Angelite Nurses

Health History

1. Presenting problem: symptoms may include changes in color or texture of skin, hair, nails; pruritus; infections; tumors; lesions; dermatitis; ecchymoses; rashes; dryness
2. Life-style: hygienic practices (skin-cleansing measures, use of cosmetics [type, brand names]); skin exposure (duration of exposure to sun, irritants [occupational], cold weather)
3. Nutrition/diet: intake of vitamins, essential nutrients, water; food allergies
4. Use of medications: steroids, vitamin use, hormones, antibiotics, chemotherapeutic agents
5. Past medical history: renal, hepatic, or collagen diseases; trauma or surgery; food, drug, or contact allergies
6. Family history: diabetes mellitus, allergic disorders, blood dyscrasias, specific dermatologic problems, cancer

Physical Examination

1. Color: note areas of uniform color; pigmentation; redness, jaundice, cyanosis.
2. Vascular changes
1. Purpuric lesions: note ecchymoses, petechiae.
2. Vascular lesions: note angiomas, hemangiomas, venous stars.
3. Lesions: note color, type (see Disorders of the Integumentary System), size, distribution, location, consistency, grouping (annular, circular, linear, or clustered).
4. Edema: differentiate pitting from nonpitting.
5. Moisture content: note dryness, clamminess.
6. Temperature: note whether increased or decreased, distribution of temperature changes.
7. Texture: note smoothness, coarseness.
8. Mobility/turgor: note whether increased or decreased.

Laboratory/Diagnostic Studies

1. Blood chemistry/electrolytes: calcium, chloride, magnesium, potassium, sodium
2. Hematologic studies: Hbg, hct, RBC, WBC
3. Biopsy
1. Removal of a small piece of skin for examination to determine diagnosis
2. Nursing care: instruct client to keep biopsied area dry until healing occurs
4. Skin testing
1. Administration of allergens or antigens on the surface of or into the dermis to determine hypersensitivity
2. Three types: patch, scratch, and intradermal

Goals

1. Restoration of skin integrity.
2. Client will experience absence of pain.
3. Client will adapt to changes in appearance.
4. Client will be free from infection.
5. Maintenance of effective airway clearance.
6. Maintenance of adequate peripheral tissue perfusion.

Interventions


Skin Grafts

1. Replacement of damaged skin with healthy skin to provide protection of underlying structures or to reconstruct areas for cosmetic or functional purposes
2. Graft sources
1. Autograft: client's own skin
2. Isograft: skin from a genetically identical person (identical twin)
3. Homograft or allograft: cadaver of same species
4. Heterograft or xenograft: skin from another species (such as a porcine graft)
5. Human amniotic membrane
3. Nursing care: preoperative
1. Donor site: cleanse with antiseptic soap the night before and morning of surgery as ordered.
2. Recipient site: apply warm compresses and topical antibiotics as ordered.
4. Nursing care: postoperative
1. Donor site
1. Keep area covered for 24-48 hours.
2. Use bed cradle to prevent pressure and provide greater air circulation
3. Outer dressing may be removed 24-72 hours postsurgery; maintain fine mesh gauze (innermost dressing) until it falls off spontaneously.
4. Trim loose edges of gauze as it loosens with healing.
5. Administer analgesics as ordered (more painful than recipient site).
2. Recipient site
1. Elevate site when possible.
2. Protect from pressure (use bed cradle).
3. Apply warm compresses as ordered.
4. Assess for hematoma, fluid accumulation under graft.
5. Monitor circulation distal to graft.
3. Provide emotional support and monitor behavioral adjustments; refer for counseling if needed.
5. Provide client teaching and discharge planning concerning
1. Applying lubricating lotion to maintain moisture on surfaces of healed graft for at least 6-12 months
2. Protecting grafted skin from direct sunlight for at least 6 months
3. Protecting graft from physical injury
4. Need to report changes in graft (fluid accumulation, pain, hematoma)
5. Possible alteration in pigmentation and hair growth; ability to sweat lost in most grafts
6. Sensations may or may not return