LaPoint 1

Notes for Skin VoiceOver PPT:

Slide 1:
Welcome to the Voice Over Power Point for Lesson Plan 12, Nursing Care of the Patient with
Complex Sensory, Perceptual Alterations and Disorders of the Integumentary System. This is
Mrs. LaPoint and I pleased and grateful that you are once again allowing me to facilitate your
learning journey this semester. You will see as we move through the slides and as you review
the objectives, we will spend more time on malignant disorders as you have already covered
sensory perception disorders in 1213 so I will not recover the same material here. Having said
that, I will encourage you to review that material to refresh the concepts or to take the time to
strengthen areas that may need them as you will see the information on your boards. As
always, as you review, please write down any questions that you may have and I will be happy to
answer them to the best of my ability when next we meet.
Slide 2:
I will not read the objectives to you, but you should recognize that they are the same objectives
from the Lesson Plan in Canvas. As a student, let me give you some advice. If you struggle
wondering what your instructors expect from you, this is it right here. Lessons are built from
objectives. Instructors facilitate learning with the objective of the learner being able to do this
list of things by the end of a specified time frame, kind of what like you do for your patients with
your concept maps. This is care planning for teachers in a way. So, as you study or work on
assignments, discussions, move through further degrees, evaluations, etc., review the objectives
as you go and it may eliminate a lot of guesswork for you. Its helped me out quite a bit during
projects and tests in the past and I thought I would share it with you now. Hope it helps.
Slide 3:
The integumentary system is the largest organ of the body and comprises the hair, skin, nails,
and glandular bodies. Within the skin lies the epidermis and dermis layers with the
subcutaneous layer immediately underneath. The subcutaneous layer is not technically part of
the skin, but it does function in conjunction with it, so it is included.
The outermost layer of the skin is the epidermis. This layer is avascular and thin, mostly formed
from melanocytes and keratinocytes of the deeper basal layer. The epidermis is recycled about
every 28 days. If these cells are changed at a rate different then that, some disease processes
are manifested, such as psoriasis.
The dermis is located below the epidermis and holds the connective tissue and the vascular bed
of the skin. This layer of the skin is also the primary responsible cellular party for wound healing

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as this is where the fibroblasts are located and they produce collagen and elastin. Also located
at this level are nerves, lymph vessels, hair, and glands.
Subcutaneous tissue is considered when discussing skin because it attaches the skin to the
muscle and bone under it. It also assists with insulation properties which is a major function of
skin - which we will cover in a minute. As you can note if you are a people watcher,
subcutaneous tissue various based on gender, age, heredity, nutritional status, and activities of
daily living. Points to anyone who does not mention my subcutaneous tissue moving on.
Joking aside, things to consider, however, for those patients that may have more tissue than
others, may be temperature regulation issues, how medication may regulate within their body if
the medication is lipid soluble, teaching points, etc.
And finally, skin appendages would include any hair, nails, and glands. Unless there is a
disorder, a normal assessment finding is hair dispersed on most of the body with the exception
of the lips, palms of the hands, and soles of the feet. Average hair loss is about 100 hairs per
day, but may be more based on heredity, disease, or treatment with certain drugs. Fingernails
should grow about 50% faster than toenails. Check for flaking and yellowing that would signify
an untreated fungus. Gland excretion fluctuates with hormone production over the lifespan.
Anyone ever around a teenager knows this to be true. Sweat glands enlarge and produce
substances that is relatively benign, but then interact with surface bacteria that causes odors
when combined.
So what is the purpose of the skin? Well, we know that it is the largest organ, so it is here to
protect us. It keeps harmful invaders out. It also keeps good stuff in. By that I mean, it keeps
us from dehydrating excessively, but at the same time, when we need to sweat, we have all
those glands, about 3000/per square inch, to do it, so it also helps to regulate temperature.
That fluffy subcutaneous tissue we talked about is a pretty good shock absorber from trauma,
too, as well as keeping us warm. As we talk about the dangers of skin exposure to sun, one
point that is often missed is that some exposure is needed as the epidermis layer begins to
synthesize the endogenous Vitamin D as provided in UV light for calcium and phosphorus
balance. As nurses, we apply drugs topically to the skin. We communicate non-verbally
through observation of various parts of the integumentary system. And, lets face it (no pun
intended) we would really be less pleasing to look at on the whole if we were walking around
without skin, so from an esthetic perspective, we are much more uniquely and diversely pleasing
to behold with skin on.
And then we start to age Some of us better than others Some changes are cosmetic, as I
am alluding to. As a clinician, when taking a health history in relation to skin, areas of import in
the gerontologic population would include prior, I STRESS PRIOR, sun exposure from the
age of a child through adulthood, the damage is done early, include tanning beds or heat lamps,
hygiene practices, nutritional intake, and hydration. As you move to the physical exam, you will

