Integumentary

Here is a review of the anatomy and physiology of the skin, diagnostic studies, interventions, and etiologies/pathologies of bacterial and viral skin infections, based on the provided sources:

Anatomy and Physiology Review

The skin is composed of three main layers: the epidermis, the dermis, and the subcutaneous tissue.

• Epidermis: This is the outer skin layer. It consists of four main cell types:

  • Keratinocytes: These are the principal cells of the epidermis.

  • Melanocytes: These cells are responsible for producing pigment.

  • Merkel cells: These function as touch receptors.

  • Langerhans cells: These originate in the bone marrow and are involved in cell-mediated immune response. The epidermis is further divided into layers including the stratum corneum (outer horny layer), stratum lucidum (thin transparent layer), stratum granulosum, stratum spinosum, and the stratum basale (innermost layer). The epidermis also contains glands such as eccrine glands (involved in thermoregulation or sweat production), apocrine glands (possibly involved in sexual arousal), and sebaceous glands (associated with hair follicles and secreting oil to the hair and skin). Other structures found in the epidermis include hair (an outgrowth of skin) and nails (hard, transparent plates of keratin).

• Dermis: This is a dense layer of tissue beneath the epidermis. It contains:

  • Fibroblasts: Cells within the connective tissue.

  • Macrophages: Phagocytic cells.

  • Mast cells: Cells that release chemicals in response to injury or inflammation. The dermis also contains lymphatic cells, a vascular capillary network, and nerve endings.

• Subcutaneous Tissue: This is a specialized layer of connective tissue. Its function is to provide cushion and insulation. Subcutaneous tissue is not found in the eyelids, scrotum, areola, tibia, cranium, or the top of the feet. The thickness of this layer is influenced by age, heredity, weight, and overeating. The skin also plays a role in thermoregulation through vasodilation (dissipation of heat) and vasoconstriction (retention of heat). It is involved in the production of Vitamin D and acts as a blood reservoir, storing about 10% of the total blood volume. The skin provides protection as a mechanical barrier against trauma, pathogenic organisms, and foreign substances. The skin also contributes to homeostasis by preventing excessive loss of water and electrolytes, and it functions in sensory reception through various sensory receptors.

C. Diagnostic Studies

• a. KOH exam and fungal culture: A Potassium Hydroxide (KOH) exam is used to diagnose fungal infections of the skin, hair, and nails. Potassium hydroxide is used to dissolve the epidermal cells and expose the fungus. The lesion is scraped, and the scraping is placed on a slide with a KOH solution for microscopic examination. A fungal culture may be done in addition to help identify the specific fungus.

• b. Tzanck’s smear: A Tzanck’s smear is used to diagnose viral skin infections such as Herpes simplex and Herpes zoster. It involves the microscopic assessment of fluids and cells from vesicles and bullae. No special preparation is needed.

• c. Scabies scraping: A scabies scraping is used to detect scabies, eggs, or feces of the scabies mite. A papule is scraped with a scalpel, and the scraping is placed on a slide for microscopic examination.

• d. Wood’s light examination: A Wood’s Light Exam is used in the diagnosis of superficial infections and pigmentation changes. The affected area is illuminated by a special filter attached to an ultraviolet lamp. Before the exam, all lotions and exudate should be removed from the skin, and the room should be darkened.

• e. Patch testing: Patch testing is used for the identification of allergens responsible for allergic contact dermatitis. It helps to identify substances that produce allergic skin responses. Small amounts of various substances are applied to the skin for 48 hours. They are then removed and the skin is examined for a positive reaction.

• f. Culture and sensitivity: A culture and sensitivity test involves swiping and swabbing a lesion (a needle biopsy is also an option). The specimen is then incubated in a culture media to allow growth for 24-48 hours, leading to the identification of the exact species of microorganism present. The "sensitivity" part of the test determines which antibiotics or antifungals will be most effective against the identified organism.

