14.1 Integumentary Disorders
- The skin has three major layers: the dermis, epidermis, and hypodermis. Each layer serves a particular function regarding the integumentary system.
- Atopic dermatitis (eczema) occurs when a person has a dysfunctional skin barrier, allowing the body to be more susceptible to pathogens. Atopic dermatitis is linked to genetics, the immune system, and epidermal dysfunction. Symptoms are itching, skin redness and dry patches, and skin thickening.
- Psoriasis is the proliferation of skin cells and chronic skin inflammation. The most common is plaque psoriasis. This autoimmune disorder is linked to several genes and is inheritable. Symptoms include itching and well-defined thick patches of reddened skin with a silver scale appearance.
- Atopic dermatitis and psoriasis are diagnosed by clinical presentation and symptoms. A skin biopsy specimen can be taken, if necessary. Additional blood tests for psoriasis may be ordered and include a CBC, renal and liver function panels, ESR, rheumatoid factor level, and others.
- The priority nursing diagnosis for AD and psoriasis is impaired skin integrity. Nurses should monitor for signs of infection and promote pharmacological and nonpharmacological interventions, such as topical medications and, when indicated, systemic medications. If the patient was administered immunosuppressants, the nurse would monitor for signs of serious infection and for renal and liver function.
- When evaluating outcomes, the desired outcome is no signs and symptoms of infection. The nurse would evaluate the patient’s compliance with medications and treatment. If the patient was administered immunosuppressants, the nurse would expect no serious infections and for renal and liver function to remain normal.
- For patients with AD, the nurse would promote referrals to a dermatologist, wound care specialist, and an allergist, if needed.
- For patients with psoriasis, the nurse would encourage referrals to a dermatologist, wound care specialist, and an allergist. Additional referrals to a nephrologist, ophthalmologist, or rheumatologist may be needed, depending on the type and severity of psoriasis.
14.2 Burns
- Depending on the degree of severity, a burn can destroy the epidermal and dermal layers of the skin. A burn causes protein denaturation and damage to collagen. After a burn injury occurs, three zones of injury arise: the zones of coagulation, statis, and hyperemia.
- The type of burn injury a patient has is based on appearance. First-degree burns are pink to red and brown, and dry; second-degree burns are moist and blistering; and third-degree burns are dry, leathery, and white or brown/black.
- The priority nursing hypothesis for most burn injuries is impaired skin integrity. Nurses will provide supportive measures such as wound care, infection prevention, pain control, fluid resuscitation, and airway management as needed.
- When evaluating the effectiveness of nursing care, the nurse would expect wound healing within the typical healing time with no signs of infection. The nurse should expect the patient’s pain to be tolerable.
- Patients with burn injuries require interdisciplinary care that can include wound care specialists, dermatologists, nutritionists, infectious disease specialists, and plastic surgeons. Additional care from other specialists may be required depending on smoke inhalation or conditions such as SJS and TENS, including pulmonologists, intensivists, and others health-care professionals.
14.3 Dermatologic Conditions
- Depending on the patient’s skin condition, pathophysiology, risk factors, and clinical manifestations will differ. Pathophysiology typically involves a disruption of the skin barrier and an inflammatory response. Risk factors can be related to underlying health conditions, age, and exposure. Usually, patients with skin conditions will present with itching, erythema, and skin lesions.
- Diagnostic and laboratory values will vary depending on the patient’s dermatological condition. Most skin conditions are diagnosed by clinical presentation and do not require additional diagnostic tests. However, some skin conditions may have underlying contributors, so the health-care provider will order tests accordingly.
- For most dermatological conditions, the priority nursing diagnosis is impaired skin integrity. In some cases, the priority is to treat the underlying condition or remove the agent causing the rash first. Nurses will provide pharmacological and nonpharmacological interventions and may administer medications and monitor laboratory values as ordered by the health-care provider.
- When evaluating the effectiveness of nursing care, the nurse will expect optimal skin integrity as an outcome in most cases. The skin will appear normal or healing and without signs of infection.
- Depending on the underlying cause of the skin condition, the nurse can promote medical therapies and collaborative care. Patients may require referrals to various specialists, depending on the severity and specifics of the condition.