01.06 Integumentary (Skin) Important Points

So there are a few other skin disorders that we want to highlight and give you some of the points you need to know, both to care for these patients, but also for exams and the NCLEX.

First, we want to point out a couple things you may see on your patients’ skin. The first is petechiae. We’ve talked about petechiae before when we talked about DIC and thrombocytopenia. They are small red spots that don’t change color and they’re very common in bleeding disorders. Essentially it’s a tiny spot of bleeding under the skin. So if you see petechiae, think about bleeding. The second is Keloid - a keloid is a thickened, irregular, dark area of scar tissue like you see here. This patient had a simple appendectomy, but the surgical scar is now a keloid scar. This is very common in darker skinned patients because of the higher levels of melanin.

Contact dermatitis. We can easily break this word down and figure out what it means, right? We know itis means inflammation, derm means skin - so, this is inflammation of the skin caused by contacting something. Typically it’s due to an allergic reaction of some sort. In this case, this child had an allergic reaction to poison ivy that touched its leg. It could be reddened with blisters like you see here, it could also have hives and vesicles, oozing, or scaling skin. First things first, we want to make sure we remove exposure to the allergen if possible and identify what it was. Then we’ll give topical corticosteroids like hydrocortisone cream. Remember corticosteroids help to decrease inflammation and slow the immune response. We could also give other topical agents like antibacterial ointment to prevent infection or an astringent to dry up any blisters or vesicles. We could even give a topical antihistamine to decrease that allergic histamine response. So, that’s contact dermatitis - again make sure you identify the allergen so the patient knows to avoid it in the future.

Next is frostbite. I’m sure you’ve heard of frostbite from TV or movies, and you see these guys climbing Mount Everest and their noses and toes are black and falling off, right? Well in the late stages of frostbite, that is a very real possibility. Frostbite happens because of excessive exposure to cold. When you’re cold your body will constrict all of the tiny blood vessels in your non-vital organs to try to keep the warm blood flowing to your vital organs - this means your arms and legs and your face and the rest of your skin tend to get the shaft. But, before they turn black and fall off, they’re going to be this silvery white color and might even blister or crack. Again, this is mostly the smallest areas of your body first and the ones farthest away from your heart. So we see it on fingers, toes, ears, and noses. Our goal for care is going to be to rewarm the area as quickly as possible with warm water and towels. Just remember the water will cool down over time so I usually use a fresh bucket of warm water every 15 minutes or so. The goal is to salvage as much tissue as possible by restoring circulation to that area.

Next is “mirsa”, or MRSA, or Methicillin Resistant Staphylococcus Aureus. If you’ve been in nursing school for at least 5 minutes I guarantee you’ve heard of this. It’s a drug-resistant superbug that patients can contract in the hospital. If it gets into a wound, it can absolutely wreak havoc. Not only is it damaging to the tissues but it’s very hard to treat. It’s also highly contagious and spread by contact, so we put patients in contact isolation. We wipe down all surfaces really really well. You shouldn’t even be taking your own stethoscope, pen light, etc. in to that room. Most facilities have disposable stethoscopes for isolation rooms. If you are forced to use your own stethoscope on a patient with MRSA, make sure you clean it THOROUGHLY with cavi wipes before you come out of the room. As far as wound care, we want to be very strict with these wounds in using sterile technique. If we get sloppy, we could allow the bacteria to spread to other places on their body. So it’s extremely important that if your patient has MRSA in their wounds, you need to take the right precautions to keep it from spreading.

Lastly, we want to talk about Stevens Johnson Syndrome. If you’ve been through pharmacology in nursing school or you’ve done our pharmacology course, you’ve probably heard of this syndrome. It is a drug induced skin reaction - essentially it’s a horrible life-threatening adverse reaction to a drug. When I was in pharmacology class over 10 years ago, I remembered them saying “it’s very rare, it’s very rare, you may not see this”. But I saw it half a dozen times in my first 2 years as a nurse! The most common drug that causes this is Bactrim DS. We give that for a UTI usually - so a lot of times you’ll see that common link here. So what happens in Stevens Johnson Syndrome is that the epidermis starts to separate from the dermis and slough off. Of course when that happens it causes inflammation and even some bleeding. It begins suddenly and spreads really quickly. If you are in a clinic or an emergency room and someone says they have this rash that just showed up on their chest yesterday and today it’s spread to their neck and shoulders - you need to suspect Stevens Johnson Syndrome. It spreads quickly and can begin to affect the face and inside of the mouth - causing a severe risk for airway compromise. We want to identify the cause and make sure we stop whatever drug caused it, and then we are going to care for the wounds. In most cases, because of this massive loss of epidermis, we can actually treat this like a burn because it’s very similar. We want to give antibiotics to prevent infection since we know we’ve lost their skin protective barrier against infection. And, we’re going to give steroids to decrease the swelling and stop that immune response to the drug. And we need to monitor their airway and their volume status, just like we would with a burn.

Our top concept for a patient with any of these skin conditions, of course is tissue/skin integrity. What we want you to see here is that there are SO many things that can cause a patient to have poor skin integrity or to be at risk for it. Remember the skin is a barrier against infection and it helps regulate temperature and hold fluids in, so any time there’s a tissue/skin integrity issue, we are considering those things, especially infection. We want to keep wounds clean ad do proper wound care, no matter what the type of wound is. We want to prevent further breakdown of skin, from whatever source. That’s the purpose of these concepts, guys, is to help you see patterns and big pictures for these patients. So any time you see a skin condition, you think tissue/skin integrity and can implement the right interventions.

So when it comes to skin, we want you to remember to assess their skin - a lot. We do detailed skin assessments on admission, with two nurses every shift change, and with every head to toe assessment. You should be assessing skin under their gown, take off their socks, lift up the blanket, look on their back. If you don’t, you’re going to miss something. Then, remember we always want to treat or remove the cause, like a drug or an allergen. And we want to do proper skin and wound care and isolate the patient if needed.

I know I said this in pressure ulcers, but we want you guys to be skin champions. We want you assessing skin like nobody’s business and taking such great care of your patients’ skin. The NRSNG family is going to be amazing skin-protecting nurses! Now, go out and be your best selves today. And, as always, happy nursing!