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note a loss of muscle and collagen, which will cause increase tenting. There will be flaking skin,
possible signs of scratching, lack of hair and perspiration, less melanocytes so more graying,
more sun damage so possible growths to document and explore further with a licensed provider,
a diminished rate of wound healing, decreased circulation, and thickened nails. This may all
lead to an altered self-image. It is also important to remember that the older adult may have a
decreased sense of thirst, poor nutrition, delayed wound healing, delayed circulation, and an
increased risk for neoplasm, with a decrease sense of self-care.
Slide 4:
As you are all aware, an assessment includes both subjective and objective data points and can
be either a full or focused exam. A skin assessment begins at the moment of contact with the
patient with a brief overlook of general appearance, color, state of health, and continues
throughout the rest of the full examination. A complete health history yields important
information as to previous surgeries, allergens, comorbid conditions, medications, nutrition, selfcare habits, genetic pre-dispositions, psychosocial concerns, or environmental exposures that
may explain dermatologic manifestations being exhibited.
The objective exam begins with inspection and may yield primary or secondary lesions. As you
note these lesions, a primary lesion will be present the onset of a disease process, such as a
cyst, a plaque, a pustule, or a wheal. Whereas in secondary lesions, the lesions change over
time or with manipulation from scratching, infection, or treatment. These lesions could be
demonstrated by a crust, ulceration, scare, excoriation, or atrophy.
Remember always that if you do not know specifically what you are looking at, that is ok, do not
name it incorrectly, but do always describe it clearly and measure it properly so that those
coming after you can find the same lesion and quote-un-quote see the same thing you do.
Describe it very clearly in relation to size, shape, color, distribution, and location. Also follow
any institutional policies for photographic documentation.
Palpation also reveals much during an objective exam as the nurse can assess temperature,
turgor, texture, and diaphoresis. Be aware of your own body temperature affecting your
assessment of the patients skin temperature. If there is a question, use the back of your hand
and follow up with a thermometer. Remember there is a loss of skin turgor in dehydration and
age. And all skin should be intact without excessive moistness or flaking.
Some assessment techniques for patients of color are slightly differently, namely if rashes are
present, it may be more difficult to inspect and palpation should be employed. As we reviewed
in the respiratory discussion, too, refer to buccal or conjunctival mucosa for signs of fever,
cyanosis, or blood loss. On a side note, however, with increased melanin production would be
increased protection from UV rays and a lower incidence rate of skin cancer in African

