Chapter 25

Chapter 25: Integumentary Problems

Copyright © 2023 by Elsevier, Inc. All rights reserved.

Sun Exposure

  • Types of Light:

    • Visible Light

    • Ultraviolet (UV) Light

    • UVA (Ultraviolet A): Responsible for tanning.

    • UVB (Ultraviolet B): Responsible for sunburn.

  • Cumulative Damage:

    • Damage caused by UV rays accumulates over time.

  • Sun Protection Strategies:

    • Protective Clothing: Wear clothes that cover skin.

    • Sunscreen: Apply sunscreen with adequate SPF.

Skin Cancer Risk Factors

  • High-Risk Factors include:

    • Fair Skin: Lighter skin types are more susceptible.

    • Hair Color: Blonde, red hair.

    • Eye Color: Blue or light-colored eyes.

    • Outdoor Sunbathing: Increased exposure to UV rays.

    • Geographical Factors: Living near the equator or at high altitudes.

    • History of Skin Cancer: Previous skin cancer increases risk.

    • Outdoor Occupations/Recreations: Jobs or activities involving prolonged sun exposure.

    • Indoor Tanning: Use of tanning booths further increases risk.

Nonmelanoma Skin Cancers

Actinic Keratosis (Solar Keratosis)

  • Description:

    • Most common precancerous skin lesions.

    • Particularly affects older white population.

    • Key factor for development is sun exposure.

    • Diagnosis Challenge: Can be indistinguishable from squamous cell cancer.

    • Treatment: Should be aggressive due to potential progression.

Basal Cell Carcinoma

  • Description:

    • The most common type of skin cancer.

    • Generally least deadly among skin cancers.

    • Typically occurs in middle-aged to older adults.

Squamous Cell Carcinoma

  • Description:

    • Aggressive type of skin cancer with potential to metastasize.

    • Main risk factors include:

    • Sun exposure.

    • Immunosuppression (especially after organ transplants).

    • Contributing factors:

    • Smoking (pipe, cigar, and cigarette) increases SCC risk on mouth and lips.

Case Study: E.N.

  • Profile:

    • 45-year-old white female.

    • Strawberry blonde hair and blue eyes.

    • Works at a garden center.

    • Presentation: Noticed a mole on the left shoulder increasing in size and darkening.

Clinical Findings

  • Mole Assessment:

    • Measurements: 5 mm × 8 mm in diameter, jagged pebble shape.

    • Patient reported:

    • Color change from brown to black.

    • Increased size.

    • Texture has become bumpy.

Melanoma Overview

  • Melanoma Statistics:

    • Leading cause of skin cancer deaths.

    • Can metastasize to any organ, including brain and heart.

    • Causes are largely unknown but include potential environmental and genetic factors.

Risk Factors for Malignant Melanoma

  • At-Risk Characteristics:

    • Red or blonde hair.

    • Blue or light-colored eyes.

    • Light-colored skin that freckles easily.

    • Chronic exposure to UV rays.

    • Family history of melanoma.

Malignant Skin Neoplasms

ABCDE Rule for Assessment

  • Asymmetry: One half does not match the other.

  • Border Irregularity: Edges are ragged, notched, or blurred.

  • Color Change: A variety of colors are present.

  • Diameter: Greater than 6 mm.

  • Evolving: The mole changes in size, shape, or color.

Diagnosis Process for Malignant Melanoma

  • Techniques of Diagnosis:

    • Dermoscopy: A non-invasive diagnostic tool.

    • Excisional Biopsy: Surgical procedure to remove a portion of the mole.

    • Breslow Measurement: Measurement of how deep the melanoma invades the skin.

Breslow Measurement

  • Significance: Important for determining the prognosis and treatment plan.

Case Study: E.N. Continued

  • Post-Diagnosis Procedures:

    • Incisional biopsy confirms diagnosis of malignant melanoma.

    • Factors influencing treatment next steps include:

    • Site of the original tumor.

    • Stage of cancer.

Treatment Plan for Malignant Melanoma

  • Interprofessional Care Approach: Treatment options include:

    • Wide Surgical Incision: To remove the tumor effectively.

    • Adjuvant Therapy: Additional treatment to enhance efficacy.

    • Tumor Staging:

    • Ranges from stage 0 to IV based on size, lymph node involvement, and metastasis.

    • Nearly 100% curable if diagnosed at stage 0.

    • 5-year survival rate is about 27% for advanced disease.

Specific Treatment Options

  • Immunotherapy:

    • Cytokines: Boosts immune system activity.

    • PD-1 Inhibitors: Targets specific pathways for immune modulation.

    • CTLA-4 Inhibitors: Another class of drug for immunotherapy.

  • Targeted Therapy:

    • BRAF and MEK Inhibitors: Target specific genetic mutations in melanoma.

  • Radiation Therapy:

    • Used for lymph node and brain metastasis treatment.

Atypical/Dysplastic Nevus

  • Characteristics:

    • Nevi larger than usual size with irregular borders.

    • Display various shades of color.

    • May have similar ABCDE characteristics but are less pronounced.

    • Increased risk of developing melanoma.

Case Study: E.N. Surgical Outcomes

  • Surgical Procedure:

    • E.N.'s mole excised and axillary lymph nodes dissected.

    • Results: Lymph nodes were negative for cancer cells.

Patient Concerns Post-Surgery

  • E.N. expresses concern regarding the size and location of her incision on her shoulder.

  • Questions about the surgical procedure performed.

Audience Response Questions

Question 1

  • Which patient is at highest risk for skin cancer?