• g. Skin biopsy: A skin biopsy involves the removal of skin tissue for histologic studies. It is performed under local anesthesia and aids in determining malignancy. There are different types of skin biopsies, including shave, punch, incisional, and excisional biopsies. A punch biopsy removes 2-8mm of tissue from the epidermis, dermis, and/or subcutaneous tissue. A shave biopsy is used for superficial lesions, removing tissue no deeper than the dermis. An excisional biopsy is used for deep specimens and involves the total excision of the lesion. An incisional biopsy involves the removal of a wedge of tissue from the lesion. Nursing management after a skin biopsy includes advising the patient not to take ASA (aspirin) for 48 hours before the procedure and to check with their doctor if they are taking anticoagulants. The site should be covered with a dressing, kept clean, and the patient should be taught the signs and symptoms of infection. Follow-up appointments are necessary to receive the biopsy results.

D. Interventions

The sources describe various interventions for skin conditions, including:

• Dressings: Used to protect healing wounds and retain surface moisture to promote healing. Types include dry dressings (protect, absorb drainage), wet dressings (decrease inflammation, soften crusts, promote granulation), absorptive dressings (remove excess exudate, helpful for necrotic wounds), and occlusive dressings (protect, maintain moisture).

• Soaks: Using sterile water, normal saline, Aveeno, Balnetar, Burrow’s solution, Betadine, or Dakin’s solution can soften dry epidermis and aid in the removal of crusts and skin debris, promoting healing, increasing absorption of topical medications, decreasing risk of infection and pruritus, and promoting cooling. Soaks are typically done for 15-20 minutes.

• Topical medications: Various creams, ointments, and solutions are used depending on the condition.

• Systemic medications: Oral or intravenous medications may be necessary.

• Surgical procedures: Including excision, curettage, cryosurgery, and Mohs micrographic surgery for skin lesions and cancers.

E. Etiologies/Pathologies

1. Bacterial skin infections

• a. Folliculitis: This is a bacterial infection of the hair follicle, examples include styes and shaving bumps. The causative organism is often Staph aureus. Precipitating factors include friction on the skin, blockage of the follicle, and injury to the follicle. Signs and symptoms include small, circumscribed, painless, hyperkeratotic papules usually on hands, feet, legs, face, itching, pustules or papules with surrounding erythema, and potential abscess development. Treatment involves topical antibiotics, saline soaks, warm moist packs, keeping the area clean, changing razor heads, and avoiding sharing washcloths.

• b. Furuncles: A furuncle is a bacterial infection or deep folliculitis, also known as a boil. The causative organism is typically Staph aureus. Precipitating factors include immunodeficiency and hot climates. Common sites include the neck, axillae, buttocks, face, and thigh. Signs and symptoms include a deep, firm, erythema, painful nodule where the core turns yellow/white and "points" (looks like the tip of a cone) in approximately 3-5 days, potentially rupturing spontaneously. Treatment may involve systemic or local antibiotics, warm moist compresses, and potentially incision and drainage followed by a topical antibiotic. Sharing personal articles should be avoided, and meticulous handwashing is important.

• c. Carbuncle: A carbuncle is a cluster of furuncles, also known as an abscess. The causative organism is usually Staph aureus. Signs and symptoms include fever, leukocytosis, pain, and nodules containing foul-smelling yellow drainage. Treatment typically involves IV antibiotics and incision and drainage. Risk factors include diabetes mellitus, animal bites, human bites, trauma to the skin, insect stings, ulcers, and lymphedema.

• d. Cellulitis: This is an infection involving the dermis, subcutaneous tissue, and lymphatics. It is diffuse in nature, and bacteria usually invade the tissue via new or existing breaks in the skin surface area. Common causative organisms are Staph aureus and B-hemolytic strep. Signs and symptoms include erythema, warmth, edema, pain with poorly defined borders, chills, fever, malaise, and leukocytosis. Diagnosis can involve tissue and blood cultures. Treatment includes warm moist dressings, systemic antibiotics, rest with the extremity elevated, and teaching to prevent the spread of infection through handwashing and proper disposal of contaminated articles. If left untreated, it can spread to surrounding tissue and may lead to necrotizing fasciitis.

