Chapter 54 Nursing Care of Patients with Skin Disorders – Flashcards
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Vocabulary
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Cellulitis
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Surgical debridement is used only if the patient has sepsis or cellulitis. cellulitis is inflammation of cellular or connective tissue.
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Eschar
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Hard scab or dry crust that results from necrotic tissue. Eschar is a black or brown hard scab or dry crust, or thick leather like tissue that forms from necrotic tissue. it may hide the depth of the wound and must be removed for the wound to heal. Surgical debridement is used only if the patient has sepsis or cellulitis, or to remove extensive eschar.
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Comedo
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in regards to acne. initial lesions are called comedones. singular comedo. closed comedones, also known as white heads, are small white papules with tiny follicular openings.
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Dermatitis
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Inflammation of the skin and is characterized by itching, redness, and skin lesions, with varying borders and distribution patterns. There are 3 types. contact, atopic, seborrheic dermatitis.
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Dermatoymycosis
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fungal infection of the skin
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Lichenified
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thickened or hardened from continued irritation.
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Onychomycosis
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disease of the nails caused by fungus.
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Pediculosis
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infestation of lice.
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Pemphigus
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acute or chronic serious skin disease characterized by the appearance of bullae blisters of various sizes on normal skin and mucous membranes.
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Pruritus
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severe itching.
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Psoriasis
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chronic inflammatory skin disorder in which epidermal cells proliferate abnormally fast.
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Purulent
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observe wound exudate. two common types of wound exudate are serosanguineous and purulent. Purulent fluid is a fluid that contains pus. it can vary in color and have different odors depending on which bacteria are present. creamy yellow pus may indicate staph. beige pus that has fishy odor may suggest proteus. green blue pus with fruity odor may suggest bactericides.
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serosanguineous
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serosanguineous exudate is fluid consisting of serum and blood. it is blood tinged, amber-colored fluid.
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Pyoderma
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any acute, inflammatory, purulent bacterial dermatitis.
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Seborrhea
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disease of the sebaceous glands marked by increase in the amount and often alteration of the quality of sebaceous secretions.
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How would you explain the pathophysiology of each of the skin disorders listed in this chapter?
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What is the pathophysiology of Pressure Ulcers also known as bedsores, decubitus ulcers, or pressure sores?
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A lesion caused by prolonged pressure against the skin, spending a prolonged period in one position, causing the weight of the body to compress the capillaries against a bed or chair especially over the bony prominences.
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What are pressure ulcers a result of?
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Tissue anoxia or mechanical forces such as pressure, friction, or shearingThey begin to develop within 20-40 minutes of unrelieved pressure on the skin. other causes tight cast, splint, traction, or other device. Those at risk are immobile patients. Those with decreased circulation, and those with impaired sensory perception or neurologic function.
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Prevention of pressure ulcers
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position patients every 2 hours and avoid direct pressure on bony prominences. use braden scale daily. administer oral nutritional supplements to older adults recovering from acute illness. apply foam or other pressure reducing mattress to the at risk patients bed. AVOID MASSAGING BONY PROMINENCES. low bp, low protein intact, loss of mobility are risk factors.
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Signs and symptoms of pressure ulcer
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Reddened area usually over bony prominence that does not blanch with pressure. a pressure ulcer always stays red, and does not blanch. if redness returns within 3 seconds, then capillary refill is considered to be adequate.
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Pressure ulcer therapeutic measure
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debridement, cleansing, and dressing the wound to provide a moist and healing environment. The epidermis skates on moisture, so the wound must be kept moist to heal..
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What are the types of debridement? Mechanical, enzymatic, autolytic, surgical.
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Mechanical-scissors, forceps, dextranomer beads, whirlpool baths, wet to dry dressings. These methods are painful, so the patient should be premedicated.
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Enzymatic Debridement
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Application of a topical enzyme debriding agent. read instructions. proteolytic enzymes that selectively digest necrotic tissue. apply them only to the wound to avoid contact with healthy tissue.
