Integumentary Problems in Med-Surg: What You'll See in Clinical and On the NCLEX

Common Integumentary Problems You’ll See in Clinical

Heather Murphy: Welcome back, everybody. I’m Heather Murphy, and today we’re gonna hang out with one of my favorite topics to teach: integumentary problems you will absolutely see in clinical and on your NCLEX-style exams. I always tell students: every skin assessment is a safety check. When you look at the skin, you’re asking, “Is there infection? Is there poor perfusion? Is there pain? Is this patient at risk for a pressure injury?” So don’t think of skin as an afterthought—it’s a window into the whole patient.

Heather Murphy: Let’s hit some common findings you’ll see on a med-surg floor. First, cellulitis. From your slides: cellulitis is usually bacterial, often Staph, and it’s commonly on the legs. Clinically, you’ll see an area that’s red, warm, swollen, and painful. For NCLEX, key priority words are fever, chills, spreading erythema, and a patient who might be immunosuppressed. Those are the patients you worry about for systemic infection and sepsis, which means systemic antibiotics, not just a cream.

Heather Murphy: Impetigo is different. That one loves to hang out around the mouth and face. Your slide notes it’s a Staph aureus infection with a broken skin barrier. You’ll think of those crusty lesions on or around the mouth, usually in kids but you can see it in adults too. The treatment is antibiotics as well, often topical if it’s limited, and you’re teaching about good hygiene and not sharing towels or razors because it’s contagious.

Heather Murphy: Now shingles—herpes zoster. Your slide describes it as a painful blistering rash, usually on one side of the body or face. The blisters scab in about 7 to 10 days. Key descriptors on exams: unilateral, painful, blistering rash in a dermatomal pattern, meaning they follow a nerve pathway. Before the rash, the patient might say, “I felt tingling or burning.” Infection control-wise, you’re thinking about contact-type precautions for those fluid-filled blisters—protecting yourself and other patients, especially immunosuppressed folks.

Heather Murphy: A different type of herpes is herpes simplex—often presents first as itching, tingling, or pain before fluid-filled blisters show up. And warts, like plantar warts, can be raised bumps or flat lesions depending on location. These are viral, so think local treatment and good hand hygiene, not systemic antibiotics.

Heather Murphy: Let’s hit inflammatory conditions. You’ll see atopic dermatitis, or eczema, and psoriasis all the time. Eczema tends to be itchy, inflamed skin; you’ll often see dry, irritated patches. Contact dermatitis can be irritant or allergic. It’s associated with allergies and hypersensitivity reactions, and they mention patch testing and avoiding known irritants. Healthcare workers sometimes develop contact dermatitis from excessive glove use and handwashing. The big red-flag teaching point is: wheezing, swollen tongue, and hives equals emergency—assess airway and administer epinephrine. That is a classic NCLEX stem: patient with new medication develops hives, wheezing, and tongue swelling. Priority action? Not calling the provider, not giving diphenhydramine—assess airway and administer epinephrine.

Heather Murphy: Psoriasis, from your slides, is described as dry, thick, raised patches that may be scaly or plaque-like, often on the scalp, elbows, and knees. It has flare-ups and is caused by an overactive immune response. Remember those T-cells we learned last quarter? That immune piece is important; it’s not an infection, so antibiotics are not the answer here. If a question stem describes dry, thick plaques on elbows and knees, itching but no fever, you’re thinking psoriasis and anti-inflammatory or immune-modulating treatments, not infection control.

Heather Murphy: Let me throw you a quick NCLEX-style question: A patient with cellulitis of the right lower leg calls the nurse and says, “The redness has spread above my knee and I have a fever of 101.8.” What is the nurse’s priority action? Options might include: elevate the leg, apply warm compresses, notify the provider, or document and recheck in 4 hours. Your slides mention cellulitis as red, warm, swollen, with treatment being antibiotics and nursing interventions like elevating legs, warm compresses, and pain control. But with new fever and spreading redness, your priority is to notify the provider because this can indicate worsening infection that may need systemic antibiotic adjustment. Elevation and warm compresses are still appropriate, but they are not the priority when you see systemic signs.