2. Viral skin infections

• a. Herpes simplex: This infection is caused by the Herpes Simplex Virus (HSV), with HSV Type 1 commonly causing oral herpes (Herpes Febralis) and HSV Type 2 typically causing genital herpes. Transmission occurs through physical contact, oral sex, and kissing. Factors involved in recurrence include sunlight exposure, menstruation, stress, wind exposure, fever, physical injury, and immunosuppression. Signs and symptoms include initial burning and itching followed by painful small groups of vesicles that contain exudate and form a honey-colored crust upon rupture. Nearby lymph glands may be swollen. The infection usually lasts 2-3 weeks but can take up to 6 weeks. Treatment focuses on symptomatic relief and includes early application of zinc sulfate (Verazinc) or Abreva, analgesics, and antiviral medications like Acyclovir (Zovirax) which can be topical, IV, or oral. Patients should be taught to wear gloves to prevent transmission, as the virus is transmitted by direct contact and is not eradicated by the body.

• b. Herpes zoster: Also known as shingles, this is an acute vesicular eruption along a nerve pathway caused by the reactivation of the varicella-zoster virus (the same virus that causes chickenpox). Risk factors include being elderly (over 80), having AIDS, childhood cancer, undergoing chemotherapy, having Hodgkin's disease, or taking immunosuppressant medications. Signs and symptoms include a cluster of vesicles along the course of peripheral sensory nerves, typically unilateral and primarily affecting the face, neck, trunk, and chest. Crusts develop and drop off 10-14 days after development. Pain is a significant symptom, along with malaise, fever, erythema, and itching. Treatment includes Acyclovir (Zovirax), analgesics, rest, calamine lotion, steroids (to decrease the incidence of neuralgia), cool compresses, and antihistamines. A vaccine, Zostavax, is available for prevention in adults over 60 years old. Complications can include postherpetic neuralgia (PHN), ophthalmic involvement potentially leading to blindness, facial/auditory nerve involvement (causing hearing deficits, vertigo, and facial weakness), and visceral dissemination (pneumonitis, myocarditis, enterocolitis, pancreatitis).

• c. Herpetic whitlow: This is an HSV infection of the finger. In adults, it usually affects one finger (thumb or index), while in children, it can be any finger. Signs and symptoms include flushing of the skin, clear or yellow pus-filled vesicles on the finger, and tenderness. It may be preceded by intense itching or pain, and fever, chills, and malaise may occur. Treatment focuses on primary symptoms and may include elevation and immobilization of the finger and analgesics.

• d. Verruca: Commonly known as warts, these are benign growths made up of keratin caused by HPV (Human Papillomavirus), with more than 60 types. Transmission occurs through direct skin contact. Different types of warts include plantar warts (soles of feet), condylomata accuminata (anogenital warts), periungal warts (around fingernails), and verrucae vulgaris (hands, arms, legs). Signs and symptoms include small, circumscribed, painless, hyperkeratotic papules usually found on hands, feet, legs, and face, although plantar warts can be extremely painful, and anogenital warts may be itchy. Warts may disappear spontaneously. Treatment options include removal by electrodessication or cryosurgery, and topical colloidal solutions containing 16% salicylic acid and 16% lactic acid, which usually takes 2-3 weeks to work.

Here is a description of the listed integumentary disorders, focusing on their defining etiologies and pathologies, based on the provided sources:

3. Fungal skin inflammations

• a. Candidiasis: This is caused by an overgrowth of the fungus Candida albicans. Several factors can predispose individuals to candidiasis, including immunosuppression, being elderly, diabetes, pregnancy, oral contraceptive use, antibiotic therapy, chemotherapy/radiation therapy, obesity, and steroid therapy. It thrives in warm, moist environments. Common sites affected include the vagina, mouth, esophagus, lungs, skin, rectum, and under the breasts.

