NCLEX: Skin disorders

A look at skin disorders

As the body’s main protective system, the skin’s various functions include sensory perception, regulation of temperature, prevention of water and electrolyte loss, and excretion. Nursing care for skin disorders requires careful examination and observation, prevention of infection, and hands-on treatment regimens, such as topical application of medication and wound debridement.

Anatomy and physiology

The skin (integument) covers the body’s internal structures and protects them from the external world. The skin has two distinct layers:
• The epidermis, or outer layer, is made up of squamous epithelial tissue, which itself contains several layers—the stratum corneum, stratum lucidum, stratum spinosum, and stratum basale.
• The dermis, the deeper second layer, consists of connective tissue and an extracellular material called matrix, which contributes to the skin’s strength and pliability. The dermis contains and supports the blood vessels, lymphatic vessels, nerves, and sweat and sebaceous glands and serves as the site of wound healing and infection control. Beneath the dermis lies the subcutaneous tissue.

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Value-added appendages

Numerous epidermal appendages occur throughout the skin. They include the hair, nails, sebaceous glands, and sweat glands. The two types of sweat glands are the apocrine glands (found in the axillae and groin near hair follicles) and the eccrine glands (located over most of the body except the lips).

Skin functions

The skin performs many functions, including:
• protecting the tissues from trauma and bacteria
• preventing loss of water and electrolytes from the body
• allowing temperature, pain, touch, and pressure sensation
• regulating body temperature through sweat production and evaporation

• synthesizing vitamin D
• promoting wound repair by intensifying normal cell replacement mechanisms.


Skin disorders may involve or stem from disorders that originate in other body systems. During your assessment, be sure to investigate even minor symptoms and systemic complaints.


Begin the assessment by taking a thorough history. With a skin disorder, expect the patient to report such problems as changes in the skin’s appearance, pruritus (itching), pain, or drainage from lesions.

Current health status
Ask these questions to elicit information about the patient’s chief complaint:
• How long have you had this problem? When did it begin? Have you had it before?
• What does the problem area look like, including its shape, size, color, location, character, and distribution?
• Is the area painful? Tender? Numb? Warm?
• Does anything seem to trigger the problem (such as stress, menstruation, or sunlight exposure)? Does anything make it worse? Does anything relieve it?
• Have you had recent contact with detergents, chemicals, or plants?
• Did you recently change soaps or skin care products?
• Have you tried using anything to make the condition feel better, such as compresses, lotions, or over-the-counter preparations?

Previous health status
Ask whether the patient has ever had a similar skin condition. (Some skin disorders, such as psoriasis, can recur.) Find out if he has ever had an allergic reaction to medication, food, or other substances (such as cosmetics). Past and present allergies—including those caused by cutaneous, ingested, or inhaled allergens—may predispose a patient to other skin disorders. Also find out if the patient has a history of diabetes mellitus, vascular problems, or immunodeficiency.

Family history
Some skin disorders, such as atopic dermatitis, acne, and psoriasis, tend to run in families. Contagious skin problems, such as scabies, may be transmitted by family members. Ask the patient if anyone in his family has had a skin problem. If so, what was it and when did it occur?
Allergies may also run in families. Find out if any family members have allergies. If so, what are they and how have they been treated?

Social history
Obtain relevant information about the patient’s lifestyle, including occupation, travel, diet, hobbies, smoking, alcohol and drug use, sun exposure, stress, and sexual contact.

Physical examination

Start by observing the overall appearance of the patient’s skin to identify areas that need further assessment. Then inspect and palpate the skin one area at a time, focusing on color, texture, turgor, moisture, and temperature. Be sure to check for and note skin lesions.

Look for localized areas of ecchymosis (bruising), cyanosis, pallor, and erythema (redness). Check for color uniformity and for areas with darker or lighter pigmentation than the rest of the patient’s body. Remember that color changes may vary depending on skin pigmentation.

Texture and turgor
Inspect and palpate the skin’s texture, noting its thickness and mobility. It should look smooth and be intact.

Turgor on trial

Assess turgor by gently grasping and pulling up a fold of skin, releasing it, and observing how quickly it returns to normal shape. Normal skin will resume its flat shape immediately.

Observe the skin’s moisture content. The skin should be relatively dry, with a minimal amount of perspiration. Skin-fold areas also should be fairly dry.

Palpate for skin temperature by using the back (dorsal surface) of your fingers or hands, which are most sensitive to temperature perception. The skin should feel warm to cool, and areas should feel the same when compared bilaterally.

Whenever you see a skin lesion, evaluate it to determine its origin. Start by classifying it as primary or secondary. A primary lesion is a change in the skin’s color or texture that can stem from environmental factors, allergic reactions, or infectious diseases, or may even be present from birth.