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Autolytic Debridement
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Use of a synethic dressing or moisture retentive dressing over the ulcer. the eschar is then self-digested via the action of the enzymes that are present in the fluid environment of the wound. not used for infected wounds, because infection could get worse.
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Surgical Debridement. may be done in pt room, or, or treatment room. grafting maybe required to close the wound. necessary for full-thickness ulcer or loss of joint function, or for cosmetic purposes. Premedicate patient.
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removal of devitalized tissue, slough, or thick, adherent eschar with a scapel, scissors, or other sharp instrument. slough is loose, yellow to tan stringy necrotic tissue. slough, like eschar, can be tightly adhered to the wound bed.
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Wound cleansing. Use a whirlpool, a handheld shower head, or an irrigating system with a pressure between 4 and 15 pounds per square inch- psi. A 30mL syringe with a 18 gauge needle works well for this purpose. Pressure less than 4 psi does not cleanse the wound, and greater than 15 psi may damage tissue.
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If an irrigation system is used, 250mL of normal saline or sometimes tap water for home wound care, should be used to thoroughly cleanse the wound. if the wound is red, gentle irrigation with a needless 30-60mL syringe should be used to prevent trauma and bleeding. however, if the wound has been diagnosised as being infected, flushing with a 30-60mL syringe and a 18 gauge needle provides the pressure needed to help remove bacteria.
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Important tips for dressings:
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Once the wound has been cleaned and debrided, apply a dressing, wounds heal more rapidly in a moist environment, with minimal bacterial colonization and a healing temperature. this takes 12 hours to occur if the wound is covered with an occlusive dressings. infected wounds are not covered with occlusive dressings;draining wounds may require frequent dressing changes.
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Negative Pressure wound therapy: helps heal large open pressure ulcers. a wound is packed loosely with sterile sponge and then covered with an occlusive dressing. An occlusive dressing is for sealing a wound. a vacuum source is placed in the wound and gentle negative pressure is applied.
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The negative pressure allows excess drainage and infectious material to be removed, which reduces pressure on delicate new tissue. With small vessels decompressed, circulation is increased, and healing is accelerated. Negative pressure wound therapy also maintains moist environment for optimal healing.
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What is the pathophysiology and etiology of Dermatitis? Dermatitis. There are 3 types of dermatitis Contact, atopic, seborrheic. Pathophysiology: inflammation of these skin and is characterized by itching, redness , and skin lesions, with varying borders and distributions patterns. All types tend to be chronic and respond well to treatment, but are prone to recur.
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Contact dermatitis is caused by exposure to an allergen or irritant such as soap, perfume, or poison ivy. Atopic dermatitis tends to be hereditary and is associated with allergies, asthma, and hay fever. Seborrheic dermatitis occurs most often on the scalp, usually in individuals with oily skin. All types tend to be chronic and respond well to treatment, but prone to recur.
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Prevention of Dermatitis?
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Avoiding irritatnts, allergens, excessive heat and dryness, and by controlling perspiration. Baths should be short, in tepid water. deodorant soaps avoided, mild superfatted soaps are recommended instead. dry skin can be lubricated with creams, oils, or ointments as appropriate. itching and scratching should be prevented as much as possible.
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Interventions for Dermatits:
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monitor if treatment is working. cleanse area. keep area clean and prevent infection. 3. provide cool moist compresses, dressings, or tepid, tub baths, to help relieve inflammation and itching debreide lesions, and soften crusts and scales. Pat skin dry rather than rubbing to prevent further trauma. Apply topical agents as ordered to help suppress inflammation and itching. to promote comfortable sleep. many antihistamines also have a sedative effect. if lesions are generalized, protein can be lost through oozing of serum. confirm appropriateness of high protein diet with primary care provider. encourage use of gloves or mitts, especially at night, to help prevent scratching. advise the patient to keep fingernails short to prevent scratching. teach the patient that application of slight pressure with a clean cloth may help relieve itching. teach relaxation exercises to help the patient cope with distressing symptoms.