• b. Dermatophytoses: These are fungal skin infections caused by plant-like organisms that feed on keratin. Transmission occurs through direct contact or via inanimate objects. Examples include Tinea pedis (toes/feet), Tinea manus (hand), Tinea cruris (groin), Tinea capitis (scalp), Tinea corporis (body), Tinea barbae (beard), and Tinea Ungum (toenails).

4. Parasitic infestations

• a. Scabies: This infestation is caused by the female itch mite that burrows under the skin to lay eggs, creating a characteristic "zigzag" blister. Transmission occurs through direct contact, including clothing, bedding, towels, sleeping together, and shaking hands.

• b. Pediculosis: This is caused by blood-sucking parasites called lice. There are three varieties: head, body, and pubic lice. During feeding, lice release toxins into the skin, causing itching and purpuric spots due to the inflammatory response. They lay their eggs (nits) on body hair and clothing fibers. Transmission occurs through direct contact, bedding, clothing, and linens.

5. Inflammatory skin disorders

• a. Dermatitis: This is a common inflammatory, often eczema-like condition.

  • 1) Contact Dermatitis: This results from a skin reaction to irritating or allergenic materials like soaps and metals.

    • Primary Irritant Contact Dermatitis: This is a non-allergenic reaction caused by exposure to an irritating substance.

    • Allergenic Contact Dermatitis: This results from the exposure of sensitized individuals to contact allergens.

  • 2) Atopic Dermatitis: This is a common chronic relapsing pruritic type of eczema, often worse during periods of decreased humidity. It has a genetic component and is associated with a family history of asthma and allergic rhinitis. The pathology involves a complex activation of mast cells, T-cell lymphocytes, and monocytes.

  • 3) Seborrheic Dermatitis: This is a common chronic inflammation of the skin affecting areas like the scalp (dandruff), eyebrows, eyelids, ear canals, nasolabial folds, axillae, chest, back, groin, and gluteal crease. The exact cause is unknown. Lesions appear as scaly, greasy, white or yellowish inflammatory plaques with mild pruritus.

• b. Psoriasis: This is a relapsing proliferative skin disorder of the immune system, involving enzymes and other biochemical substances that regulate skin cell division. It may be due to genetic factors and is noninfectious and not curable. The production of epidermal cells occurs at a rate approximately 6-9 times faster than normal, leading to an accumulation of profuse scales and plaques because cell maturation and growth are not normal. There is some evidence that cell proliferation is mediated by the immune system, and 35% of individuals have a genetic predisposition.

• c. Acne vulgaris: This is a common inflammatory disorder of the pilosebaceous gland contiguous with the hair follicle. It is most common in adolescence and is multifactorial, with genetic influences playing a role in individual susceptibility and severity. The exact cause is unknown, but it involves an increased production of sebum related to androgenic hormones in pilosebaceous follicles located primarily on the face, upper chest, and back. Lesions include inflammatory pustules, papules, and nodules, as well as comedones (hair follicles filled with debris), which can be closed (whiteheads) or open (blackheads).

• d. Acne rosacea: This is an inflammation of the skin occurring in middle-aged adults (30-50 years), more common in fair-skinned individuals with a history of easy facial flushing and affecting females more frequently than males. Lesions include erythema, papules, pustules, and telangiectasia (permanent dilatation of superficial capillaries and venules), occurring primarily in the middle third of the face (forehead, nose, cheeks, and chin). Hypertrophy of sebaceous glands can also occur, sometimes leading to rhinophyma (bulbous nose).

• e. Pemphigus vulgaris: This is a chronic disorder that results in blisters (bullae). It is an autoimmune disease caused by circulating IgG autoantibodies. These autoantibodies react with the intracellular cement, leading to blisters and acantholysis (loss of cohesion between epidermal cells).

6. Skin tumors

• a. Keratosis: This refers to any cornification or growth of the outer layer of the skin.

