1. Skin Structure & Functions
The integumentary system comprises the epidermis, dermis, and subcutaneous layer.
Epidermis
- Keratinocytes (squamous cells): produce keratin (outer layer, hair, nails)
- Melanocytes: produce melanin; deficiency → albinism (congenital absence) or vitiligo (white patches)
- Appendages: hair, nails, sweat glands
- Eccrine glands: major sweat glands, present all over body
- Apocrine glands: primarily in axilla & pubis
Dermis
- Connective tissue containing blood vessels, nerves, and lymphatics
- Elasticity from collagen & elastin
Subcutaneous Layer
- Beneath dermis; loose connective tissue & fat cells
Nails
- Formed of keratin; normal angle ~160°
- Clubbing: >180°, drumstick appearance; seen in chronic hypoxia (COPD, cyanotic heart disease)
2. Diagnostic Tests
- Skin Biopsy: incisional, excisional, punch, shave; pre: hold anticoagulants; post: monitor for bleeding/infection, keep dry until healed
- Allergic Skin Tests: intradermal, patch test, scratch test, RAST (detects IgE antibodies)
- Tzanck's Smear: scraping of ulcer base to look for Tzanck cells (giant multinucleated cells) — indicated in herpes, chickenpox, CMV
- Wood's Lamp: UV light in dark room — normal scalp (purple fluorescence), Tinea capitis (greenish), head lice (white)
3. Primary Skin Lesions
| Lesion | Description |
|---|
| Macule | Flat, circumscribed, up to 2 cm |
| Papule | Elevated, < 1 cm |
| Nodule | Solid, elevated, extends into dermis |
| Wheal (hive) | Irregular superficial elevation (food allergies) |
| Vesicle (blister) | Serous fluid-filled, < 1 cm |
| Bulla | Blister > 1 cm |
| Pustule | Vesicle/bulla with purulent exudate |
Topical Preparations
- Emollients: glycerin, petrolatum, lanolin, vitamin A&D, Lubriderm
- Topical antibiotics: Bacitracin, Neomycin, Gentamicin, Mupirocin (Bactroban)
- Antipruritics: Calamine lotion, Burow's solution, corn starch, oatmeal bath
- Keratolytics: Salicylic acid, coal tar
4. Burns
Types by Source
- Thermal: hot metals, liquids (scalding), flame
- Smoke inhalation: erythema, hoarse voice, carbonaceous sputum, singed nasal hair, stridor, CO poisoning (CO has 200× affinity for Hgb vs O₂; death if CO > 50%)
- Chemical: acid, alkali, vesicant
- Electrical: high voltage/lightning → cardiac arrest, ventricular fibrillation
Burn Depth Classification
| Degree | Depth | Appearance | Pain |
|---|
| 1st (Superficial) | Epidermis only | Erythema, blanches on pressure, no vesicles | Very painful |
| 2nd (Superficial partial-thickness) | Epidermis & dermis | Vesicles, red, shiny, wet after rupture | Very painful |
| 3rd (Deep partial / Full thickness) | Epidermis, dermis, subcutaneous | Dry, edematous, deep red/black/white/brown, charred/leathery | Little or none |
| 4th (Deep full thickness) | All layers + muscle, tendon, bone | White/brown/black, charred, hard inelastic eschar | None |
Rule of Nines (TBSA)
- Adults: Arms 9% each, Legs 18% each, Trunk 36%, Head 9%, Perineum 1%
- Children (Lund & Browder): Head 18–19%, Trunk 32%, Each leg 15%, Each arm 9.5%
Burn Pathophysiology
- Vasoactive substances (histamines, catecholamines, prostaglandins) released → ↑ capillary permeability → plasma leaks → edema
- Capillary permeability decreases by 18–36 hr
- Hypovolemia → ↓ tissue perfusion → organ failure (renal, ileus)
- ↑ Hct temporarily (hemoconcentration), then ↓ day 3–4 from hemolysis
- Initially hyponatremia & hyperkalemia; when fluid returns (3–5 days) → hypokalemia
- Death first 48 hr → fluid/electrolyte disturbance; after 48 hr → sepsis
Phases of Burn Care
Emergent Phase: RACE (Rescue → Alarm → Confine → Extinguish). Remove constricting jewelry; wrap in clean sheet; initiate IV; insert Foley (goal 30–50 mL/hr urine). CO poisoning → 100% O₂ non-rebreather.
Shock / Oliguric Phase (first 48 hr): hypovolemia, hyponatremia, hyperkalemia, metabolic acidosis, ↑ Hct. Focus = fluid resuscitation.
Diuretic / Fluid Remobilization Phase: interstitial fluid returns → diuresis, ↑ BP, ↑ urine output; hyponatremia & hypokalemia.