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Americans. Native Americans also share this lower risk than caucasians. This is not to say that
melanoma does not occur, but it just occurs at a lower rate. The unfortunate thing is that when it
does happen, it often goes undetected until advanced stages.
Certain risk factors abound for skin cancer. Some are modifiable some are not. Those that
are fair skinned, have a familial history of skin cancer, have freckles, red hair, blue eyes, have
had environmental exposures, and early, prolonged exposure to UV light whether sun or artificial
are the most high risk patients to develop skin cancer, especially melanoma. The best
prevention is health promotion. In the geographic area we live in, in the profession you are
entering, you are in the prime position for health promotion education to reach children and
parents of children on sun protection education. The damage of UV rays now on skin and eyes
will affect them as adults in the form of skin cancer. Not pushing or anything, but it may be a
consideration for a health fair somewherejust throwing it out there as a thought
So now that you think you have found something, lets examine it a little more closely using the
ABCDE mnemonic of melanoma. This will help you to assess the lesion and also to teach the
patient to assess on a monthly basis so that they may report any changes to their healthcare
provider. This is another place where baseline and subsequent photographs are helpful. A is
for Asymmetry in that both halves of the lesion are unlike each other, B is for Border irregularity,
C is for Color meaning there are various shades of pigmentation or there is an evolution of color
over time, D is for diameter in that the lesion is >6 mm in size is roughly the size of a pencil
eraser, and E is for Evolving in that one or more of these characteristics of the lesion is changing
over time. This again is an assessment tool for you as the professional and a teaching point to
send the patient home with.
Slide 5:
One form of pre-malignant skin lesion is known as actinic keratosis or solar keratosis because it
is caused primarily by the over-exposure of skin to the sun as years pass. It is mostly found in
older, white adults in sun-exposed areas as scaly rough, slightly raised areas that often have a
red base to them. There are often multiple sites and when removed, they often return.
Treatment options include surgery, creams, chemical peels, layering, and irradiation. Biopsy
should be performed on removed lesions.
Nevi is another word for moles. All moles or nevi should be documented and photographed to
monitor for changes. Use the ABCDE methodology. Atypical Nevi however may be
premalignant. These moles are often flat on one side and raised on another, hence border
irregularity, have a larger diameter, typically greater than 5 mm, and vary widely in color from
pink to black. The most frequent site to find these atypical nevi are on patients backs, but
atypical sites can also be found. I once found one on the sole of a patients foot, believe it or

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not. As these lesions are monitored, any changes should be noted and documented.
Suspicious lesions would benefit from an excisional biopsy.
Carcinomas can either be basal or squamous cell. Speaking first about the basal cell
carcinomas, these are slow growing lesions with pearly borders. Often the center will be
depressed or eroded. These lesions originate in the epidermal basal cells. Normally, the
cancer cells are localized to the skin and do not metastasize or spread, but if left untreated,
localized tissue damage can and will occur. Depending on the stage of disease, treatment
may include surgery, curettage, cryosurgery, radiation, chemotherapy, and phototherapy.
Squamous cell carcinoma also originates with epidermal cells, but with the keratinizing cells.
These lesions will frequently develop in those sun-exposed areas and can be highly aggressive
with metastasis possible. Besides sun-exposure, tobacco products lends to the formation of
lesions of the mouth or lips. These lesions may be scaly, have ulcerations, indistinct borders, be
erythematous, and firm. Remember from the respiratory lecture that a biopsy is required to
confirm any suspected cancer prior to an official diagnosis. Once that is obtained, treatment
options include surgery, cryotherapy, radiation, chemo, and curettage dependent on spread of
disease. Lymph nodes closest to the site of lesion should be examined with the biopsy. Of
course early detection and treatment leads to the highest cure rate and is second only to
prevention.
Slide 6:
Malignant melanoma is the most prevalent and deadly form of skin cancer. It is an aggressive
tumor that originates from melanocytes that can be found in skin, eyes, mucous membranes
including those of the digestive tract, or anywhere else that melanin producing cells are found. It
has the ability to metastasize to anywhere in the body, including the brain. History of atypical
nevi, environmental exposures, and genetic predisposition like being fair-skinned lend to a
potential development for melanoma. There is a familial risk, as well. As you see from this
ABCDE representation of melanoma in the left-hand picture, there are asymmetric borders,
irregular colors, wide diameters, and an evolution to the lesion. 1/4 of melanomas start as
moles. In women they are likely to begin on lower legs and backs and on men the trunk, the
head, or neck. Remember that these lesions are based on melanocytes, so they will be
pigmented and change color.
Suspicious lesions should be biopsied using excisional biopsy techniques only. Dependent on
the site of the original tumor, the depth of involvement, the spread of disease, the patients age,
and the patients state of health, the treatment options may change. Treatment may include
surgery including lymph node evaluation. If lymph nodes are involved with spread to other
organs, that is considered stage IV and treatment options are aimed at palliative care. If the
tumor is localized and less than 1 mm deep, surgery may be all that is needed. Stages in

