Suggested Answers to Critical Thinking Exercises

Chapter 60, Assessment of Integumentary Function

1. You are working in a dermatology clinic. A 44-year-old woman presents for

treatment of squamous cell carcinoma that is present on her upper chest. She
notes that she plays tennis and rarely uses sunscreen because she likes having
a “healthy-looking tan.” You note on her health history that she also has three
young children at home. You wish to educate her on the appropriate use of
sunscreens for her and her family.
a. Identify the evidence to support the use of protection from the sun, including
sunscreens, to prevent further skin cancer from occurring.
Health care research strongly establishes the link between exposure to the
sun and sunburns to the development of skin cancers later in life. The
research shows that a statistically significant difference between the
development of skin cancer in those who correctly use sunscreen and those
who do not. Factors to consider in the research include the use of sunscreen,
type/strength of the sunscreen, time spent in the sun, and the frequency of
sunburn.

b. Discuss the strength of the evidence that supports the use of sunscreens.
Identify the criteria used to evaluate the strength of the evidence for this
practice.
The criteria used to evaluate the strength of the evidence for use of
sunscreen would be a decreased incidence of sun-exposure related skin
conditions, including skin cancer. The evidence is strong, based on years of
dermatology research.
Criteria used to evaluate the strength of the evidence for health practices and
guidelines can be reviewed at
http://archive.ahrq.gov/clinic/epcsums/strengthsum.htm.

2. As a home health nurse, you are making a first-time visit to a new patient, an
80-year-old woman who was discharged from an acute care rehabilitation facility
after receiving a total hip replacement for a hip fracture 2 weeks ago. The
patient shows you areas on her forearm where she had intravenous lines placed
while she was in the hospital that are still visibly bruised. She asks you why it
seems to take longer than it used to for any type of wound to heal and why her
skin seems so much more fragile than it did than when she was younger.
a. How do you respond to her?
Cellular changes associated with aging include a thinning at the junction of
the dermis and epidermis. The result of this thinning is fewer anchoring sites
between the two skin layers, which means that even minor injury or stress to
the epidermis can cause it to shear away from the dermis. This phenomenon
may account for the increased vulnerability of aged skin to trauma. Cellular
replacement slows as a result of aging. As the dermal layers thin, the skin
 becomes fragile and transparent. The blood supply to the skin also changes
with age. Vessels, especially the capillary loops, decrease in number and
size. These vascular changes contribute to the delayed wound healing
commonly seen in the older adult patient.

3. You work in an internal medicine clinic. A woman who has just seen her primary
provider for a routine visit reports to you that she forgot to ask something. Her
sister was recently diagnosed with melanoma, and she is wondering what the
implications are for herself and her children.
a. How would you explain this condition to her?
Melanoma is a cancerous neoplasm in which neoplastic melanocytes are
present in the epidermis and the dermis (and sometimes the subcutaneous
cells). It is the most lethal of all the skin cancers. Most melanomas arise
from cutaneous epidermal melanocytes, but some appear in preexisting nevi
(i.e., moles) in the skin or develop in the uveal tract of the eye or from the
mucosal lining of the GI or genitourinary tract (Tan, et al., 2013).

Melanomas spread in two growth phases, radial and vertical. During the
radial growth phase, cutaneous melanomas tend to spread radially within the
layer of the epidermis. It is during this earlier phase of radial growth that the
tumor is most amenable to treatment. The second growth phase, called the
vertical phase, is characterized by vertical tumor growth into the dermal
layer and eventual metastasis. Those melanomas that progress more rapidly
from the radial to the vertical growth phase are considered more aggressive
types and have a poorer prognosis (Tan, et al., 2013).

Tan, K.-B., Tan, S.-H., Aw, D. C.-W., Jaffar, H., Lim, T.-C., Lee, S.-J., & Lee,
Y.-S. (2013). Simulators of squamous cell carcinoma of the skin: Diagnostic
challenges on small biopsies and clinicopathological correlation. Journal of
Skin Cancer. Available at:
http://www.hindawi.com/journals/jsc/2013/752864/cta/

b. List the priority precautions you would advise for this woman and her
children?
The nurse would list the following priority precautions for this woman and her
children:
 Educate about the early signs.
 Patients at risk are should examine their skin and scalp monthly in a
systematic manner.
 Patients should seek prompt medical attention if changes are detected.
 Because melanoma is thought to be genetically linked, the family as well
as the patient should be taught sun-avoiding measures and the
importance of annual assessment by a primary provider.