  • 1) Seborrheic Keratosis: This is a benign proliferation of basal cells, usually seen in older people, appearing as multiple lesions that vary in color from tan to waxy yellow and often appear oval and greasy with a hyperkeratotic scale.

  • 2) Actinic Keratosis: Also known as Senile or Solar Keratosis, this is the most common epithelial precancerous lesion among whites, caused by sun exposure. While there is a small but definite risk of malignant degeneration with metastasis, it occurs most frequently with chronic high-intensity sun exposure.

• b. Basal cell carcinoma: This is a surface epithelial tumor of the skin originating from basal cells. It rarely metastasizes but can be locally destructive and invasive.

• c. Squamous cell carcinoma: This is a tumor of epidermal keratinocytes found in areas exposed to the sun. It may present as a scaly ulcer or raised lesion and grows more rapidly than basal cell carcinoma, with the potential to infiltrate surrounding structures and tissue and metastasize to lymph nodes, making it potentially dangerous.

• d. Malignant melanoma: This is a malignant tumor of the skin originating from melanocytes. It is highly malignant and metastatic. Causative factors include genetic predisposition, sun exposure, and fair skin. There are several types, including superficial spreading, lentigo maligna, primary nodular, and acral-lentiginous melanoma, each with distinct characteristics. The prognosis depends on the depth of invasion within the skin.

• e. Cutaneous T-cell lymphoma: This is a malignant disease involving T helper cells, where malignant T cells migrate to the skin. The cause is unknown, and it is ultimately fatal with every organ potentially involved.

Based on the provided nursing process outline and the information in the sources, here's how each component relates to the care of a client with actual or potential integumentary needs:

A. Recognizing and Analyzing Cues – Subjective Data

• 1. Client complaint: This is a critical starting point. The sources highlight various common complaints associated with skin disorders, such as pruritus (itching), rashes, ecchymoses, masses, color change (including changes in warts/moles), pain, and tenderness. The onset, duration, location, and any precipitating/aggravating factors related to the complaint are important to ascertain.

• 2. Past medical history: This is crucial for identifying predisposing factors and potential systemic involvement. The sources mention the importance of noting previous skin problems, allergies, and lesions, as well as systemic diseases such as endocrine, collagen, hepatic, immunological, vascular, and renal disorders. A history of allergies (including medications, foods, and environmental factors), recent exposure to infection/childhood diseases, medications (current and recent, including OTC and photosensitizing drugs), and family history of genetically transmitted skin diseases (e.g., alopecia, atopic dermatitis, psoriasis, diabetes mellitus) are all relevant subjective data.

B. Recognizing and Analyzing Cues – Objective Data

• 1. Physical findings: A thorough skin assessment is essential. This includes observing color (pallor, erythema, cyanosis, jaundice, uniform/non-uniform, variations), moisture (dry, oily, clammy, perspiration), temperature (uniformly warm or variations), turgor (elasticity), capillary refill (< 3 seconds is normal), and the presence of edema (location, pitting, taut, shiny, weeping, anasarca). Assessment of tenderness, odor (associated with lesions, poor hygiene, pressure ulcers), distribution (dense, diffuse, single/multiple, bilateral, localized, generalized, symmetrical/asymmetrical, sun-exposed areas), location (anatomical landmarks), size (measured in cm), color (flesh, brown, red, yellow, tan, blue), and configuration (shape or outline, e.g., circular, grouped, polycyclic, annular, discrete, linear, arciform, confluent, zosteriform) of any lesions is critical. The sources also list various common skin lesions like solar lentigo, senile purpura, cherry angiomas, seborrheic keratoses, acrochordons (skin tags), and wrinkles. Assessment of hair (distribution, thickness, texture, lubrication, signs/symptoms of infection/infestation) and nails (color, shape, texture, integrity, thickness, capillary refill) is also part of the objective data. Abnormal nail color (pallor, erythema, cyanosis, jaundice) should be noted.

