treatment and nursing interventions for skin disorders is based on improved appearance of the skin, absence of signs of infection, relief from itching and pain, and signs of healing. Many skin disorders are slow to respond to treatment, and patience is required on the part of both the patient and you. Even a minor fungal skin infection may take 7 to 14 days to clear with topical medication. A fungal infection of a nail may take up to a year to clear. A major part of evaluation is to determine that treatment is not aggravating the condition.

Get Ready for the Next-Generation NCLEX® Examination!

Key Points

• The skin is essential for the maintenance of life; it is the first line of defense against pathogenic organisms. Skin has two layers, the epidermis and the dermis. New cells to heal the skin are contained in the dermis.

• Factors in the prevention of skin disorders include cleanliness, appropriate diet, proper skin care, limiting exposure to the sun, and careful handling of fragile skin.

• With increased age the skin becomes thinner and more fragile, less elastic, and drier.

• Fragile skin requires special attention: protective clothing (such as long sleeves), lubrication with creams or lotions, bed transfer techniques that prevent shear, padded side rails and assistive devices, use of nonadherent tape, and use of solvent to loosen dressings and peeling them slowly.

• Several types of diagnostic measures are used: biopsy, culture, microscopic examination of scrapings or tissue, special light inspection, diascopy, and skin patch testing.

• A thorough health history is key in the diagnosis of skin disorders (see Focused Assessment: Data Collection for Skin Disorders).

• Teach self-examination of the skin, including the ABCDs: A = asymmetric; B = irregular border; C = color change; D = diameter greater than ¼ inch (see Patient Teaching: Self-Assessment of the Skin).

• Standard Precautions are used when touching patients with weeping lesions or when drainage is present.

• Treatments for skin disorders include medicated baths, special laundry precautions, application of compresses or dressings, and topical therapy.

• Systemic therapy may be used for some fungal infections and for serious bacterial infections.

Additional Learning Resources

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Clinical Judgment and Next-Generation NCLEX® Examination–Style Questions

1. You note that a 55-year-old, light-skinned patient has dry, flaky skin. Which action by the patient should alert you to a problem?

1. The patient always puts a moisturizing lotion on their hands after washing them.

2. The patient takes daily showers with soap and hot water.

3. The patient takes a daily multiple vitamin.

4. The patient spends some time outdoors and uses sunscreen that they reapply every 1½ to 2 hours.

NCLEX Client Need: Health Promotion and Maintenance

2. You are teaching teenagers about the importance of protecting the skin from UV rays. What information should you include? (Select all that apply.)

1. Use a sunscreen with a sun protection factor (SPF) of at least 30.

2. Apply sunscreen thinly.

3. Wear light, loose clothing.

4. Evaluate skin condition while in the sun.

5. Wear sunglasses and a hat.

NCLEX Client Need: Health Promotion and Maintenance

3. A patient with a suspicious skin lesion is scheduled for a punch skin biopsy. What is the most accurate explanation you would give about the procedure?

1. “It is shaving a top layer off a lesion that rises above the skin line.”

2. “It is removing a core from the center of the lesion.”

3. “It is removing the entire lesion.”

4. “It is aspirating a tissue sample.”

NCLEX Client Need: Physiological Integrity: Reduction of Risk Potential

4. A patient has a rash of unknown origin. Which assessment question(s) would help determine the underlying cause of the lesion? (Select all that apply.)

1. “When did the rash first appear?”

2. “Can you think of any event or different food you ate or substance you were using just before it appeared?”

3. “What drugs are you taking? Do you take any over-the-counter medications?”

4. “Are you getting your usual amount of sleep?”

5. “Is there a history of any skin disorders in your family?”

NCLEX Client Need: Physiological Integrity: Physiological Adaptation

5. What physiologic changes in aging predispose older adults to skin breakdown? (Select all that apply.)

1. Thickening of skin

2. Loss of collagen

3. Increased elastic fibers

4. Decreased adipose tissues

5. Reduced sebaceous gland activity

NCLEX Client Need: Physiological Integrity: Physiological Adaptation

6. You need to apply a dressing to a patient who has fragile skin. Which intervention would you use to protect the patient from skin tears?

