Adult Health Nursing: Chapter 3

Bulla (table 3.1 p. 59-63)

vescile > 1 cm in diameter Examples: blister, pemphigus vulgaris

Vit C effective in

viral infection

Bacterial Disorders of the Skin

Cellulitis Impetigo Contagiosa Folliculitis, Furuncles, Carbuncles, & Felons

Nevi (Moles)

congenital skin blemish usually benign, but may become malignant assess for any change in color, size, or texture assess for bleeding or pruritus

Mneumonic for assessing growths or changes in a mole: ABCDE

*A* is the mole Asymmetric? *B* are the Borders irregular? *C* is the Color uneven or irregular? *D* has the Diameter of growth changed recently? (<6 mm-pencil eraser) *E* has the surface area become Elevated?

Dematitits Venenata, Exfoliative Dermatitis, and Dermatitis Medicamentosa

*Etiology and Pathophysiology*: -Dermatitis venenata results from contact with plants (poison ivy/oak) -Exfoliative dermatitis caused by ingestion of heavy metals, such as arsenic or mercury, or by antibiotics, aspirin, codeine, gold, or iodine -Dermatitis medicamentosa-people are given a medication in which they are hypersensitive *Clinical Manifestations*: -mild to severe erythema (redness) w/ vesicular eruptions -severe reactions , respiratory distress may occur *Assessment*: Subjective data: c/o of pruritus, burning Objective data: observation of lesions (white in the center and red on the periphery. Vesicles common in dermatitis venenata. Pts w/ dermatitis medicamentosa may have severe dyspnea *Diagnostic Tests*: -Lab exm of IgE and eosinophilia *Medical Managment*: -Therapeutic baths to administration of corticosteriods *Nursing Interventions & Pt. Teaching*: -OTC of calamine lotion used to reduce itching -Therpeutic baths using colloid solution, lotions, ans oitments also help relieve pruritus -Dermatitits venenata-wash affected part immediately after contact -Dermatitis medicamentosa- identify the drug and dicontinue. If offending allergen cannot be pinpointed no drugs should be given -Teach: to wear a medical alert bracelet/necklace *Prognosis*: -Full recovery when offending agent is removed

Herpes Zoster (shingles)

*Etiology and Pathophysiology*: -Person with shingles has hx of chickenpox -varicella virus lies dormant until the person's resistance of infections becomes lowered -Risk factors for shingles: suppressed immunity, aging, infection, and stress -increased lymphocytes *Clinical Manifestations*: -Eruption of the vesicles is preceded by pain -Rash occurs in the thoracic region generally, but can affect lumbar, cervical, & cranial areas -Stops midline -Spinal nerve pathaway -extreme pain and buring (knife-like) -can last 7-28 days *Assessment*: Subjective data: 1) sharp, burning pain, usually on one side 2) severe pruritus of the lesions 3) general malaise 4) hx of chickenpox Objective data: 1) evidence of skin excoriation r/t scratching 2) patches of vesicles on erythematous skin following peripheral nerve pathway 3) demonstration of tenderness to touch in the involved area. Other-frequent requests for analgesics *Diagnostic Tests*: culture that isolates the virus *Medical Management*: -Directed at controlling the pain & preventing 2ndary complications -oral and IV acyclovir w/in 72 hours of onset-reduces pain as well as analgesics , often opiods -steriods may be given to decrease inflammation -lotions (kenalog, Lidex)- relieve pruritus and inflammation -Vaccine to prevent herpes zoster, called Zostavax, recommened for adults over 60 yrs of age and who have had varicella *Nursing Interventions & Pt Teaching* -directed at education about the disease & plan of tx, relieving pain & pruritus, & preventing 2ndary complications -tranquilizers such as lorazapam-decrease anxiety associated w/ severe pain -medicated baths and warm compresses may be ordered to sooth the skin -Begin pt teaching by assessing readiness and knowledge: methods for controlling pain, application of medication and wet dressings, methods for inhibiting the spread of disease, techniques to prevent 2ndary infections, proper diet w/ vit c to promote healing *Prognosis*: Generally good older adults more susceptible to postherpetic neuralgia

Cellulitis

*Etiology and Pathophysiology*: -Potenitally serious infection , involves the underlying tissues of the skin -spread by direct contact with open area on a person who has infection -most common cause in adults are Group A streptococci and staphylococcus aurea. Haemophilus influenzae type B is more common in children -Risk is increased by venous stasis, DM, lymphedema, surgery, malnutrition, substance abuse, presence of another infection, compromised immune function resulting from HIV, treatment with steroids or cancer chemotherapy, or autoimmune diseases, such as lupus erythematous -Cellulitis develops as and edematous, erythamateous area of skin that feels hot & tender, occurs with bacteria enters the skin -may spread and become life-threatening as the infection invades the deeper tissues, lymph nodes, and bloodstream *Clinical Manifestations*: -First S/S: erythema, pain & tenderness over the area of the skin, warm to the touch *Assessment*: -primarliy inspection of skin Subjective data: C/O of fatigue, tenderness, pain, limited movement, general malaise Objective data: Elevated temp accompanied by tachycardia & leukocytosis (elevated WBC) *Diagnostic Tests*: -watch for sepsis; blood cultures, Lactic (+) at 2, septic shock at 4 -CBC-identification of elevated WBC -sometimes tests performed to differntiate between cellulitis & DVT *Medical Managment*: -Antibiotics: if mild oral, serious infection, HCP will order IV antibiotics -Infuse pt with 2-3 L of fluid *Nursing Interventions & Pt Teaching*: -Administer ABX, monitor Pt progress, assess pain, administer analgesic, change dressings & monitor Pt nutrition & hydration status -Keep glucose 100-150 -We want it to drain, can use hot compresses (vasodilate), packing -Teach: important to take entire Rx of antibiotics and to monitor s/s for 2ndary diseases such as yeast infections *Prognosis*: -Cure is possile w/ 7-10 day treatment