• 2. Diagnostic tests: The sources mention several diagnostic tests used for integumentary disorders, which would be part of the objective data once results are available. These include:

  • Potassium Hydroxide (KOH) Exam and Fungal Culture: To diagnose fungal infections.

  • TZANCK’S SMEAR: To diagnose viral skin infections like herpes simplex and herpes zoster.

  • Scabies Scraping: To detect scabies, eggs, or feces.

  • Wood’s Light Exam: To aid in the diagnosis of superficial infections and pigmentation changes.

  • Patch Testing: To identify allergens in allergic contact dermatitis.

  • Culture & Sensitivity: To identify the exact species of bacteria or fungi and determine antibiotic effectiveness. This can be done via swipe, swab, or needle biopsy.

  • Skin Biopsy (shave, punch, incisional, excisional): For histologic studies, aiding in determining malignancy.

  • Tissue & blood cultures: Used in the diagnosis of cellulitis.

• 3. Changes in the older adult: The sources note several age-related skin changes, including thinning of skin layers, degeneration of elastin fibers (leading to wrinkles), decreased sweat glands, thinning at the junction of the epidermis and dermis, and decreased capillary numbers and size. Older adults are also at a higher risk for certain conditions like herpes zoster and seborrheic keratosis, and may present with specific skin lesions like solar lentigo and senile purpura.

C. Form and Prioritize Hypotheses (Nursing Diagnoses)

Based on the subjective and objective data, the nurse would formulate and prioritize nursing diagnoses. The provided list includes relevant possibilities:

• 1. Impaired skin integrity: This would be considered in the presence of lesions, wounds, blisters, thin or fragile skin, or any disruption of the skin's protective barrier. Conditions like dermatitis, psoriasis with plaques, bullae in pemphigus vulgaris, and burns directly indicate impaired skin integrity.

• 2. Pain: Many integumentary disorders can cause pain, such as herpes zoster, furuncles and carbuncles, cellulitis, and even pruritus that leads to painful scratching. The client's complaint of pain and objective findings of inflamed or irritated skin would support this diagnosis.

• 3. Body image disturbance: Visible skin conditions like psoriasis with extensive plaques, severe acne, rosacea with facial redness and potential rhinophyma, large or disfiguring skin tumors, and the scarring associated with some conditions can lead to concerns about appearance and self-esteem. The client's verbalization of negative feelings or withdrawal from social situations could indicate body image disturbance.

• 4. High risk for infection: Any break in the skin integrity increases the risk of infection. Conditions with open lesions, weeping wounds, or compromised immune function (e.g., in candidiasis, atopic dermatitis, or in clients receiving immunosuppressants) would warrant this diagnosis. Signs and symptoms of infection (redness, swelling, warmth, pain, increased drainage, fever) should be monitored.

D. Form and Prioritize Hypotheses (Goals and Expected Outcomes)

These hypotheses focus on what the nurse wants to achieve for the client:

• 1. Regain or maintain optimal functioning: This is a broad goal that encompasses managing symptoms, promoting healing, and preventing complications to help the client return to their highest possible level of activity and well-being.

• 2. Initiate or continue nursing care plan: This involves developing and implementing appropriate interventions based on the identified nursing diagnoses and the client's specific needs.

E. Generating Solutions (Nursing Interventions)

The sources provide various nursing interventions for integumentary disorders:

• 1. Dressings: Different types of dressings serve various purposes, including protecting wounds, absorbing drainage (dry dressings), decreasing inflammation, softening crusts, and promoting tissue granulation (wet dressings), promoting removal of excess exudate (absorptive dressings), and maintaining moisture to promote healing (occlusive dressings). The Unna boot is used for debridement. Wound vacs are used for various chronic and traumatic wounds to promote healing with negative pressure.

• 2. Therapeutic baths: These can include soaks with sterile water or normal saline, Aveeno (colloidal oatmeal), Balnetar (tar preparations), Burrow’s solution (aluminum acetate), Betadine, and Dakin’s solution. Therapeutic baths help to soften dry epidermis, aid in crust removal, cleanse and debride the skin, increase absorption of topical medications, decrease the risk of infection, decrease pruritus, and promote cooling of the skin.