1. Ask the health care provider to give specific orders for wound care.

2. Gently clean and apply a sterile transparent dressing.

3. Tape the dressing with paper tape and prevent tension.

4. Allow any tape and gauze dressing materials to fall off naturally.

NCLEX Client Need: Safe and Effective Care Environment: Safety and Infection Control

7. You are observing a nursing assistant who is providing skin care to an older adult patient. Which action by the nursing assistant indicates a need for further training?

1. Using soap and hot water every day to clean the patient’s body

2. Alerting you about a wet dressing

3. Reporting redness and blanching over the sacral area

4. Applying lotion while the skin is still damp

NCLEX Client Need: Safe and Effective Care Environment: Coordinated Care

8. You are supervising a new graduate nurse (GN) who is examining a new patient with skin lesions. You would intervene if the GN:

1. gently handles the patient’s extremities to prevent skin tears.

2. observes the condition of the skin and measures the size of the lesions.

3. removes the scales and crusts from the lesions to clean the skin.

4. assesses for and documents any home remedies that the patient has tried.

NCLEX Client Need: Safe and Effective Care Environment: Coordinated Care

9. You are taking care of a 75-year-old man who spends most of his time in bed or sitting. What steps should be taken to prevent a skin tear? (Select all that apply.)

1. Have the patient wear long sleeves and long pants.

2. Lubricate the patient’s skin with cream or lotion twice a day.

3. Massage the skin vigorously, especially over bony prominences.

4. Never use a lift sheet to move or turn the patient.

5. Pad bed rails, wheelchair arms, leg supports, or other equipment where the patient may bump an extremity.

NCLEX Client Need: Physiological Integrity: Reduction of Risk Potential

10. You read in a patient’s record that the health care provider observed “circumscribed, superficial vesicles with a collection of serous fluid.” You anticipate that the health care provider will make which recommendation for the patient?

1. A prescription for a topical application for acne

2. Isolation precautions for herpes zoster

3. Over-the-counter antihistamine for an insect bite

4. Patient education to self-monitor the wart

NCLEX Client Need: Physiological Integrity: Physiological Adaptation

11. A 45-year-old female is undergoing patch testing for allergies. Multiple test strips have been applied to her upper back. What instructions should be given for at home? Place an X by the items that should be included in patient teaching for patch testing.

Options

Make sure to get at least a total of an hour each day of sunlight exposure

Do not shower while the strips are in place

Continue to take your medications for your autoimmune disease

Avoid heat and humidity

There may be itching at the sites of the strips

Signs and symptoms of anaphylaxis

12. An 85-year-old female is admitted to the telemetry unit for heart failure. She has bilateral pitting ankle edema and generally dry skin. She is short of breath and has difficulty moving in bed. Identify by placing an X in the appropriate column which of the nursing actions listed below are Indicated (appropriate and necessary), Contraindicated (could be harmful) or Non-Essential (not necessary or makes no difference) to manage her care.

Nursing Action Indicated Contraindicated Non-Essential

Elevate heels off of the bed.

Reposition patient every 2 hours.

Encourage adequate dietary intake.

Bathe with lotion every 4 hours.

Encourage hydration with electrolyte drinks.

Evaluate oxygen saturation with VS.

Use repositioning slings.

Place sequential compression devices on legs for DVT prophylaxis.

Arrange for a volunteer to read to the patient.

Perform skin assessment every shift

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Test your knowledge on the anatomy and functions of the skin. This quiz covers skin layers, cells responsible for pigmentation, aging effects, and nursing care for skin disorders. Perfect for students and health professionals interested in dermatology.

Skin Structure and Health Quiz

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Questions and Answers

What are the main components of the skin's structure?

Which cells in the epidermis are responsible for skin color?

What is the primary function of the stratum corneum?

Which layer of the skin contains blood vessels?

What is a common effect of aging on the skin barrier?