Collateral damage

Secondary lesions result from changes to primary lesions due to natural progression or from external factors, such as trauma or manipulation.
• Measure and record the lesion’s size, shape or configuration, color, degree of elevation or depression, pedunculation (connection to the skin by a stem or stalk), and texture.
• Evaluate the lesion’s odor, color, consistency, and amount of exudate.
• Assess the lesion’s distribution pattern, including the extent and pattern of involvement. Note the location of the lesion or lesions, such as on a specific dermatome (cutaneous areas of peripheral nerve innervation), on flexor or extensor surfaces, in skin folds, on clothing or jewelry lines, or on palms or soles—or whether lesions appear randomly.
• Accurately describe the arrangement of lesions to help determine their cause. Is each lesion discrete? Are the lesions grouped? Do they merge together? Are they diffuse? Linear? Annular (ring shaped)? Arciform (curved or arced)? Do the lesions revolve around a fixed point (gyrate)?

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Diagnostic tests

Several studies can help differentiate among integumentary disorders. They include the patch test, potassium hydroxide (KOH) preparation, skin biopsy, and the Tzanck test.

Patch test

The patch test identifies the cause of allergic contact sensitization. Indicated in patients with suspected allergies or allergies from an unknown cause, this test uses a sample of common allergens, or antigens, to determine if one or more will produce a positive reaction. If the doctor suspects a particular causative agent, he may test it for a positive reaction.

Nursing considerations
• If the patient has an acute inflammation, postpone the patch test until the inflammation subsides because a patch test may worsen it.
• Apply the patch to normal, hairless skin on the back or on the inner surface of the forearm.
• Instruct the patient to leave the patch in place for 48 hours—but to remove it immediately if pain, itching, or irritation develops.
• Check findings after removing the patch, and then recheck 48 hours later for a delayed reaction.

Potassium hydroxide preparation

KOH preparation helps identify fungal skin infections. It involves scraping scales from the skin, mixing them with a few drops of 10% to 25% KOH on a glass slide, and then lightly heating the slide. Skin cells lyse, leaving fungal elements (hyphae and spores) visible on microscopic examination.

Nursing considerations
• Gently scrape the border of a rash or skin lesion with a sterile scalpel blade to obtain a specimen. After scraping, inspect the area for bleeding and apply light pressure, if necessary.
• Tell the patient that the KOH preparation may identify a fungal infection—but because the test may be inconclusive, he should comply with treatment until fungal culture results are known.

Skin biopsy

During a skin biopsy, a small piece of tissue from a suspected malignancy or other skin lesion is excised. One of three techniques—excision, shave, or punch—may be used to secure the specimen.
• An excision biopsy removes a small lesion in its entirety. This technique is indicated for rapidly expanding lesions; sclerotic, bullous, or atrophic lesions; and examination of the border of a lesion and surrounding normal skin.
• A shave biopsy cuts the lesion above the skin line, leaving the lower dermal layers intact.
• A punch biopsy removes an oval core from the center of a lesion.

Nursing considerations
• Explain to the patient that he’ll first receive a local anesthetic.
• After the procedure, apply pressure to the biopsy site to stop bleeding, if necessary, and apply a dressing.
• After the biopsy specimen is obtained, place it in a container with 10% formaldehyde solution.
• If the patient has sutures, instruct him to keep the area clean and as dry as possible. Tell him when the sutures will be removed.
• If the patient has adhesive strips, instruct him to leave them in place for 14 to 21 days.

Tzanck test

In the Tzanck test, vesicular fluid or exudate from an ulcer is smeared on a glass slide and stained with Papanicolaou’s, Wright’s, Giemsa, or methylene blue stain. Herpesvirus is confirmed if microscopic examination of the slide reveals multinucleated giant cells, intranuclear inclusions, and ballooning degeneration.

Nursing considerations
• To obtain a specimen for staining, unroof an intact vesicle and, using a sterile scalpel blade, scrape the base of the lesion to obtain fluid and skin cells. Apply the specimen to a glass slide, allow it to air dry, and then stain.

• Always wear gloves while obtaining the specimen because herpesvirus is transmissible.


Usually, treatment for skin disorders involves hands-on care. Most medications are applied topically. Surgery is usually performed with only a local anesthetic, and monitoring depends less on laboratory tests than on simple observation.