• 3. Phototherapy: Ultraviolet A (UVA), often combined with psoralen (PUVA), and Ultraviolet B (UVB) are used in the treatment of conditions like psoriasis, atopic dermatitis, vitiligo, and cutaneous T-cell lymphoma. Goeckerman therapy, used for psoriasis, involves tar emulsion baths, topical tar application, and UV light exposure. Sun exposure should be limited during peak hours, and protective clothing and sunscreen should be used.

• 4. Pharmacologic agents: A wide range of topical and systemic medications are used, including corticosteroids (for inflammation and itching), antifungals (topical and oral for fungal infections), antivirals (e.g., acyclovir for herpes simplex and zoster), antibacterials (topical and systemic for bacterial infections like folliculitis, furuncles, carbuncles, and cellulitis), antipruritics (to relieve itching), acne products (benzoyl peroxide, salicylic acid, tretinoin, oral antibiotics, sex hormones, isotretinoin), keratolytics (to remove scales), topical anthralin and vitamin D analogues for psoriasis, antihistamines for itching, immunosuppressives for severe inflammatory or autoimmune conditions, and medications for parasitic infestations (e.g., lindane, permethrin).

• 5. Surgical intervention: Various surgical techniques are used to treat skin lesions and tumors, including electrodessication and curettage, cryosurgery, excision (shave, punch, incisional, excisional biopsy, total excision), Mohs micrographic surgery for skin cancer, comedo extraction, intralesional steroids, dermabrasion, and chemical peels for acne and scarring, and surgical excision for rhinophyma.

• 6. Prevention and health teaching: Educating clients about limiting sun exposure (especially between 11:00 AM and 3:00 PM), using sunscreen (SPF 15 or higher), wearing protective clothing, avoiding tanning beds, maintaining adequate hydration and nutrition, performing monthly skin self-exams (SSE), identifying and avoiding irritants and allergens, using mild detergents, wearing loose cotton clothing, keeping fingernails short, managing stress, avoiding extreme temperatures, practicing good hygiene (e.g., handwashing, not sharing personal items), and following prescribed treatment regimens are crucial aspects of nursing care. For specific conditions like herpes simplex, teaching about transmission (direct contact, including oral sex and kissing) and factors involved in recurrence (sunlight, menstruation, stress, wind, fever, injury, immunosuppression) is important. For scabies and lice, teaching about transmission through close contact and the need for simultaneous treatment of household members and cleaning of linens is essential.

F. Evaluation

The nurse evaluates the effectiveness of the interventions based on the established goals and expected outcomes:

• 1. Client expresses pain relief: Pain scales and client reports would be used to assess the effectiveness of pain management interventions.

• 2. Client verbalizes feelings: Assessing the client's emotional response to their skin condition and the impact on their body image is important. Verbalization of improved self-esteem or coping mechanisms would indicate a positive outcome.

• 3. Client maintains optimal activity: Evaluating the client's ability to perform activities of daily living and participate in desired activities without significant limitations due to their skin condition.

• 4. Remains free of infection: Assessing for signs and symptoms of infection and reviewing any relevant lab results (e.g., white blood cell count, culture results) to determine if infection has been prevented or resolved.

G. Community Resources

The provided list offers valuable support for clients with integumentary disorders:

• 1. American Burn Association: Provides resources and support for burn victims and their families.

• 2. National Burn Victim Foundation: Offers similar support and resources for individuals affected by burns.

• 3. National Psoriasis Foundation: A resource for individuals with psoriasis, offering information, support, and advocacy.

• 4. Skin Cancer Foundation: Provides education and resources on skin cancer prevention, detection, and treatment.

By utilizing the nursing process in this comprehensive manner, nurses can provide holistic and effective care to clients with a wide range of integumentary needs.