Which term describes raised, fluid-filled lesions on the skin?

What is a key nursing responsibility when caring for patients with skin disorders?

What should be a primary focus in teaching adolescents about skin health?

What is the recommended time frame for reapplying sunscreen while exposed to the sun?

What factor increases the risk of developing a skin tear in older adults?

Which time period is considered to have the most hazardous sun exposure?

Which clothing style might not provide adequate protection from the sun's rays?

What is a common misconception regarding vitamin D production during sun exposure?

How long does it take for sunburn to become painful after exposure?

What is the effect of using tanning booths on individuals under 36 years old?

What role does the fern extract Polypodium leucotomos play concerning UV protection?

What should you do to facilitate adequate protection for patients with fragile skin?

What is the consequence of the ingredients in sunscreen being absorbed into the systemic circulation?

To prevent skin tears, what should be avoided during patient transfers?

Which external factor can exacerbate sun exposure effects, leading to sunburn?

Which practice is not recommended for sunscreen application?

What indicates poor skin turgor when assessing skin elasticity?

Which area is recommended for assessing skin turgor in older adults?

What is a common characteristic of senile purpura in older adults?

How often should individuals examine their skin for changes?

Which of the following is NOT one of the ABCDs for assessing melanoma?

What should be done when a reddened area is detected on the skin?

What is the main focus when performing a physical examination of the skin?

What is signified by skin that remains tented after being pinched?

When is total skin assessment recommended to be done?

What characteristic of lesions should be documented accurately?

Which of the following is a primary nursing goal for patients with skin disorders?

What assessment is critical when a patient is admitted to a facility?

How should lesions be measured during assessment?

What general guideline should be followed in caring for patients with skin diseases?

What is the primary risk associated with improper bathing practices in hospitalized patients?

What is the recommended solution to reduce contamination from traditional bath basins in health care settings?

Which substance was found to significantly decrease health care−acquired infections but was later abandoned due to patient intolerance?

What skin condition is more likely to affect individuals with fair skin, especially those who freckle?

How often should older adults with dry skin ideally bathe to maintain skin health?

Which factor is NOT mentioned as a risk for skin health when considering environmental impacts?

What type of skin care product should be applied to older adults’ skin immediately after bathing?

What is a common misconception about tanning and sun exposure?

Which demographic group requires special skin care due to delicate skin characteristics?

Which condition is associated with both skin aging and inadequate skin care?

What is the correct classification for a skin tear that has complete tissue loss and no epidermal flap?

Which recommendation should be given regarding the use of soap for people with oily skin?

Which step should be taken first when managing a skin tear?

Which type of dressing is preferred when a skin tear flap is viable?

What is a vital consideration when bathing those with skin disorders?

What is the effect of dehydration on the skin?

What is the recommended interval for removing sutures from an excisional biopsy on the scalp?

Which age-related change impacts the skin's health?

What aspect of skin tear management should not be applied for about 5 days?

Which method is NOT a type of biopsy mentioned in the content?

What should be done after a culture and sensitivity test is performed?

What is a specific indication for using a Wood light in dermatological examination?

What is one of the primary purposes of a skin biopsy?

What is the purpose of the diascopy method in skin examination?

Which of the following is NOT a sign that a wound may be infected?

What should be the focus of dressing for a skin tear?

What is a primary concern when handling specimens for culture and sensitivity testing?

What is the primary structural component providing strength and elasticity in the dermis?

Which glands are responsible for producing sebum?

How does the skin primarily help regulate body temperature?

What effect does aging have on the collagen fibers in the dermis?

What is the primary role of melanin in the skin?

Which of the following changes occur due to reduced activity of sebaceous glands as one ages?

What is the primary structural component of nails?

Which part of the nail is known as the free edge?

What is a common psychological impact of skin disorders?

What is the correct description of a macule?

What type of lesion is characterized by being filled with purulent fluid?

How can extensive skin damage affect the body’s fluid balance?

Which of the following is not a function of the skin?

Which intervention is appropriate for a patient with disrupted sleep patterns due to pain?