Drug therapy

Categories of drugs used to treat skin disorders include:
• anti-infectives, such as acyclovir (Zovirax), bacitracin, clotrimazole (Lotrimin AF), lindane, and mupirocin
• astringents, such as aluminum acetate and calcium acetate
• topical corticosteroids, such as hydrocortisone (Cortaid) and triamcinolone (Kenalog)
• demulcents, emollients, and protectants, such as calamine, oatmeal, and para-aminobenzoic acid
• keratolytics, such as podophyllum and salicylic acid
• miscellaneous agents, such as acitretin (Soriatane), i sotretinoin (Sotret), topical minoxidil (Rogaine), selenium sulfide, and tretinoin ( Retin-A).


Surgical techniques used to treat skin disorders include cryosurgery, laser surgery, Mohs’ micrographic surgery, and skin grafting.

Cryosurgery is a common procedure in which extreme cold is applied to the skin to induce tissue destruction. Cryosurgery causes epidermal-dermal separation above the basement membranes, helping to prevent scarring after reepithelialization.

Simple to sophisticated

The procedure can be performed quite simply, using nothing more than a cotton-tipped applicator dipped in liquid nitrogen and applied to the skin, or it may involve a complex cryosurgical unit.

Patient preparation
Before the procedure, take these steps:
• Ask the patient if he has any allergies or hypersensitivities, especially to iodine or cold.
• Tell him he’ll initially feel cold, followed by a burning sensation, during the procedure.

Monitoring and aftercare
After the procedure, take these steps:
• After cryosurgery, clean the area gently with a cotton-tipped applicator soaked in hydrogen peroxide.
• If necessary, apply an ice bag to relieve swelling and give the patient an analgesic, as ordered, to relieve pain.

Home care instructions
Before discharge, give the patient these instructions:
• Tell the patient that he should expect pain, redness, and swelling, and that a blister will form within 24 hours of treatment. The blister may be large, and it may bleed. Usually, it flattens within a few days and sloughs off in 2 to 3 weeks. Serous exudation may follow during the first week, and a crust or a dry scab may develop.

Don’t touch!

• To promote healing and prevent infection, warn the patient not to touch the blister. Tell him that if the blister becomes uncomfortable or interferes with daily activities, he should call the practitioner, who can decompress it with a sterile blade or pin.
• Tell the patient to clean the area gently with soap and water, alcohol, or a cotton-tipped applicator soaked in an anti-infective agent, as ordered.
• To prevent hyperpigmentation, instruct him to cover the wound with a loose dressing when he’s outdoors. After the wound heals, he should apply a sunblock over the area.

Laser surgery
Laser surgery uses the intense, highly focused light of a laser beam to treat dermatologic lesions. Performed on an outpatient basis, laser surgery spares normal tissue, promotes faster healing, and helps prevent post-surgical infection.

Patient preparation
Before the procedure, take these steps:
• If the surgical suite has windows, keep shades or blinds closed. Cover reflective surfaces and remove flammable materials.

• Make sure everyone in the room, including the patient, is wearing safety goggles, because reflection of the laser beam may damage the eyes.

Monitoring and aftercare
After the procedure, apply direct pressure over any bleeding wound for 20 minutes. Initial wound care varies with the procedure.

Home care instructions
Before discharge, give the patient these instructions:
• Tell the patient to dress the wound daily. Permit him to take showers, but advise him not to immerse the wound site in water.
• If bleeding occurs, instruct the patient to apply direct pressure on the site with clean gauze or a washcloth for 20 minutes. If pressure doesn’t control the bleeding, he should call the doctor immediately.
• To avoid pigmentation changes, caution the patient to protect the wound from sun exposure.

Mohs’ micrographic surgery
Mohs’ micrographic surgery involves serial excision and histologic analysis of cancerous or suspected cancerous tissues. By allowing step-by-step tumor excision, Mohs’ surgery minimizes the size of the scar (important if the treatment is done on the face) and helps prevent recurrence by removing all malignant tissue. This surgery is especially effective in basal cell carcinomas.


Support for scarring

Mohs’ surgery has two common complications: bleeding and facial scarring. Bleeding is easily controlled with direct pressure. The potentially devastating psychological effects of a large facial scar or defect are harder to treat and require considerable emotional support.

Patient preparation
Before the procedure, take these steps:
• Make sure the patient understands that the procedure usually takes many hours, most of which will be spent waiting for histologic results.
• Explain that the doctor will use electrocauterization to control bleeding and that a grounding plate will be affixed to the patient’s leg or arm to complete the circuit between the cautery pencil and generator. Warn him to expect a burning odor.

Monitoring and aftercare
After the procedure, take these steps:
• Assess the patient’s level of pain, and provide an analgesic, as ordered.

• Periodically check for excessive bleeding. If it occurs, remove the dressing and apply pressure over the site for 20 minutes.

