Transcript 4AlterationsinSkinIn..

Lisa M. Dunn MSN/Ed, RN, CCRN, CNE
Exemplar: Xerosis (Dryness)
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A common problem among older patients
Fine flaking of the stratum corneum
Generalized pruritus
Scratching may result in secondary skin lesions,
excoriations, lichenification, and infection
Collaborative Management
 Nursing interventions aim to rehydrate the skin and
relieve itching.
 Bathing with moisturizing soaps, oils, and lotions may
reduce dryness.
 Water softens the outer skin layers; creams and lotions
seal in the moisture provided by water.
Exemplar: Pruritus (Itching)
 Pruritus is caused by stimulation of itch-specific nerve
fibers at the dermal-epidermal junction.
 Itching is a subjective symptom similar to pain.
 “Itch-scratch-itch” cycle.
 Cool sleeping environment is helpful.
 Fingernails should be trimmed short.
 Antihistamines.
 Topical steroids.
 The nurse is applying a topical corticosteroid to a
client with eczema. The nurse would be concerned
about the potential for increased systemic absorption
of the medication if the medication were being
applied to which of the following body areas?
a. Back
b. Axilla
c. Soles of the feet
d. Palms of the hands
Exemplar: Sunburn
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First-degree, superficial burn
Cool baths
Soothing lotions
Antibiotic ointments for blistering and infected skin
Topical corticosteroids for pain
Exemplar: Urticaria (Hives)
 Urticaria—presence of white or red edematous
papules or plaques of varying sizes
 Removal of triggering substances
 Antihistamines helpful
 Avoidance of overexertion, alcohol consumption, and
warm environments, which can worsen symptoms
Exemplar: Trauma
 Phases of wound healing:
 Inflammatory phase
 Fibroblastic or connected tissue repair phase
 Maturation or remodeling phase
Question
 The nurse manager is observing a new nursing graduate
caring for a burn patient in protective isolation. The
nurse manager intervenes if the new nursing graduate
planned to implement which incorrect component of
protective isolation technique?
A. Using sterile sheets and linens
B. Performing strict hand-washing technique
C. Wearing gloves and a gown only when giving direct
care to the patient.
D. Wearing protective garb, including a mask, gloves,
cap, shoe covers, gowns, and plastic apron
Process of Wound Healing
Process of Wound Healing (Cont’d)
 First intention resulting in a thin scar
 Second intention (granulation) and contraction—a
deeper tissue injury or wound
 Third intention (delayed closure)—high risk for
infection with a resultant scar
Exemplar: Partial-Thickness
Wounds
 Involve damage to the epidermis and upper layers of
the dermis
 Heal by re-epithelialization within 5 to 7 days
 Skin injury immediately followed by local
inflammation
Re-epithelialization
Exemplar: Full-Thickness Wounds
 Damage extends into the lower layers of the dermis
and underlying subcutaneous tissue.
 Removal of the damaged tissue results in a defect that
must be filled with granulation tissue to heal.
 Contraction develops in healing process.
 Wound may tunnel
Exemplar: Pressure Ulcer
 Tissue damage caused when the skin and underlying
soft tissue are compressed between a bony prominence
and an external surface for an extended period.
 Mechanical forces that create ulcers:
 Pressure
 Friction
 Shear
Shearing Force
Identification of High-Risk Patients
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Mental status changes
Independent mobility
Nutritional status
Incontinence
Pressure-Relieving Techniques
 Adequate pressure relief key to prevention of pressure
ulcers
 Capillary closing pressure
 Pressure-relief products and devices
 Positioning
Question
 The evening nurse reviews the nursing documentation
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in the patient’s chart and notes that the day nurse has
documented that the patient has a stage II pressure
ulcer in the sacral area. Which of the following would
the nurses expect to note on assessment of the
patient’s sacral area?
A. Intact skin
B. Full-thickness skin loss
C. Exposed bone, tendon, or muscle
D. Partial- thickness skin loss of the dermis
Wound Assessment
 Pressure ulcers and their features are classified and
assessed in four stages:
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Stage I
Stage II
Stage III
Stage IV
Four Stages of Pressure Ulceration
Wound Assessment
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Location
Size
Color
Extent of tissue involvement
Cell types in the wound base and margins
Exudate
Condition of surrounding tissue
Presence of foreign bodies
Exemplar: Wound
Contamination/Wound Infection
 A wound that is exposed is always contaminated but
not always infected. Contamination is the presence of
organisms without any manifestations of infection.
 Wound infection is contamination with pathogenic
organisms to the degree that growth and spread
cannot be controlled by the body’s immune defenses.
Nonsurgical Management
 Dressings:
 Mechanical débridement
 Natural chemical débridement
 Hydrophobic material
 Hydrophilic material
Nonsurgical Therapy
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Physical therapy
Drug therapy
Nutrition therapy
New technologies:
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Electrical stimulation
Vacuum-assisted wound closure (VAC)
Hyperbaric oxygen (HBO)
Topical growth factors
Skin substitutes
Hyperbaric Oxygen Therapy
Surgical Management
 Surgical débridement
 Skin grafting
Community-Based Care
 Home care management
 Health teaching
 Health care resources
Exemplar: Bacterial Infections
 Folliculitis—superficial infection involving only the
upper portion of the follicle
 Furuncle (boil)—much deeper infection in the follicle
 Cellulitis—generalized infection with either
Staphylococcus or Streptococcus involving deeper
connective tissue
Furuncle
Cellulitis
Question
 The nurse is reviewing the health record of the
patients scheduled to be seen at the health clinic. The
nurse determines that which of the following
individuals is at the greatest risk for development of an
integumentary disorder?
