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Chapter 56
Management of Patients With
Dermatologic Problems
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Care of Patients With Skin Conditions
• Objectives of therapy are to prevent additional
damage, prevent secondary infection, reverse
inflammatory processes, and relieve symptoms
• Nursing care includes administration of topical and
systemic medications and providing wound care,
dressings, and patient hygiene
• Nursing care also needs to address the
educational, emotional, and psychosocial needs of
the patient
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Psoriasis
• A chronic, noninfectious inflammatory disease of the
skin in which epidermal cells are produced at an
abnormally rapid rate
• Affects about 2% of the population, primarily those of
European ancestry
• Improves and recurs; a life-long condition
• May be aggravated by stress, trauma, and seasonal
and hormonal changes
• Treatment: baths to remove scales and medications;
see PUVA therapy (Table 56-6 )
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Psoriasis (cont.)
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Nursing Process—Assessment of the
Patient With Psoriasis
• Appearance of the skin
• Coping of the patient with condition
• Note impact of the disease on the patient
activities and interactions
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Nursing Process—Diagnosis of the
Patient with Psoriasis
• Deficient knowledge
• Impaired skin integrity
• Disturbed body image
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Collaborative Problems/Potential
Complications
• Infection
• Psoriatic
arthritis
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Nursing Process—Planning the Care of the
Patient With Psoriasis
• Major goals may include:
– Increased understanding of psoriasis and the
treatment regimen
– Achievement of smoother skin with control of
lesions
– Development of self-acceptance
– Absence of complications
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Interventions
• Patient teaching regarding the disease, skin
care, and treatment regimen; see Chart 56-5
• Measures to prevent skin injury: avoid picking
or scratching
• Measures to prevent skin dryness: use
emollients, avoid excessive washing, use
warm (not hot) water, and pat dry
• Use of the therapeutic relationship for support
and to aid coping
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Infectious Diseases of the Skin
• Bacterial infections
– Impetigo
– Folliculitis, furuncles, and carbuncles
• Viral infections
– Herpes zoster
– Herpes simplex: orolabial and genital
• Fungal infections: tinea pedis, tinea corporis, tinea
capitis, tinea cruris, tinea unguium; see Table
56-5
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Impetigo
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Herpes Zoster (Shingles)
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Tinea Corporis (Ringworm) of the Face
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Patient Teaching—Bacterial Infections
• Impetigo is contagious and may spread to other
parts of a patient’s body or to other persons
• Patient teaching regarding antibiotics, hygiene,
and skin and lesion care
• Do not share towels, combs, etc.
• Bathe daily with antibacterial soap
• Furuncles, boils, or pimples should never be
squeezed
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Patient Teaching—Viral Infections
• Herpes zoster: provide instruction regarding
prescribed antiviral medications, lesion care,
dressings, and hand hygiene
• Herpes simplex: provide instruction regarding
prescribed use of antiviral and prophylactic
medications, information about the spread of
herpes, and measures to reduce contagion of
partner or of neonates born to mothers with
genital herpes
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Patient Teaching—Fungal Infections
• Instruction regarding medications, use of oral and topical
agents, and shampoos
• Instructions regarding hygiene; use clean towels and
washcloths every day
• Do not share towels, combs, etc.
• Keep skin folds and feet dry
• Wear clean, dry, cotton clothing including underwear and
socks; avoid synthetic underwear, tight-fitting garments,
wet bathing suits, and plastic shoes
• Avoid excessive heat and humidity
• Hair loss associated with tinea capitus is temporary
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Parasitic Skin Infestations
• Pediculosis (lice): pediculosis capitus, pediculosis
corporus, and phthirius pubis
• Scabies (mites): Sarcoptes scabiei
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Patient Teaching—Pediculosis Capitis
• Head lice may infest anyone and are not a sign of
uncleanliness
• Provide instruction in use of shampoo (lindane: Kwell;
pyrethrin: RID) and combing of hair with fine-tooth comb
dipped in vinegar to remove all nits
• Note lindane may have toxic effects and must be used
only as directed
• All articles of clothing and bedding must be disinfected,
washed in hot water, or dry cleaned; furniture and floors
should be frequently vacuumed
• Do not share combs, hats, etc.
• All family members and close contacts must be treated
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Patient Teaching—Pediculosis
Corporis and Pubis
• Pediculosis corporis is a disease related to poor
hygiene and occurs in those who live in close
quarters
• Pediculosis pubis is common and spread chiefly by
sexual contact
• Bathe in soap and water; apply prescription
scabicide or an OTC permethrin, such as NIX;
mechanically remove any nits; if eyelashes are
involved, Vaseline may be applied twice a day for
8 days
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Patient Teaching—Pediculosis
Corporis and Pubis (cont.)