Home care instructions
Before discharge, give the patient these instructions:
• Tell the patient to leave the dressing in place for 24 hours and to change the dressing daily afterward.
• If he experiences frank bleeding, advise him to reinforce the bandage and apply direct pressure to the wound for 20 minutes, using clean gauze or a clean washcloth. If this measure doesn’t control bleeding, he should call the practitioner.
• Instruct the patient to report signs or symptoms of infection.
• Advise him to refrain from alcohol, aspirin, and excessive exercise for 48 hours to prevent bleeding and promote healing.
• Recommend acetaminophen (Tylenol) for discomfort.

Skin grafting
Skin grafting covers defects caused by burns, trauma, and surgery.
This procedure is indicated:
• to repair surgical defects when primary closure isn’t possible or desirable
• to cover areas denuded of skin.
Grafting may be done using a general or local anesthetic. It can be performed on an outpatient basis for small facial or neck defects.

Getting graphic about grafts

Types of skin grafts include:
• split-thickness grafts, which consist of the epidermis and a small portion of dermis
• full-thickness grafts, which include all of the dermis as well as the epidermis
• composite grafts, which also include underlying tissues, such as muscle, cartilage, or bone.

Patient preparation
Before the procedure, take these steps:
• Because successful skin grafting begins with a good graft, preserve potential donor sites by providing meticulous skin care.
• Assess the recipient site. The graft’s survival depends on close contact with the underlying tissue. Ideally, the recipient site should consist of healthy granulation tissue free from eschar (a dry crust or thick scab appearing after a burn), debris, or the products of infection.

Monitoring and aftercare
After the procedure, your primary role is to ensure graft survival.
• Position the patient so that his graft site is protected. If possible, keep the graft area elevated and immobilized.
• Modify your nursing care to protect the graft. For example, never use a blood pressure cuff over a graft site.

Keep it clean

• Use sterile technique when changing the dressing, and work gently to avoid dislodging the graft.
• Keep the donor site clean, dry, and protected.

Home care instructions
Before discharge, give the patient these instructions:
• Advise the patient not to disturb the dressings on the graft or donor sites for any reason. If they need to be changed, instruct him to call the practitioner.
• If grafting was done as an outpatient procedure, stress that the graft site must be immobilized to promote proper healing.
• After the graft has healed, instruct the patient to apply an emollient cream to the site several times daily to keep the skin pliable and aid scar maturation.
• Because sun exposure can affect graft pigmentation, advise the patient to limit his time in the sun and to use a sunblock on all grafted areas.
• Explain that when scar maturation is complete, the practitioner may use other plastic surgery techniques to improve graft appearance.


Debridement may involve mechanical, chemical, or surgical techniques to remove necrotic tissue from a wound. Although debridement can be extremely painful, it’s necessary to prevent infection and promote healing of burns and skin ulcers.

Mechanical debridement
Mechanical debridement consists of wet-to-dry dressings, irrigation, hydrotherapy, and bedside debridement.
• Wet-to-dry dressings are appropriate for partially healed wounds with only slight amounts of necrotic tissue and minimal drainage.
• Irrigation of a wound with an antiseptic solution cleans tissues and removes cell debris and excess drainage.
• Hydrotherapy (commonly called “tubbing” or “tanking”) involves immersing the patient in a tank of warm water, which is agitated intermittently. Hydrotherapy is often performed on burn patients.
• Bedside debridement of a burn wound involves careful prying and cutting of loosened eschar with forceps and scissors to separate it from viable tissue beneath. One of the most painful types of debridement, it may be the only practical way to remove necrotic tissue from a severely burned patient.

Chemical debridement
In chemical debridement, topical debriders are used to absorb exudate and particulate debris. These agents also absorb bacteria, thus reducing the risk of infection.

Surgical debridement
Surgical debridement is done under general or regional anesthesia. It provides the fastest and most complete debridement, but it’s usually reserved for burn patients or those with extremely deep or large ulcers. It’s commonly performed with skin grafting.

Patient preparation
Before the procedure, take these steps:
• Explain the type of debridement the patient will undergo. Reassure him that he’ll receive an analgesic if needed.
• If ordered, give analgesics 20 minutes before the procedure.

Monitoring and aftercare
After the procedure, take these steps:
• Assess the patient’s pain, and provide analgesics, as ordered.
• During dressing changes, note the amount of granulation tissue, necrotic debris, and drainage. Watch for signs of wound infection.
• If the patient’s arm or leg was debrided, keep it elevated to promote venous return—especially if the patient has a stasis ulcer.

Home care instructions
Before discharge, take these steps:
• Teach the patient how to perform dressing changes if appropriate.
• Instruct him to watch for and report signs or symptoms of infection or poor healing.

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