Convalescent / Rehabilitation Phase (until ~12 months after healing): wound closure, scar management, pressure garments, physical therapy.
Fluid Resuscitation — Parkland Formula
Parkland (Baxter) Formula:
4 mL RL × kg body weight × % TBSA burn = total fluid for 1st 24 hr
First half given in first 8 hours (from time of burn, not admission)
Second half given over next 16 hours
Colloids started after first 24 hours
Wound Care
- Surgical debridement / Chemical (enzymatic) debridement: Collagenase (Santyl), Dextranomer (Debrisan)
- Hydrotherapy: special tub for wound care, ≤ 30 min immersion
- Topical antibiotics: Mafenide (Sulfamylon) — S/E: pain, rash, metabolic acidosis; Silver Sulfadiazine (Silvadene) — S/E: leukopenia; Silver nitrate — stains black/grey; Nitrofurazone (Furacin)
- Systemic antibiotics: Gentamycin — nephrotoxic, ototoxic
- Analgesics (narcotics) 30 min before wound care; tetanus prophylaxis
- Skin grafting; pressure garments for hypertrophic scarring
Burn Complications
- Circumferential thoracic burn → pulmonary insufficiency
- Circumferential extremity burn → compartment syndrome
- Facial burn → corneal abrasion; ear → auricular chondritis; perineal → auto-contamination
- Curling ulcer (stress ulcer) → give prophylactic antacids & antihistamines to keep gastric pH > 5
- Paralytic ileus → continuous NG suction
Burn Nursing Care
- Pain management before wound care; schedule wound care ≥ 1 hr before meals
- Monitor electrolyte balance; hourly urine output via Foley (minimum 30 mL)
- Nutrition: NG or TPN initially; high-calorie, high-protein, high-carb with vitamin/mineral supplements
- Prevent Curling ulcer & paralytic ileus
5. Pressure Ulcers
Staging
Stage I: Intact skin, non-blanchable redness; returns to normal after 15–20 min of pressure relief
Stage II: Partial-thickness skin loss; red-pink wound or serum-filled blister; white/yellow eschar possible
Stage III: Full-thickness loss into dermis & subcutaneous tissue; white/yellow/grey eschar; undermining/tunneling possible; purulent drainage common
Stage IV: Deeper, extends into muscle & bone; brown/black eschar; undermining/tunneling; purulent, foul-smelling drainage
Unstageable: Full-thickness covered by eschar or extensive necrotic tissue
Suspected Deep Tissue Injury (DTI): Purple/maroon discolored intact skin
Risk Assessment Scales
- Norton Scale — assesses physical condition, mental state, activity, mobility, incontinence
- Braden Scale — sensory perception, moisture, activity, mobility, nutrition, friction/shear
Wound Care
- Non-infected: clean from center → periphery; Infected: clean from periphery → center
- Enzymatic debridement: Collagenase (Santyl), Elase, Dextranomer (Debrisan)
- Enzymes to promote healing: Papain (Panafil), Hyaluronidase (Wydase)
- Wound protectives: DuoDerm (hydrocolloid), Tegasorb, Tegaderm, ZnO₂ paste, Benzoin
- Non-adherent dressings: Petrolatum, Xeroform, Adaptic, Telfa, Sofsorb, Calcium alginate
- Wet-to-dry dressing: for oozing lesions with slough; removes eschar when dry dressing is pulled off
- Wound VAC: negative pressure wound therapy at −125 mmHg; major complication = bleeding
- Nutrition: additional protein, vitamin C, multivitamins, Zn sulfate/gluconate
- Turn & position q2h; special mattresses; Montgomery straps to minimize tape irritation
6. Skin Cancers
| Type | Features |
|---|
| Basal Cell Epithelioma | Most common; between hairline & upper lip; classic pearly texture; rarely metastasizes |
| Squamous Cell Carcinoma | Mucous membranes, lower lip, neck, dorsum of hands; can metastasize |
| Malignant Melanoma | Least frequent but most serious; high metastatic potential |
Precancerous Lesions
- Leukoplakia: white shiny patches in mouth / on lips
- Nevus: may change color to black or bleed
- Senile keratosis (Seborrheic keratosis): brown scaly spots on older individuals
Risk Factors
- Caucasians, blue eyes, red hair, blondes; UV exposure; high number of moles; immunosuppression
Management
- Surgical excision ± radiation; chemotherapy & immunotherapy for melanoma; cryotherapy (liquid nitrogen)
- Prevention: PABA-containing sun block with adequate SPF
7. Cellulitis
Localized or diffuse inflammation of connective tissue involving dermal & subcutaneous layers. Caused by normal skin flora or exogenous bacteria. Often where skin was broken (cracks, cuts, blisters, burns, insect bites, surgical wounds, IV sites).