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Signs and symptoms of dermatitis?
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itching and rashes or lesions are the main clinical manifestation of dermatitis. rashes and lesions may present as dry, flaky scales, yellow crusts, redness, fissures, acules, papules, and vesicles. scratching can make them worse. Wear cotton gloves at night to prevent scratching. if infection is suspected, cultures are done to identify.
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Therapeutic measures for dermatitis?
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control itching, alleviate discomfort, and pain, decrease inflammation, control or prevent crust formation and oozing, prevent infections, prevent further damage to the skin, and heal lesions as much as possible. antihistamines, analgesics, antipruritic, colloidal oatmeal preparation, steroids, hydrocortisone, or methylprednisoone. Tub baths and wet dressing help control oozing and prevent further crust formation. These interventions serve to loosen exudates, scales, and other wound debris, providing a clean area for topical application of medication. skin is protected by lightly patting dry, avoiding friction, avoiding hot water, and using a sunscreen agent when outdoors.
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Atopic Dermatitis: tends to be hereditary and is associated with allergies, asthma, and hay fever.
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Seborrheic dermatitis occurs most often on the scalp, usually in individuals with oily skin.
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Signs and Symptoms of Dermatitis
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itching and rashes or lesions are the main clinical manifestation of dermatitis. The lesions vary depending on the type and location of dermatitis. Rashes and lesions may present as dry, flaky, scales, yellow crusts, redness, fissures, macules, papules, and vesicles. scratching may make any of these lesions worse.
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Complications of Dermatitis
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the lesion or rash worsens with continued irritation, exposure to irritating agents, or scratching. infections of the skin are common and maybe due to the many open areas and breaks in the skin, as well as the patients reluctance to properly wash the affected area because of the pain from the lesions. some infections become systemic.
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Diagnostic Tests for Dermatitis: is based on history, systems, and clinical findings, if infection is suspected, cultures of the lesions may be ordered to identity the infecting agent.
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Psoriasis pathophysiology and etiology: Autoimmune in nature, with T cells attacking healthily skin cells causing an increase in skin cell, T cell, and white cell production. family history. average age of onset 27. contain can be severe if onset is in childhood.
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it is a Chronic inflammatory skin disorder in which the epidermal cells proliferate abnormally fast. usually epidermal cells take about 27 days to shed, with psoriasis, the cells shed every 4-5 days. the abnormal keratin forms loosely adherent scales with dermal inflammation.
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Characterized by exacerbations and remissions. sun and humidity may suppress lesions. aggravating factors include strep, emotional upset, smoking, hormonal changes, cold weather, skin trauma, smoking, alcohol, drugs, lithium, beta bluchers, antimalarial agents.
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Prevention of Psoriasis: because etiology is not known, measures to prevent exacerbation of symptoms are specific to the patient circumstances. General preventive: avoid URI, esp strep. avoidance of or coping with emotional stress, avoidance of skin trauma, including sunburns, and avoiding medication that can cause flare up.
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Sign and symptoms of psoriasis
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Lesions are red papules that going to form plaques with distinct borders. Silvery scales develop on untreated lesions. areas most often affected are the elbows and knees, scalp, umbilicus, and genitals. other symptoms include nail involvement, involvement in the gluetal fold, called intergluteal pinking, itching, and dry or brittle hair.
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complications of psoriasis : secondary infections from itching. Psoriatic arthritis may develop after the psoriasis has developed. nail changes and destructive arthritis in large joints, the spine, and interphalangeal joints. if the psoriasis becomes severe and widespread, fever, chills, increased cardiac output, ad benign lymphadenopathy can result.
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Diagnostic tests for psoriasis- physical assessment only. skin biopsy or other diagnostic tests may be performed to rule out concurrent disease or secondary infection.
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Therapeutic measures- topical corticosteroid, occlusive dressings, keratolytic ointments, salicylic acid, synthetic vitamin D, fish oil supplements,Tar, uv light, acitretin, retinoids, antimetabolites, methotextrate, Cyclosporine and etanercept (Enbrel). basic treatment is to decreased the rapid epidermal proliferation, inflammation, and itching and scaling. usually patient is instructed to bathe daily in a tub, using a soft brush to assist in the removal of scales.