• All family members and sexual contacts must be
treated and instructed regarding personal hygiene
• All clothing and bedding must be washed in hot
water or dry cleaned
• Patient and partner should be scheduled for a
medical checkup to assess for coexisting sexually
transmitted disease
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Patient Teaching—Scabies
• Mites frequently involve fingers and hands; contact may
spread infection; health care personnel should wear
gloves when providing care until infection is ruled out
• Instruct patient to take a warm, soapy bath; allow skin
to cool; apply the prescription scabicide lindane,
crotamiton, or 5% permethrin to entire body, not
including the face or scalp; leave on for 12 to 24 hours
• Wash clothing and bedding in hot water and dry in a hot
dryer
• Treat all contacts at the same time
• Pruritus may continue for several weeks and does not
mean retreatment is required
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Nursing Process—Assessment of the
Patient With Blistering Diseases
• Appearance of the skin
• Monitor VS frequently and assess for signs and
symptoms of infection
• Pain, pruritus, and discomfort
• Coping skill of the patient with the condition
• Note impact of the disease on the patient’s
activities and interactions
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Nursing Process--Diagnosis of the
Patient With Blistering Diseases
• Acute pain: skin and oral cavity
• Impaired skin integrity
• Anxiety
• Ineffective coping
• Deficient knowledge
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Collaborative Problems/Potential
Complications
• Infection and sepsis
• Fluid volume deficit and electrolyte imbalance
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Nursing Process—Planning the Care of the
Patient With Blistering Diseases
• Major goals may include:
– Relief of pain and discomfort of lesion
– Skin healing
– Reduced anxiety
– Improved coping
– Absence of complications
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Interventions
• Provide meticulous oral hygiene
• Avoid commercial mouthwashes
• Keep lips moist with lip balm, petroleum, or lanolin
• Provide cool humidified air
• Apply cool, wet dressing or baths; initiate hygiene
measures
• Apply powder liberally to keep skin from adhering
to sheets
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Interventions (cont.)
• Monitor for and prevent hypothermia
• Skin care may be similar to that of the patient
with extensive burns
• Initiate measures to prevent secondary infections
• Encourage adequate fluid and nutritional intake
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Skin Cancer
• Frequently related to sun exposure; prevention involves
use of sunscreen and avoidance of sun exposure
• Incidence is increasing
• Prevention of all types of skin cancer involves protection
from excessive sun exposure
• Basal cell carcinoma
– Most common type and most successfully treated
because tumors remain localized
• Squamous cell carcinoma
– Prognosis depends upon presence of metastasis
• Treatment involves eradication of the tumor
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Basal Cell Carcinoma and Squamous Cell
Carcinoma
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Skin Cancer
• Malignant melanoma
– Risk factors: see Chart 56-8
– Worldwide incidence and mortality rate are
increasing
– Peak incidence occurs between ages 20 to 45
– Types: superficial spreading, lentigo-maligna
melanoma, and nodular melanomas
– Treatment: surgical excision and other therapies
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Malignant Melanoma
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Nursing Process—Assessment of the
Patient With Malignant Melanoma
• Inspect the skin carefully
• Ask specific questions about pruritus, tenderness,
pain, changes in moles, and new pigmented lesions
• Assess knowledge level and risk factors
• Assess coping and anxiety
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Nursing Process—Diagnosis of the
Patient With Malignant Melanoma
• Acute pain
• Anxiety
• Depression
• Deficient knowledge
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Collaborative Problems/Potential
Complications
• Metastasis
• Infection of surgical site
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Nursing Process—Planning the Care of the
Patient With Malignant Melanoma
• Major goals may include:
– Relief of pain and discomfort
– Reduced anxiety and depression
– Increased knowledge of early signs of melanoma
– Absence of complications
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Interventions
• Pain: provide appropriate analgesics and measures
to promote comfort
• Provide emotional support; allow patient to express
feelings, clarify misconceptions, and supply
information; support coping; and involve family in
the discussion
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Kaposi’s Sarcoma (KS)
• A malignancy of endothelial cells that line the blood
vessels: dark reddish-purple lesions of the skin, oral
cavity, GI tract, and lungs
• Categories
– Classic KS
– Endemic (African) KS
– Immunosuppression: associated KS
 Occurs in transplant recipients and people with
AIDS
 Much more aggressive form that involves multiple
body organs
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AIDS-Related Kaposi’s Sarcoma
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Dermatologic and Reconstructive
Surgeries
• Skin grafts
– Autografts, allografts, and xenografts
– Split thickness or full thickness
• Pedicle flaps and free flaps
• Chemical peels
• Dermabrasion
• Facial reconstruction surgery
• Rhytidectomy (face lift)
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Laser Treatment of Lesions
• Argon laser
• Carbon dioxide laser
• Pulse-dye laser
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Layers of Skin Appropriate for SplitThickness and Full-Thickness Grafts
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Common Donor Graft Sites
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Nursing Process—Assessment of the
Patient With Facial Reconstructive
Surgery
• Emotional responses
• Coping mechanisms and support
• Patient knowledge and understanding
• Assess family coping, knowledge, and support
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Nursing Process—Diagnosis of the Patient
With Facial Reconstructive Surgery
• Ineffective airway clearance
• Pain
• Deficient knowledge
• Imbalanced nutrition
• Impaired verbal communication
• Disturbed body image/self-esteem/self-concept
• Anxiety
• Coping impairments
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Collaborative Problems/Potential
Complications
• Infection
• Bleeding and hematoma formation
• Compromised circulation of flap and tissue necrosis
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Interventions
• Provide patient and family teaching and support
• Monitor airway and for signs of hypoxia
• Keep head slightly elevated to minimize edema
• Provide analgesics as prescribed
• Maintain aseptic technique
• Provide frequent, gentle oral hygiene
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Interventions (cont.)
• Monitor nutritional status: I&O, weight, serum
protein, and electrolyte levels
• Provide individualized nutritional care
• Address communication needs preoperatively;
use pencil and paper, pictograph board, or other
methods as needed; refer patient to speech
therapy
• Provide emotional reassurance and support
• Encourage socialization as appropriate
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