Skin Tips for the NCLEX

There are a lot of skin problems and they sorta all look the same! So here are some tips for answering skin questions on the NCLEX.

Layers of the skin

Knowing the layers of the skin is helpful when you are talking about pressure ulcer stages and burn stages. Don’t worry, we’ll come back to the layers! For now, they are:

• epidermis: top layer of skin
• dermis: blood vessels, nerves and sweat glands
• hypodermis: subcutaneous fat

Wound drainage colors

Wound drainage colors are important to recognize because depending on what’s oozing out, you have a different kind of problem. The wound drainage colors are:

• serous: clear or straw-colored – this is a normal finding
• serosanguineous: pink-colored – normal after surgery or a recent skin injury that’s healing
• sanguinous: red-colored – (sangria: I think of that red wine drink with all the fruit) this is active bleeding and NOT normal after several minutes of a wound injury.
• purulent: yellow, gray or green-colored – NOT normal and indicates infection

Rashes

• rashes are usually always a bad sign, especially if the client just started taking a new med – let the HCP know
• Steven’s Johnson syndrome and TEN (toxic epidermal necrolysis) is a blistery rash on the skin caused by many meds. That’s never a good sign.
• tell clients to keep nails short and not to scratch rashes or pick at lesions – it puts them at risk for infection

Meds to give for Pruritus

Most skin problems and rashes cause itchiness (pruritus), so even though there are a lot of causes, it’s common to give the same 2 types of meds. They are:

• steroids – they end in -sone and -lone. They are anti-inflammatory and help calm the rash down. They can be given as a pill or a cream.
• diphenhydramine – this is the generic name for benedryl. It is an anti-histamine that also decreases itchiness.

Infectious vs. Non-infectious skin diseases

Be able to know the difference between an infectious or non-infectious skin disease. Why? Because then you’ll then if antibiotics will be given.

Skin Cancer

Use the ABCDE skin cancer assessment tool to recognize it.

• Asymmetry – 1/2 of it doesn’t match the other 1/2
• Border irregularity
• Color that is not uniform – it can be a mix of red, white or blue
  • I call melanoma the burning flag cancer because the lesion is red, white and blue and it’s highly metastatic/cancerous. you never want to see a burning flag, right?!
• Diameter – it’s large and greater than 6 mm across
• Evolving size, shape or color

Pressure Ulcers

If your patient can’t move around very well, you’ll want to be doing a few things to prevent a pressure ulcer. They are:

• turn every 2 hours
• assess bony areas like coccyx, elbows, heels and ears
• keep skin dry
• don’t massage areas that look like a pressure ulcer might be starting. You’ll damage the small capillaries, then nutrients and oxygen won’t be able to reach the area

You’ll also want to be able to recognize a pressure ulcer. Do you know the stages? They go along with the layers of the skin. (Finally! Actually knowing the skin layers helps!) They are:

1. Stage 1: the epidermis is intact, but the skin is red. And it stays red when you press your finger on it. That’s called “non-blanching”
2. Stage 2: the epidermis has come off. That’s the first layer of the skin. It can also be a shallow crater into the dermis or look like a blister.
3. Stage 3: the crater has now gone fully into the dermis and subcutaneous tissue.
4. Stage 4: you can see bone, tendon or muscle

Burns

If there are 6 things to know about burns, know this:

• there is a high risk of airway problems due to smoke inhalation
  • give oxygen and look for singed hair
• patients get A LOT of fluids. So don’t be surprised to see a patient getting up to 500 mL/hour of Lactated Ringers
  • parkland formula: (4 mL) X (weight in kilograms) X (% burned) = amount of fluids given in first 24 hoursgive 1/2 of that number in first 8 hoursgive the rest in the remaining 16 hours
• urine output is the best indicator of fluid resuscitation
  • make sure at the minimum it’s >30 mL/hour
• put your patient in protective isolation: private room and wear sterile gloves and a gown for dressing changes
• calculate the “rule of 9’s”
• if the patient gets a skin graft, be sure to immobilize the extremity to prevent trauma and promote adhering of the new skin

There are a lot of skin problems, but these tips will help you choose better answers on the NCLEX and be a better nurse! What kind of skin problems would you like to know more about? Post in the comments section.