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Topical corticosteroids for anti-inflammatory effect. Occlusive dressing are commonly used to enhance penetration of medications. keratolytic ointments or gels to enhance the effects of salicylic acid to loosen or remove scales, synthetic vitamin D cream slows the proliferation of skin cells. fish oil supplements may reduce inflammation in some patients. Tar preparations as an antibiotic, slowing the epidermal cell division. occlusive dressings are not used with tar.
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antimetabolites are reserved for most severe cases. methotrexate. Cyclosporine and etanercept (Enbrel) work by altering immune system.
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Nursing Care: avoid triggers. teach how to use medications, explain that drinking alcohol can interfere with some treatments. consult with physician about recommending small amounts of sunlight to help improve skin lesions.
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What are some inflammatory skin disorders?
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Dermatitis and Psoriasis
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What are some infectious Skin Disorders?
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Herpes Simplex, Herpes zoster, Varicella, Shingles, fungal infections, cellulitis, acne vulgaris
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Herpes Simplex type 1- above the waist. causes fever blister, cold sore.
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Herpes Simplex type 2- below the waist. causes genital herpes. Recurrance of symptomatic infections can happen spontaneously or may be triggered by stressor such as fever, sunburn illness, menses, fatigue, or injury.
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The primary infections occurs through direct contact, respiratory droplet, or fluid exposure from another infected person. the virus lies dormant in nerve ganglia near the spinal column where the immune system cannot destroy it. the pat is asymptomatic at this time.
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The secondary lesion may appear isolated or as groups of small vesicles or pustules on an erythematous base. crusts eventually form, and the lesions heal in about 1 week. the lesions are contagious for 2-4 days before crusts form.
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Prevention-avoid contact with known infection lesion during the blistering phase can prevent primary lesions. avoid sharing toothbrushes, lipsticks, and drinking glasses. This disease can recur spontaneously. Avoidance of stressors, such as sunburn, injury, and fatigue, may delay recurrence. The use of sunscreens, especially on the lips may be helpful.
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Signs and symptoms: prodromal phase of burning or tingling at the site for a few hours before eruption. the area becomes erythematous and swollen. vesicles and pustules erupt in 1-2 days. there may be redness with no blistering. lesions can burn, itch, and be painful. the attacks vary in frequency but diminish with age, the patient is contagious with each outbreak until scabs are formed.
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complications: if present during childbirth, the newborn may be infected. if person touches the affected area and rubs eyes, the eyes can become severely infected. Secondary bacterial infection of lesions can occur. rarely, herpes, encephalitis can occur. tHis is deadly if not treated promptly.
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Diagnostic Tests: cultures of lesions provide a definitive diagnosis. most lesions are diagnosed on the basis of history, signs, and symptoms.
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Therapeutic Measures-No cure. reoccurances will happen. topical acyclovir, for primary lesions. to suppress the multiplication of vesicles. it does not benefit secondary lesions. oral antivirals, acyclovir, famiciclovir, or valacyclorvir may be recommended for severe or frequents attacks, of more than 6 a year. various lotions, crams, and ointments may be prescribed to accelerate drying and healing of lesions, camphor phenol, alcohol, antibiotics may be indicated for secondary infections.
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Herpes Zoster Shingles
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What are the pathophysiology and etiology of Fungal Infections? Fungal infections occur when there is an impairment of the skin integrity in a warm, moist environment. this infection occurs through direct contact with infected humans, animals, or objects.
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Tinea- describes a fungal infections. the name used after tinea indicates the body area affected. For example tinea capitis is a fungal infection of the scalp. and tinea pedis is a term used for athletes foot. the term candidiasis is used when candida is the infecting organism.