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between the two may include treatment options including additional therapies of chemotherapy,
biologic therapy, or radiation.
Cutaneous lymphoma is a slow progressive disease in that it is chronic in nature. It is typical
after an environmental chemical exposure or, if you note the picture on the bottom right of this
PowerPoint slide, in a patient immunocompromised by HIV and exposed to a fungal infection.
Cutaneous lymphoma is twice as likely to happen to men as it to women and is most likely to be
caused by mycosis fungoides, or MF. There are three stages of clinical manifestations and
those are the patch, the plaque, and the tumor. During the patch phase there will be macular
eruptions followed by red plaques, leading to eventual tumors. Intense itching and swollen
lymph nodes accompany this disease. There is no cure for this disease so treatment is aimed
at the control of symptoms. Light therapy, as with psoriasis, steroid treatments, topicals,
radiation, and biologic therapies.
Slide 7:
You all know you wouldnt get out of this PowerPoint without a Table! Seriously, though, this just
reiterates everything we went over the last two slides, but you can review it at your leisure, you
can print it for your reference, and you can compare the information on the various forms of
malignancies. Thought it might help.
Slide 8:
Now that you know how to look for lesions and what they look like, lets talk about different ways
to test for and remove them. One method is curettage. This is the scooping of small, soft
tumors like basal and squamous cell carcinomas. Local anesthesia is used prior to the
procedure and localized bleeding may be controlled through cautery or pressure. Small scaring
may persist.
Punch and excisional biopsies are both done under local anesthetic. Because this implement is
sharper and less pliable then with curettage, it can be used on a wider variety or type of lesion
dependent on size. A punch biopsy is used for small lesions of about 0.5 cm or less. A sample
of the lesion would be obtained by twirling a device that resembles a stylet within the
practitioners fingers that ends up hollowing out a sample of the lesion that can then be sent off
for testing. Any bleeding is controlled as previously discussed with curettage and the same
scarring is expected. Excision biopsies, in comparison, remove the whole of the abnormal
tissue and some of the surrounding normal tissue. While this may be more time consuming as
slides are examined to ensure that tissue samples are returning with normal instead of
malignant cells, this ensures the better outcome for the patient. This is where some of you may
have hear the phrase clean margins utilized. This is in reference to a lesion removal with
normal tissue excision surrounding it, resulting in no abnormal pathology viewed under

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microscope, so the wound is closed because clean margins are visualized. If clean margins are
not seen, more tissue will be excised until clean margins are obtained. Depending on how much
tissue is removed and where the lesion is, the patient may have the wound closed, the wound
may have to heal via primary intention, or the patient may have to receive a skin graft.
Cryosurgery is the use of liquid nitrogen to freeze lesions off. Some of you may have even seen
over the counter versions of this for plantar wart therapy at home. Same principles, but this can
be done at higher levels for premalignant and malignant growths. The subzero temperatures
halts cellular growth and blood flow, thus necrosing the tissue. The tissue eventually falls off
and new skin grows in its place. Disadvantages of cryotherapy are that you cannot sample the
lesions that you are freezing and that you may damage surrounding tissue.
Slide 9:
Once again, the largest role the nurse can provide is education on the prevention of skin cancer.
Sun safety, tanning beds, nutrition to include protein and vitamins K, D, A, B, and C, skin
hygiene, mole checks, restful sleep habits, exercise to increase circulation to the skin and
mental outlook, and cautioning against self-treating with over-the-counter medications would be
valuable teaching points for skin health.
If your patient is to have a procedure, the role the nurse plays is that of any other procedure that
you have been taught up to this point, prep and educate the patient and family, ensure consent
is on the chart, medicate as appropriate and ordered. Post-procedure care may include wet to
dry dressings, special soaks, creams, or powders. Depending on the area being treated, too,
there may be some difficult areas to dress or keep intact. It can take a pretty ingenious nurse to
figure it out, but it can be done!
Pharmacologic interventions can include foams, sprays, creams, jellies, lotions, oils, ointments,
pastes, powders, solutions, and various other products. These may be used as an
antimicrobial, anti fungal, anti-inflammatory, antineoplastic, antipruritic (for itching), antiviral, for
debridement, local anesthetics, or as an emollient to soften the skin. Drugs that nurses use all
the time and that you may have seen before and not thought about fall into this category, such
as: aloe vesta skin cream for your patients skin care during bath time, EMLA topical cream prior
to a venipuncture, and a Betadine scrub before a surgical cut. Take a look at the Lilley reading p
901-915. You may be surprised at how many dermatologic drugs you recognize. Also, at the
end of the chapter, it does a nice, quick job of going over an impaired skin integrity care plan
with the implementation as it relates to pharmacology and teaching tips on the following page.
Useful information as there are always patients with creams and impaired skin integrity as you
are going about your clinical days.

