Table 6.

Nursing Management for Skin Conditions

Patient Problem	Nursing Management	Patient Education
Anxiety r/t Diagnoses Treatment Prognosis	Assess the patient’s level of understanding of the disease, treatment, and prognosis Provide the patient with opportunities to verbalize concerns and questions Provide the patient with understanding of what to expect Assess patient’s ability to cope and effective past coping strategies Assess support systems Assess for signs and symptoms of anxiety Administer medications to decrease anxiety as ordered Monitor changes in level of anxiety Provide a calm reassuring environment	Instruct patient/caregiver: What to expect Signs and symptoms of anxiety What increases their anxiety Strategies to minimize anxiety, including relaxation exercises, mediation, distraction Ways to decrease environmental stimuli When to notify a healthcare professional
Fatigue	Assess for fatigue Assess ability to perform ADLs Assess for contributing factors: pain, emotional distress, sleep disturbances, anemia, nutritional status, and comorbidities Screen for potential etiologic factors Monitor blood counts (CBC, Hgb, and HCT) Transfuse prn Develop an exercise program appropriate to the patient’s condition Encourage rest as needed Consider physical therapy, nutrition, or psychosocial referral	Instruct the patient regarding The signs and symptoms of fatigue Practicing energy conservation, including setting priorities, planning and pacing activities, delegating, scheduling activity at peak energy time, napping, structured routine, and distraction
High risk for infection r/t alteration in skin	Monitor blood counts (CBC with diff) Assess skin and wound site for drainage Monitor for signs and symptoms of infection Monitor vital signs Administer antibiotics, antifungals, antiviral, and antipyretic as ordered Monitor for CMV and reactivation of HSV, VZV	Instruct the patient/caregiver regarding: The signs and symptoms of infection/healing The increased risk of infection Wound care When to notify the health care professional Long term steroid use with GVHD and the risk of infections
	Obtain culture and sensitivity as ordered - If the patient’s wound exhibits signs of infection or the wound are not healing a culture should be taken after obtaining an order. This would allow the team to identify the organism and the appropriate antibiotic to treat the infection. It is important to obtain a wound culture
	Using the swab technique. The culture should be collected after the wound tissue is cleansed with a nonantiseptic sterile solution (i.e. Normal Saline).Lippincott: Introduced: April 15, 2016
Alteration in skin integrity Skin care/Pruritus	Perform skin assessment Visually inspect and palpate the skin Assess skin (all body sites) for color (pigmentation changes) temperature, moisture, texture, mobility, turgor and skin lesions Describe the type of lesion, location and distribution Evaluate for other symptoms Assess for pruritus Take photographs to document lesion and extent of involvement skin condition May consider being treated in a highly specialized skin unit or burn unit Ensure hand washing Use aseptic techniques for wound care Keep bullae intact Use prescribed ointment or silver nitrate on open areas Débride areas per orders Wound/skin care consult Monitor for signs and symptoms of infection Obtain a culture if ordered if infection suspected and obtain results Monitor vital signs Administer antibiotics as ordered Administer medications/treatments per orders i.e. antihistamine Assess nutritional and hydration status Review diet Monitor fluid and electrolytes Administer IV fluid per orders May consider increasing room temperature to 30–32 ° C especial for large amounts of epidermal detachment. May consider a blanket warm per orders Careful handling of skin Minimize shearing force especially moving or changing in the patient’s position (anti-shear handling) No evidence to suggest best skin practice Cleanse wounds and intact skin by irrigating with warm sterile water or normal saline applied emollient to the whole skin No tape on skin Keep nails short and clean Use mittens as needed Administer topical creams per orders Apply a topical antimicrobial agent to sloughed areas per orders Should avoid use of silver sulfadiazine until sulfonamides are ruled out as the cause Use of appropriate dressing to reduce fluid/protein loss, decrease risk of infection, pain control and