Findings
- Skin appears red, hot, tender
- May resemble DVT — differentiated by ultrasound (↓ circulation in DVT)
Risk Factors
- Elderly, immunodeficiency, chronic venous insufficiency, varicose veins
Management
- Antibiotics based on C&S; pain management; warm compress
8. Herpes Zoster (Shingles)
Reactivation of varicella zoster virus (VZV) — same virus causing chickenpox. Affects cranial & spinal sensory nerve ganglia. Contagious to anyone who hasn't had varicella or who is immunosuppressed.
Findings
- Neuralgic pain, itching, burning
- Cluster of vesicles along peripheral sensory nerves; usually unilateral, primarily trunk, thorax, or face
Complications
- Deafness, vision loss, facial palsy, trigeminal neuralgia
Management
- Antiviral: Acyclovir (Zovirax)
- Neuralgic pain: Gabapentin (Neurontin), Carbamazepine (Tegretol), Pregabalin (Lyrica)
- Corticosteroids; acetic acid compresses (anti-pseudomonal); vaccine: Zostavax
- Contact precautions — contagious until lesions crust over
9. Contact Dermatitis & Psoriasis
Contact Dermatitis
- Delayed hypersensitivity from prolonged allergen exposure (chemical, biologic, mechanical)
- Examples: diaper rash, latex allergy
- Findings: pruritus, erythema, vesicles → rupture → crust → scale
- Management: antipruritics (Burow's solution), avoid causative agent, topical steroids/antibiotics, mild soap (Dove/Ivory), avoid wool/nylon/fur, soak affected area in plain water 20–30 min
Psoriasis
- Chronic dermatitis with rapid epidermal cell turnover; possibly autoimmune; stress/trauma/infection can trigger exacerbation
- Findings: silvery white scaling plaques (scalp, elbows, knees), yellow nail discoloration, pruritus, Koebner's phenomenon
- Management: topical corticosteroids, coal tar, PUVA therapy (UVA + Psoralen), Methotrexate (Folex), intralesional steroids (Triamcinolone/Kenalog), Anthralin, Salicylic acid, Adalimumab (Humira)
- Nursing: protect coal tar area from sunlight 24 hr; occlusive wrap over steroids; stress reduction; discourage scratching
10. Skin Grafting
Graft Sources
- Autograft: patient's own skin (e.g., thigh)
- Isograft: genetically identical donor (identical twin)
- Homograft / Allograft: cadaver of same species
- Heterograft / Xenograft: another species (porcine/pig, bovine/cow, equine/horse)
- Human amniotic membrane
Pre-Op Care
- Donor site: antiseptic soap wash night before & day of surgery
- Recipient site: warm compresses & topical antibiotics
Post-Op Care
- Donor site: keep covered 24–48 hr; bed cradle to prevent pressure; outer dressing removed at 24–48 hr; inner fine-mesh Vaseline gauze left until it falls off; donor site more painful than recipient site
- Recipient site: elevate if possible; protect from pressure with bed cradle; warm compresses; monitor for hematoma/fluid accumulation; monitor circulation distal to graft
- Discharge: lubricating lotion for 6–12 mo; protect from direct sun for ≥ 6 months; report changes in graft appearance; sweating lost in most grafts; sensation may/may not return
11. NCLEX Priorities
🟡 Top NCLEX Priorities — Integumentary
- Burn — first action: remove from source, establish airway (especially with smoke inhalation), give 100% O₂ if CO poisoning suspected
- Parkland formula: 4 mL RL × kg × % TBSA; give first half in first 8 hours from time of burn
- Curling ulcer: stress ulcer in burn patients — give prophylactic antacids & antihistamines; keep gastric pH > 5
- Circumferential burns: high risk for compartment syndrome — monitor distal pulses; prepare for escharotomy/fasciotomy
- Silver Sulfadiazine (Silvadene): most common topical for burns; S/E includes leukopenia
- Mafenide (Sulfamylon): causes metabolic acidosis — monitor ABGs
- Pressure ulcer staging: know the difference — Stage I (intact, non-blanchable) vs Stage II (partial thickness, blister) vs Stage III/IV (full thickness, depth)
- Wound VAC: negative pressure at −125 mmHg; monitor for bleeding as major complication
- Herpes Zoster: contact precautions until lesions crust; antivirals (Acyclovir) within 72 hr for best effect; neuralgic pain treated with gabapentin
- Malignant melanoma: ABCDE — Asymmetry, Border irregular, Color variation, Diameter > 6 mm, Evolution/changing
- Skin graft donor site: more painful than recipient site; inner dressing left to fall off on its own
- Cellulitis vs DVT: cellulitis has erythema, warmth, tenderness; DVT shows diminished circulation on ultrasound
- Psoriasis PUVA therapy: protect eyes with goggles; avoid sunlight 24 hr after coal tar