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Something else to consider as you are reviewing your patients drug therapy are any
medications that may provide a warning in the drug book listed as photosensitivity.
Hydrochlorothiazide is one of them. Just to see what it would look like in the drug book I
happen to have Davis the 14th edition and on page 437 under Adverse Reactions/Side Effects
for Derm it list photosensitivity is regular letters, not bolded, not red, normal reaction type like
any other. If you turn your attention to the photo on the PowerPoint, that is a gentleman that has
had a reaction to sunlight after being started on hydrochlorothiazide. This can be a first dose
reaction. It should be a teaching point for your patients. You dont have to scare them, but you
should caution them about exposure to sunlight with their medication and what photosensitivity
means. Know where to find that in whatever drug reference you are using.
Lastly, malignancy can by psychologically devastating to begin with, let alone if there is any
disfigurement that accompanies it. Basal cell carcinoma, in particular, while it does not carry a
high mortality rate, it is highly disfiguring. This may weigh heavily on your patients mind.
Support groups, family, and faith are options for some patients for psychologic support. For
physiologic support, some cosmetics or prosthesis or cosmetic procedures cover lesions or their
removal.
Slide 10:
These last few slides we will go through fairly quickly because I am told you have had these
benign disorders in NUR 1213. As always, though, I am here to facilitate your learning, so if you
have questions or would like more information, please feel free to ask me when you see me.
Bacterial infections of the skin are primarily related to strep or staph. Major prevention involves
good hygiene and infection control. Those at higher risk would include patients with comorbid
conditions such as obesity, diabetes, steroid use, on antibiotics, or chronic diseases. Viral
infections are usually related to a herpes virus and the most common forms are simplex, zoster,
and warts. These lesions follow dermatomes and nerve pathways and quite painful so please
remember this for patient symptom management, as well as good infection control so that the
virus is not spread. Fungal infections are very embarrassing to patients. Candidia is common in
a variety of areas to include the mouth, skin, and vagina. Some of you may know it more
commonly as thrush or a yeast infection. Left untreated, however, it can be very painful and
spread systemically.
Infestations do happen. Im sure we have all heard stories, I know I have my own, about
patients coming in and needing to delouse them in some way shape or form. We are
professionals with professional poker faces and it is part of the care we provide. We also
provide care for any allergic reaction to bites they be experiencing and provide education on the
avoidance of another such infestation such as hygiene, self-exams, selection of sexual partners,
and a healthy living environment.

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Allergic reactions provide an opportunity to assess a family and personal history thoroughly.
Offer education to avoid any noted triggers. Offer further education to develop a plan of safety
for subsequent reaction attacks should they occur. Prep for and educate to allergy testing.
Slide 11:
Psoriasis is an auto-immune disorder that causes the rapid over growth of the epidermal cells
that leads to a build up of a scaly plaque. This in turn may make the patient self-conscious
about their appearance and withdraw from social contact.
Acne can become so severe and psychosocially damaging to teenagers that both topical and
oral medications are prescribed for the inflammatory lesions. Strong warnings accompany this
medication, however, in that it cannot be used if intending to become pregnant, near pregnant
women, if intending to donate blood, and it may cause liver damage.
Lipomas are benign, fatty tumors. These are most common in middle age. They are
compressible, mobile, they vary in size and become quite large. They are more common on the
trunk, neck, and forearms. They do not require treatment unless cosmetic or to rule out another
form of malignancy.
Lentigo is old age spots. It is an abnormal number of melanocytes in the basal layer of the
epidermis due to the normal aging process or due to sun exposure. These lesions will be dark
brown to black, flat, and found in sun-exposed areas. Follow the ABCDE criteria for progression
to ensure that they are indeed liver spots and not another form of lesion. Request a biopsy if
suspicious. No other treatment is necessary if lentigo other than laser resurfacing for cosmetic
purposes.
Slide 12:
What I did here was throw together a quick start to a nursing care plan. I know you do concept
mapping so yours would look a little different as you would have the patient in the center and
surround the patient with your objective and subjective supporting data, etc., but I wanted to give
you an idea of how to start tying some of this information together with finite start and stop
points.
If you look at the beginning you will see a medical diagnosis. You know we work in conjunction
with the rest of the medical team and we have to think of the medical diagnosis, but work within
our nursing scope of practice. Note that our patient has a suspected malignant melanoma so
perhaps testing has been done, but the definitive pathology has not returned as of yet.