 A. An adolescent
 B. An older female
 C. A physical education teacher
 D. An outdoor construction worker
Exemplar: Herpes Simplex Virus
 Type 1 herpes simplex virus (HSV-1)—classic recurring
cold sore
 Type 2 herpes simplex virus (HSV-2)—genital herpes
 Herpes zoster (shingles)
Herpes Simplex Virus(Cont’d)
• Herpetic whitlow—a form of herpes simplex
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infection occurring on the fingertips of
medical personnel who have come in contact
with viral secretions
Exemplar: Herpes Zoster/Shingles
 Caused by reactivation of the dormant varicella-zoster
virus in patients who have previously had chickenpox.
 Multiple lesions occur in a segmental distribution on
the skin area innervated by the infected nerve.
 Eruption lasts several weeks.
 Postherpetic neuralgia occurs after lesions have
resolved.
Exemplar: Fungal Infections
(Dermatophyte)
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Tinea pedis
Tinea manus
Tinea cruris
Tinea capitis
Tinea corporis
Candida albicans
Assessment
 History
 Laboratory assessment:
 Tzanck smear
 Swab culture
 Potassium hydroxide (KOH) test
Interventions
 Skin care with proper cleansing
 Isolation Precautions
 Drug therapy
Skin Care
 Bathe daily with an antibacterial soap.
 Remove any pustules or crusts gently.
 Apply warm compress twice a day to furuncles or areas
of cellulitis.
 Apply Burow's solution to viral lesions.
 Avoid excessive moisture.
 Ensure optimal patient positioning.
Drug Therapy for Skin Disorders
 Antibacterial drugs
 Antifungal drugs
 Anti-inflammatory drugs
 A topical corticosteriod is prescribed for the client
with dermatitis. The nurse provides instructions
to the client regarding the use of the medication.
Which of the following, if stated by the client,
would indicate a need for further instruction?
a. “I need to apply the medication in a thin film.”
b. “I should gently rub the medication into the
skin.”
c. “The medication will help relieve the
inflammation and itching.”
d. “I should place a bandage over the site after
applying the medication.”
Exemplar: Cutaneous Anthrax
 Infection caused by the spores of the bacterium
Bacillus anthracis
 Diagnosis based on appearance of the lesions and
culture or anthrax antibodies in the blood
 Oral antibiotics for 60 days—ciprofloxacin or
doxycycline
Cutaneous Anthrax
Exemplar: Pediculosis
 Pediculosis—infestation by human lice:
 Head lice—pediculosis capitis
 Body lice—pediculosis corporis
 Pubic or crab lice—pediculosis pubis
 Pruritus most common symptom
 Drugs
 Laundering of clothing and bed linen
Question
 The home health nurse visits a client suspected of
having scabies. Which of the following precautions
will the nurse institute during the assessment of the
client?
 A. Wear gloves only
 B. Wear a mask and gloves
 C. Wear a gown and gloves
 D. Avoid touching the client’s home furnishings
Scabies
 Scabies is a contagious skin disease caused by mite
infestations.
 Scabies is transmitted by close and prolonged contact
or infested bedding.
 Examine skin between fingers and on the palms.
 Infestation is confirmed by an examination of a
scraping of a lesion under a microscope.
Common Inflammations
 Contact dermatitis, atopic dermatitis
 Interventions include:
 Steroids
 Avoidance of oil-based products
 Antihistamines
 Compresses and baths
Psoriasis
 Lifelong disorder with exacerbations and remissions
 Scaling disorder with underlying dermal
inflammation; possibly an autoimmune reaction
 Psoriasis vulgaris most often seen
 Exfoliative psoriasis—an explosively eruptive and
inflammatory form of the disease
Exemplar: Psoriasis Vulgaris
Treatment of Psoriasis
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Corticosteroids
Tar preparations
Other topical therapies
Ultraviolet light therapy
Systemic therapy:
 Biologic agents
 Cytotoxic agents
 Immunosuppressants
 Emotional support
Exemplar: Benign Tumors
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Cysts
Seborrheic keratoses
Keloids
Nevi (moles)
Exemplar: Skin Cancer
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Actinic keratoses
Squamous cell carcinomas
Basal cell carcinomas
Melanomas—highly metastatic; survival depends on
early diagnosis and treatment
Skin Cancer (Cont’d)
Surgical Management of Skin
Cancer
Surgical management:
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Cryosurgery
Curettage and electrodesiccation
Excision
Mohs’ surgery
Wide excision
Nonsurgical Management of Skin
Cancer
 Drug therapy
 Radiation therapy
Exemplar: Plastic Surgery
 Rhytidectomy (face-lift)
 Rhinoplasty (reconstruction of the nose)
Exemplar: Acne
 Red pustular eruption affecting the sebaceous glands
of the skin
 Progressive disorder that manifests as
noninflammatory comedones, inflammatory papules,
pustules, and cysts
 Topical agents
 Systemic antibiotics and possibly isotretinoin
(Accutane) helpful
Exemplar; Other Skin Disorders
 Lichen planus with itchy papules
 Pemphigus vulgaris with chronic blistering
 Toxic epidermal necrolysis—a rare, acute drug
reaction
 Stevens-Johnson syndrome
 Leprosy
Steven Johnson Syndrome
References
Ignatavicius, D., & Workman, M.L. (Ed.). (2010). Medical-Surgical Nursing
Critical Thinking For Collaborative Care. (6th Ed.) St. Louis: Elsevier
Saunders.
MedicineNet.com: We Bring Doctors’ Knowledge To You. (2010) Skin Health
Center. Retrieved April 8, 2010, from:
http://www.medicinenet.com/skin/focus.htm
Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed). St. Louis,
Missouri: Mosby.