    • a. A 56-year-old Native American with colon polyps.

    • b. A 72-year-old retired high school chemistry teacher.

    • c. A 32-year-old who uses a tanning booth twice a week.

    • d. A 44-year-old who regularly bathes with perfumed soap.

  • Answer: C (A 32-year old who uses a tanning booth twice a week).

Skin Infections and Infestations

  • Types of Infections:

    • Bacterial infections.

    • Viral infections.

    • Infestations and insect bites.

    • Fungal infections.

Allergic Skin Problems

Contact Dermatitis

  • Types:

    • Irritant Contact Dermatitis: Results from exposure to irritants.

    • Allergic Contact Dermatitis: Triggered by allergens leading to hypersensitivity reactions.

  • Management:

    • Family history plays a role.

    • Patch testing can identify allergens.

    • Recommendations to avoid known irritants.

Cutaneous Drug Reactions

  • Conditions:

    • Stevens-Johnson Syndrome (SJS): Severe reaction occurring 4-21 days after offending drug usage.

    • Toxic Epidermal Necrolysis (TEN): More severe manifestation involving similar timing.

  • Management:

    • Identify and stop the offending drug(s).

    • Provide supportive care.

Benign Dermatologic Problems

  • Common issues:

    • Acne: A common skin condition affecting many people.

    • Psoriasis: A longstanding skin disorder.

    • Seborrheic Keratosis: Benign growths on the skin.

Interprofessional Care for Dermatologic Problems

  • Care Strategies:

    • Phototherapy: Treatment based on light exposure.

    • Radiation Therapy: Used for severe cases.

    • Laser Technology: Advanced option for various conditions.

    • Drug Therapy:

    • Antibiotics for infections.

    • Corticosteroids to reduce inflammation.

    • Antihistamines for allergy management.

    • Topical Fluorouracil for particular skin lesions.

    • Immunomodulators for immune-related skin problems.

Diagnostic and Surgical Therapy for Skin Conditions

  • Techniques Include:

    • Skin scraping: For diagnostic purposes.

    • Electrodesiccation: Removal of lesions by drying them out.

    • Electrocoagulation: Coagulating blood vessels to reduce bleeding.

    • Curettage: Scraping off lesions mechanically.

    • Punch Biopsy: Removing a portion of skin for analysis.

    • Cryosurgery: Freezing lesions for removal.

    • Excision using Mohs surgery: Precision surgery for skin cancer removal.

Nursing Management Strategies

Basic Nursing Management

  • Includes:

    • Wet compresses to soothe the skin.

    • Therapeutic baths to hydrate and cleanse the skin.

    • Ensuring hygienic practices to prevent infection.

    • Administration of topical medications.

Prevention and Care

  • Control of Pruritus:

    • Break the itch/scratch cycle.

    • Maintain cool environment, hydration, and apply wet compresses.

    • Use moisturizers for skin hydration.

    • Medications include:

    • Topical and injectable corticosteroids for inflammation relief.

    • Systemic antihistamines to manage itch and allergic reactions.

Advanced Care

  • Prevention of Spread: Educate on minimizing skin contact with irritants.

  • Prevention of Secondary Infections: Maintain skin integrity and cleanliness.

  • Post-procedure Care: Monitor healing post-surgery.

Chronic Skin Problems

  • Psychological Effects:

    • Nurses should aid patients in adhering to treatment plans.

    • Support groups may be beneficial.

    • Camouflage cosmetics can be recommended for emotional support.

Audience Response Question

Skin Condition Related Anxiety

  • Nursing Intervention for Anxiety:

    • a. Encourage the patient to express feelings of anxiety.

    • b. Use touch to demonstrate acceptance of appearance.

    • c. Refer the patient for counseling and further evaluation.

    • d. Teach the patient the use of cosmetics and cover-up techniques.

  • Answer: A (Encourage the patient to express feelings of anxiety).

Cosmetic Procedures

  • Types of Procedures:

    • Topical procedures.

    • Injections for enhancement.

    • Surgical options:

    • Laser surgery for skin concerns.

    • Face lifts.

    • Liposuction for contouring.

Nursing Management in Cosmetic Surgery

Preoperative Management

  • Key Elements:

    • Ensure informed consent is obtained.

    • Set realistic expectations with patients.

    • Provide necessary patient education prior to the procedure.

Postoperative Management

  • Key Elements:

    • Manage pain effectively.

    • Monitor for signs of infection and adequate circulation post-surgery.

Skin Grafts

Types of Skin Grafts

  • Uses and Types:

    • Free Grafts:

    • Autograft: Graft taken from the same individual.

    • Isograft: Graft taken from a genetically identical individual (e.g., twin).

    • Reconstructive Microsurgery: Advanced techniques for skin grafting.

    • Skin Flaps: Tissue moved from one part of the body to another.

    • Soft Tissue Expansion: Technique to increase tissue coverage for grafting.

    • Engineered Skin Substitutes: Biologically compatible substitutes used for grafting purposes.

Audience Response Question

Pressure Dressing Post-Surgery

  • Patient Inquiry:

    • Patient reports restriction feeling from dressing applied to face and neck after facelift surgery. Asks if it can be loosened.

  • Response Options:

    • a. “This dressing is used to prevent bleeding into the skin.”

    • b. “The dressing will support and secure the incision edges.”

    • c. “A dressing is necessary to prevent infection after surgery.”

    • d. “Face dressings provide time to become adjusted to a change.”

  • Answer: A (This dressing is used to prevent bleeding into the skin).