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What is the pathophysiology and etiology of Cellulitis - cellulitis is inflammation of the skin and subcutaneous tissue resulting from infection, usually with staphyloccus or streptococcus bacteria. Mehicillin-resistant staphylococcus aureus also known as MRSA is becoming a common cause, and is resistant to many antibiotics.
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How does cellulitis occur? Cellulitis can occur as a result of skin trauma; as secondary bacterial infection of an open wound, such as a pressure ulcer' or it may be unrelated to skin trauma. it most often occurs in the extremities, especially the lower lets.
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Prevention of cellulitis- good hygiene and prevention of cross-contamination are important. if an open wound is present, preventing infection and promoting healing is critical.
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Signs and symptoms of cellulitis is a localized are of inflammation that may become more generalized if not treated. warmth, redness, localized edema, pain, tenderness, fever, and lymphadenopathy. the infection can worsen rapidly and become systemic if not treated properly.
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Diagnostic Tests
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culture and sensitivity testing of any pustules or drainage is necessary to identify the infecting organism. blood cultures to rule out bacterium.
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Therapeutic Measures
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Topical and systemic antibiotics are prescribed according to culture and sensitivity test results. debridement of nonviable tissue is necessary if an open wound is present. systemic antibiotics are indicated if fever and lyphadenopathy are present. elevation of the extremity may reduce pain and swelling. monitor vital signs and report hypotension and tachycardia, because such changes can indicate systemic infection. measure extremity daily to monitor progress. outline the affected area. it may be difficult if margins aren't clear.
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What is the pathophysiology and etiology of Acne Vulagris: acne occurs when the ducts through which this sebum flows becomes plugged. hereditary, tendency, stress, external irritates. not related to diet, chocolate, sex, or uncleanness. common skin disorder of the sebaceous glands and their hair follicles that usually occurs on the face, chest, upper back, and shoulders. the etiology is multifocal. the most common cause is hormonal changes during puberty. Stimulation of androgens during adolescence or the menstrual cycle in turn stimulates the sebaceous glands to increase sebum production.
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this along with gradual obstruction of the pilosebaceous ducts with accumulated debris, ruptures the sebaceous glands, which causes an inflammatory reaction that may lead to papules, nodules, and cites.
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how can you prevent acne? acne vulgaris occurs regardless of interventions however, certain interventions can lessen the severity or prevent complications. avoid picking prevents further inflammation and scarring. avoid excessive washing, irritants, and abrasives.
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Signs and symptoms: white heads also known as comedones. they may eventually become open comedones, or blackheads. the color is not caused by dirt but by lipids and melanin pigment. scarring occurs as a result of significant skin inflammation, picking can worsen these effects. the resulting inflammation can lead to papules, pustules, nodules, cyst, or abscesses.
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Therapeutic Measures: benzoyl peroxide, antibiotics erythromycin or tetracycline, vitamin a acid, retin a, tretinoin, topical agents may be used alone or in combination. it may take 3-6 weeks before improvement is seen.
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medical treatment helps prevent new lesions and helps control current lesions. Effective topical agents include benzoyl peroxide, which is an antibacterial agent that may help prevent pore plugging, antibiotics to kill bacteria in follicles, and vitamin a acid, retina-a, tretinoion to loosen pore plugs and prevent occurrence of new condones.
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How do you apply topical medications to acne? Apply with clean hands to acne prone areas, not just where acne occurs. apply to dry skin, not near eyes, nasoliabial folds, or corners of the mouth-due to possible irritation.
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Tretinoin at night and others in morning or afternoon. tretinoin is neutralized if mixed directly with other agents. careful of sun exposure or sun lamps with tretinoin. continue treatment even if skin better.
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What should be used for severe acne? systemic antibiotics, long term, low dose. and accutane, isotretinoin are usually reserved for severe cases. estrogen therapy, oral contraceptives. come done extraction. cryosurgery. mild peeling, dermabrasion, excision of scares. injection of fibrin or collagen.