may increase re-epithelialization Ideally blisters should be left in place and only punctured if necessary, allowing the blister roof to serve as a biologic dressing If bullae are prominent, blister fluid should be aspirated/expressed thus allowing blister roof to settle onto the dermis Apply a dressing to collect exudates if indicated Clinician may consider debridement Limit trauma by avoiding use of sphygmomanometer cuffs, EKG leads and adhesive dressings (use non-adherent dressings) For SJS/TEN patients Mucosal involvement is dependent on degree of skin detachment Oral care-see mucositis Genital changes in female patient may lead to adhesions or strictures May be treated with wet dressing or sitz baths	Instruct patient/caregiver on basic hygiene: Hand washing technique and nail care Aseptic technique Avoid abrasive washing and gently pat dry when washing Teach signs and symptoms of infection Avoid exposing skin to extreme heat or cold Wear loose fitting clothing Avoid scratching skin Lubricate with prescribed skin emollients Test all new products on a small area of skin to rule out hypersensitivity reaction Prevent dry skin Use non-perfume emollients Avoid hot baths & frequent bathing Instruct patient/caregiver on expected side effects and when to notify a healthcare professional
Alteration in comfort
Pain	Assess for pain including location, intensity, quality, onset, duration, is it affecting ADL, aggravating and alleviating factors Administer analgesics as order and assess patient’s response Assess for side effects Assess effects on sleeping, coping and ADL Implement strategies to prevent/reduce side effects (i.e. bowel function or nausea & vomiting) Administer analgesics prn with special consideration for dressing changes, movement Use nonpharmacologic strategies Consider placing on a alternating pressure air mattress may help with pain	Instruct patient/caregiver: To report pain and response to intervention Explain treatment plan and address patient concerns Monitor for potential side effects of interventions Teach other techniques Distraction Relaxation/ guided imagery Prayers/meditation Counseling
Mucositis	Perform oral and pain assessment Grade mucositis using CTCAEv4 Grade 1- No oral lesions or discomfort Grade 2- Moderate pain; not interfering with oral intake; modified diet indicated Grade 3 -Severe pain; interfering with oral intake Grade 4 -Life-threatening consequences; urgent intervention indicated Perform oral care Clean mouth with water or saline Administer lidocaine rinse as ordered Assess nutritional status Maintain adequate nutrition Apply moisture to lips 4–6 times/day Assess for mouth dryness or thrush Topical agents for pain Consult with dietician or dentist as needed	Instruct patient/caregiver daily oral hygiene Preventive measures (oral rinse with water, saline, baking soda rinse and avoid alcohol containing mouthwash) Encourage oral intake Encourage high protein diet, soft bland diet Discourage smoking and alcohol Oral hygiene and care The importance of adequate nutrition
Eye involvement	Consult with an ophthalmologist Apply lubricant eye drops per orders-usually every 2 hrs. Ocular hygiene performed by special trained staff Administer eye drops per orders	Instruct patient/caregiver regarding Eye care Hygiene Eye drops
Alteration in body images/sexuality	Encourage patient to express feelings Acknowledge the patient may see her body differently Discuss patient’s concerns about sexuality and plan ways to manage the problem Review potential side effects	Instruct patient/caregiver regarding Explore other methods of expression (hand holding and hugs)
Psychosocial concerns	Identify pt’s nature/level of concerns/distress Assess support and past coping skills Allow patient to verbalize Refer to social worker, counseling services or chaplaincy care Provide advocacy and education Provide community resources Teach coping strategies	Instruct patient/caregiver regarding Disease, treatment, side effects, symptom management Teach coping strategies Teach relaxation techniques
Rehabilitation focus	Assess patient’s ability to perform ADL and return to normal activities Consider referrals, i.e. physical therapy Review need for equipment and or supplies Schedule follow up appointments	Instruct patient/caregiver regarding Educate on the importance of follow up care Exercises as prescribed by the physical therapist despite the discomfort that they may cause patient