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Moving down to the nursing diagnosis we have impaired tissue integrity, probably related to an
open surgical wound from the diagnostic testing site. As we move to the full nursing diagnosis,
we see this is true. Of course if we had more data, there would be more information filled in
here and this is not and should not be deemed an all inclusive or perfect plan. I just want to
show a couple of highlights over a few consistent areas I see overlooked frequently.
As you develop the plan for the patient, be sure to address the time frame. Your goals should
be within the time that you are going to be there to measure them. The goals should be
measurable. As you write the goals or interventions, they should be nursing and not medical.
They should be realistic. They should allow the patients plan of care to progress.
It would not have been realistic for me to write that my patient was going to be pain free at all
times. This patient has an open wound. I could ask my patient what a tolerable pain level is to
them and write that as their goal. Looking at #2 there could be a progression to a second
clinical day with the same patient. They verbalized the steps on the first day. My plan on the
second day then becomes for the patient to learn to change the dressing themselves, thus
propelling them towards discharge. By making nutrition a goal, not only do I promote wound
healing, but I get to educate the patient on protein for wound healing, hopefully to instill the
same process continues after discharge. We start these processes on day 1 not on day of
discharge. All the patient wants when you come with discharge paperwork is to have a
signature and a wheelchair to the door. They do not want to hear about protein and dressing
changes then. If we keep reinforcing it everyday they are there, it may stick.
And while we are on the subject of reinforcement, I want to just touch on the subject of
delegation of care. I know not many acute care settings are utilizing the skill of the LPN right
now in our immediate area. That being said, not all of you will practice here or in acute care.
You may work with LPNs. You will all also have to pass your boards where you may encounter
delegation questions. I am here to tell you, LPNs cannot assess, teach, nor evaluate
effectiveness of treatment. If the LPN is assigned to patients and assessing, the RN is legally
responsible to assess the same patients and sign the assessment. The RN must provide all
teaching and the LPN may reinforce the teaching the RN. The LPN may provide some
treatments, dressings, and medications depending on state standards, but the RN must
evaluate treatment effectiveness, whereas the LPN can monitor for changes. There is a
difference. I just wanted to clarify the delegation a little bit as you move towards your
management course, get closer to boards, and have had a few questions on it, and may see
more. Hope it helps.
Slide 13:
I always like to end with a little photo or encouragement of some sort. And as I was putting this
together I realized that this was probably the last little bit of work I was going to get to do with

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yall. I cant summarize that in a couple clip arts. But I did want to give some advice which you
can take or leave as you go out in the world as nurses.
Buy good nursing shoes, whatever they may be for you, and buy new ones at least once a year.
You will need your feet and your backs for the rest of your career. Be kind to them.
Stand tall as a nurse. Own your responsibility and your achievement proudly. You are important
everyday in every way. You touch and save lives like no one else can and have traveled a
journey that know one else can understand but the people sitting next to you as nurses. Be kind
to each other.
Remember the person under the label of patient always. Try not to assume things, try to find
time to hold a hand, try not to get so caught up in the tasks that you are taken away from your
art of nursing. Be kind to all.
I would like to thank each and every one of you for an incredible internship. I have learned so
much from you and I see inspired greatness amongst you. I appreciate you allowing me to be
part of your journey and I look forward to seeing you for a little bit more this term and again at
pinning in August.