Heather Murphy: So as you assess skin in clinical, keep looping in those themes: Is this infection getting worse? Does this need systemic treatment, like antibiotics, instead of just topical? Is this a hypersensitivity reaction heading toward an emergency? And always think about isolation and precautions when you see rashes with blisters or open lesions. That mindset will serve you both at the bedside and on your exams.

Wounds, Ulcers, and Dressing Choices

Heather Murphy: Let’s shift into wounds, ulcers, and what to put on them. Your slides break wound healing into three stages: hemostasis and inflammation, proliferation, and tissue remodeling. In hemostasis and inflammation, the clotting cascade triggers, vasoconstriction happens, then vasodilation, you get some darkening and edema, and neutrophils come in to kill bacteria and debride necrotic tissue. Proliferation starts around day 3 and can take weeks—granulation tissue forms, blood vessels repair, fibroblasts proliferate, and epithelialization begins. Tissue remodeling can last from day 21 up to a year; collagen strengthens the wound and edges contract.

Heather Murphy: Now, what slows all of that down? Your slide lists moisture from incontinence or skin folds, friction from pulling patients up in bed, decreased perfusion like low oxygen levels and smoking, poor nutrition especially protein, immunosuppression from cancer or corticosteroids, venous insufficiency such as peripheral vascular disease or diabetes, and stress with high cortisol. Those are all exam buzzwords. If you see a patient who smokes, has diabetes, poor nutrition, and is incontinent, you should be thinking: delayed wound healing and high risk for pressure injuries. And don’t forget simple interventions like using an overhead trapeze so the patient can move in bed without dragging their heels and sacrum.

Heather Murphy: Let’s compare chronic wounds on your slide: arterial ulcers, venous ulcers, and diabetic foot ulcers. Arterial ulcers result from decreased blood flow to the area. Remember in our cardiac chapter, we learned that when arterial blood flow is insufficient, oxygen-rich blood may not fully make it to those extremities. This results in deep wounds with a punched-out appearance. They may contain eschar and are associated with poor perfusion—pale, hairless, cool skin. Venous ulcers, on the other hand, result from a pooling of venous blood in the extremity. Edema is a classic sign- think blood pooling equals edema. They are typically shallow, over the medial lower extremity, with no eschar. Then you’ve got diabetic foot ulcers, often on the plantar area of the foot, may include callus, and can range from superficial to deep.

Heather Murphy: Pressure injuries are another big exam favorite. Remember Stage 1, 2, 3, 4, unstageable, and deep tissue injury? Stage 1 is nonblanchable erythema with skin intact. As you move through the stages, you go deeper—from epidermis and dermis into subcutaneous tissue, muscle, and finally bone with Stage 4. The at-risk group: immobility, impaired perception, decreased circulation, poor nutrition, decreased muscle mass, urinary incontinence, and peripheral neuropathy. Nursing interventions listed include high-calorie, protein-rich diet, turning and repositioning every 2 hours, mobility and sequential devices, strengthening exercises or PT, checking and cleaning frequently, and inspecting the skin often—especially bony prominences like heels, sacrum, back of head, shoulders, elbows, hips, and inner knees.

Heather Murphy: Dressing choices can be intimidating, but your slides give some clear guidance. Transparent film dressings provide no absorption but create a barrier and a moist environment, good for superficial skin tears or necrotic tissue. Foam dressings are absorbent, provide a moist environment, and offer padding—great over bony prominences. Hydrocolloid dressings are good for mild to moderate wounds with exudate; they’re not recommended for infected wounds and they’re not transparent, so you can’t see the wound unless you remove them. Alginate and hydrofiber dressings are best for wounds with a large amount of exudate and can stay in place for several days.

Skin Cancer, Prevention, and High-Yield NCLEX Exam Strategies

Heather Murphy: Let’s finish with skin cancers and some test-taking strategy. Your slides divide these into nonmelanoma and melanoma. Nonmelanoma includes actinic, or solar keratosis, basal cell carcinoma, and squamous cell carcinoma. Actinic keratosis is described as the most common precancerous skin lesion, affecting most of the older white population, with sun exposure as a key factor.

Heather Murphy: Basal cell carcinoma is the most common type of skin cancer and luckily the least deadly. It is usually a small, translucent papule with rolled borders, usually in middle-aged to older adults. Squamous cell carcinoma is more aggressive and has the potential to metastasize. Main risk factors: sun exposure and immunosuppression after organ transplant. Pipe, cigar, and cigarette smoking contribute to SCC on the mouth and lips.