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What are some Parasitic Skin Disorders
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Pediculosis, Scabies, Pemphigus
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Pediculosis comes in 3 forms. Pediculosis capitis, head lice. pediculosis corporis body lice, pediculosis pubis, pubic or crap lice.
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Generally, the lice bite the skin and feed on human blood, leaving their eggs and excrement, which can cause intense itching. the lice are oval and are approximately 2 mm in length.
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complications
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Secondary bacterial infections can occur with pediculosis capitis, resulting in impetigo, furnuncles, pustules, crusts, and matted hair. complications of pediculosis corporis include secondary infection and hyper pigmentation. most importantly body lice may be vectors for rickettsial or other systemic diseases
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therapeutic measures
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medical treatment is aimed at killing the parasites and mechanically removing nits. OTC pediculicides containing pyrethrins or permethrin are the most commonly recommended compounds. some lice develop pesticide resistance. manually removal may be necessary.
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Scabies pathophysiology
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A contagious disease caused by the mite sarcoptes scabiei. it results from intimate or prolonged skin contact or prolonged contact with infected clothing, bedding, or animals. dogs, cats, or other small animals. the parasite burrows into the superficial layer of the skin. These burrows appear as short, wavy, brownish black lines. the patient is asymptomatic while the organism multiplies, but it is most contagious at this time. symptoms do not occur until almost 4 weeks after the time of contact.
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Prevention: all persons and animals in intimate contact with an infected patient should be treated at the same time to eliminate the mites. the mites survive less than 24 hours without human contact. therefore, bed linens, clots, and towels should be washed, but furnishings need not be cleaned. Clean clothing and linens should be applied.
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signs and symptoms: the major complaints are itching and rash. itching can be intense, especially at night. the itching occurs about 1 month after infestation and may persist for days to weeks after treatment. the rash appears as small, scattered erythematous papules, concentrated in finger webs, axillae, wrist folds, umbilici, groin, and genitals. crust and scales may be present. male patients may have excoriated papules on the penis and groin area.
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Complications: Hypersensitivity reaction to the mite can result in crusted lesions, vesicles, pustules, excoriations, and bacterial super infections.
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Diagnostic tests: it is confirmed by a superficial shaving of a lesion and microscopic evaluation for adult mites, eggs, or feces.
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Therapeutic Measures- Topical scabicides permethrin, crotamition are used for chemical disinfection. usually the cream or lotion is applied in a thin layer to the entire body from neck to feet including genitals, umbilicus, and skin fold areas., is left on overnight 8-12 hours, and is washed off in the morning, however, package instructions, should be referred to for each medication.
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Patient Education: a warm soapy bath or shower removes scales and skin debris. Advise the patient to apply the topical medications as ordered. not to use scabicides repeatedly, because they can increase itching and cause further skin irritations, to follow medication directions, to treat family members simultaneously to eliminate mites' to wear clothing. and use clean linens. remind the patient that itching may continue for up to 2 weeks after treatment, until the allergic reaction subsides. Dead mites remain in the epidermis until exfoliated.
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Animals infested with scabies should be treated by a vet, so they won't infect humans.
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What is the pathophysiology and etiology of Pemhigus?
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Pemphigus is an acute or chronic, serious skin disease characterized by the appearance of bullae, large fluid filled blisters of various sizes on otherwise normal skin and mucous membranes. Etiology is unclear, but it is known to be an autoimmune disorder. sun exposures, genetic predisposition, and certain foods and drugs-pencillin, may trigger the disorder. occurs in patients from middle to older age. one type is associated with malignancy.
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the autoimmune response that occurs in pemphigus causes patient own antibodies to attack
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What are some forms of skin lesions?
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Malignant Skin Lesions
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What data should you collect when caring for patients with disorders of the integumentary system?
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What nursing care will you provide for patients with each of the skin disorders?
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How will you know if your nursing interventions have been effective?
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If medical and nursing care have been effective, the lesions will be controlled or in remission, the patient will state that itching and discomforts are controlled, the patient will be able to socialize without undue difficulty, and the patient will be able to describe and demonstrate self care measures.