Heather Murphy: Melanoma is the big one: it causes most skin cancer deaths and may metastasize to any organ, including brain and heart. The cause is unknown, but environmental and genetic factors play a role. Risk factors listed: red or blonde hair, blue or light-colored eyes, light-colored skin that freckles, chronic UV exposure, including tanning beds, and family history.

Heather Murphy: The slide that compares normal mole, basal cell, squamous cell, and melanoma is a great mental picture. Normal moles are small brown spots or growths that appear in the first few decades of life, can be flat or raised, generally round. Basal cell: shiny bump, pink growth, scar-like area, or an open sore that doesn’t heal easily. Squamous cell: persistent bleeding, warts, scaly patches, open sores, rapidly growing bumps. Melanoma: usually larger than a pencil eraser, multicolored, changes shape and size, with asymmetry and uneven borders.

Heather Murphy: That leads right into the ABCDE rule on your slide: A for asymmetry, B for border irregularity, C for color change, D for diameter greater than 6 millimeters, and E for evolving in appearance. On NCLEX, if the stem says “rapidly changing mole that is asymmetrical with multiple colors and irregular borders,” that is the concerning lesion that needs prompt evaluation. A stable, small, symmetrical brown mole is much less urgent.

Heather Murphy: For melanoma diagnosis and staging, your slide mentions dermoscopy, excisional biopsy, and assessment of tumor thickness with a Breslow measurement. Tumors are staged from 0 to IV based on size, nodal involvement, and metastasis. Stage 0 is nearly 100% curable by excision; advanced disease has about a 27% 5-year survival rate. Treatment depends on site and stage, and can include wide surgical incision, immunotherapy, targeted therapy with BRAF and MEK inhibitors—about half of melanomas have BRAF mutations—and radiation for lymph node and brain metastasis.

Heather Murphy: There’s also atypical or dysplastic nevi on your slide—larger than usual moles with irregular borders and various shades of color. They may have the same ABCDE characteristics but less pronounced, and they carry an increased risk of developing melanoma. So those patients need good follow-up and education.

Heather Murphy: Prevention-wise, your skin care slide emphasizes sun exposure and sun protection: visible and UV light, UVA causing tanning, UVB causing sunburn, and UV damage being cumulative. Protective clothing and sunscreen are specifically listed as sun protection. So for patient teaching and exam questions, you’re encouraging patients—especially those with fair skin, red or blonde hair, blue eyes, and a history of tanning bed use—to limit UV exposure, use sunscreen as directed, and wear protective clothing when out in the sun, even on cloudy days.

Heather Murphy: Let’s do a quick NCLEX-style prioritization. Which statement from a patient would concern you most? “I have a small, round brown mole I’ve had since childhood that hasn’t changed”; “I started using sunscreen and a hat when I’m outdoors”; or “This mole on my back has gotten bigger and has multiple colors now”? Based on the ABCDE rule and the slide description, the rapidly changing, multicolored mole is your priority—evolving color and size are red flags.

Heather Murphy: In terms of answering skin and wound questions, I want you to think in this order: safety and potential for rapid deterioration first, then infection risk, then comfort. Key words that signal priority: rapidly changing mole, nonblanchable erythema over a bony prominence, warm tender leg with redness that’s spreading, new fever in a wound patient, hives with wheezing and swollen tongue. Those go to the top of your list. Comfort issues like itching from eczema are important, but not ahead of airway compromise or possible sepsis.

Heather Murphy: Finally, use your pathophysiology to eliminate distractors. If you know psoriasis is an overactive immune response, you can toss out antibiotics as an answer. If you know alginates shouldn’t go on dry wounds, you won’t pick them for a dry necrotic heel. If you know UV damage is cumulative and tanning beds are UV exposure, you’ll recognize that frequent tanning is a big risk factor even in younger adults. Alright, I’m gonna stop myself there before I go off on another tangent about sunscreen. Keep reviewing those slides, link the visuals to the key words in stems, and you’ll be in great shape for both clinical and exams. We’ll tackle more adult med-surg content in our next episode.