Impetigo Contagiosa

*Etiology and Pathophysiology*: -caused by S. aureus, steptococci or mixed bacterial invasion of the skin -highly contagious inflammatory disorder seen in all ages but particluarly in children -spread by touching contaminated linens, clothes etc -lesions start as macules-develop into postulant vesicles and then rupture to form a dry exudate (honey-colored) *Clinical Manifestations*: -manifests on face, hands, arms, and legs -distributed randomly -exudate ranges from pinpoit to size of nickel or larger -highly contagious through contact *Assessment*: Subjective data: pruritus, pain, malaise, spread of the disease to other parts of the body, presence of other diseases Objective data (all or some): erythema, pruritic areas, honey-colored crust over dried lesions, smooth red skin under the crust, low grade fever, leukocytosis, positive culture for S. aureus or steptococcus, purulent exudate *Diagnostic Tests*: -Culture of the exudate & identifying the specific bacterium -Inspection & symptoms *Medical Managment*: -Provider prescribes systemic antibiotics based on C&S, topical atibiotics such as Bactroban -Clean the invloved area with atiseptic soaps and remove crusted exudate -Primary goal is to prevent glomerulonephritis (toxic to kidneys) *Nursing Inteventions & Pt Teaching*: -Prevent the spread of infection -Instruct pt and family the principles of hygine *Prognosis*: -Good with proper treatment -Pt complete Rx therpies

Angioedema

*Etiology and Pathophysiology*: -form of uticaria & is caused by the same offenders -occurs in SQ tissue instead of skin and mucosa -Local edema of entire area such as the eyelids, hands, feet, tongue, larynx, GI tract, genitalia, or lips *Assessment*: Subjective data: burning, pruritus, acute pain if in the GI tract, respiratory distess in the larynx Objective data: edema, overlying skin appears normal *Diagnostic Tests*: -Careful pt hx -hx of allergies more likely to have angioedema *Medical Management*: -Antihistamine drugs -Epinephrine injections -Infusion of corticosteriods *Nursing Interventions & Pt. Teaching*: -Cold compact/compress -Respiratory assessment -Wear a medical alert bracelet -Education is key to prevent recurrent episodes *Prognosis*: w/ tx is excellent

Uticaria

*Etiology and Pathophysiology*: -presence of wheals or hives in an allergic reaction, commonly caused by drugs, food, insect bites, inhalents, emotional stress, exposure to heat or cold -Anaphylactic shock: SOB, wheeze, anxiety, hypotensive *Clinical Manifestations*: -capillaries dilate, resulting in increased permeability. Respiratory involvement may occur *Assessment*: Subjective data: c/o of pruritus, edema, burning pain, & sometimes dyspnea Objective data: identifies transient wheals of varying shapes & sizes w/ well defined erythematous margins & pale centers -intense scratching may be seen -repsiration may be compromised *Diagnostic Tests*: -detailed health hx -allergy skin test -serum examination of IgE *Medical Managment*: -administration of antihistamine and sometimes epinephrine -ID causitive agent *Nursing Interventions & Pt. Teaching*: -ID cause and decrease the discomfort from pruritus -Teach: possible causes and preventions methods, review s/s of anaphylactic shock *Prognosis*: -Pt recover fully when offending agent is removed

Pityriasis Rosea

*Etiology and Pathophysiology*: -skin rash that may affect people of any age but is noted most often in young adults -linked to viral infection -caused by a virus, but unclear which virus *Clinical Manifestations*: -Herald patch, scaly area up to 4 in in diameter -W/in 7-14 days after the initial eruption, smaller matching spots become widepread on both sides of the body *Assessment*: -Inspecting the skin & gathering a detailed health hx. Ask questions r/t subjective data *Diagnostic Tests*: -based on inspection and subjective data provided by pt. No specific laboratory tests support a definitive diagnosis *Medical Managment*: - 1% hydrocortisone cream, UV light such as sunbathing for 30 min shortens duration *Nursing Interventions*: -symptomatic relief -analgesics and oatmeal baths decrease pain -antihistamines and topical steriods control pruritus -sun exsposure aids in resolution of lesions *Prognosis*: -Self limiting and resolves in a few weeks

Contact Dermatitis

*Etiology and Pathophysiology*: Caused by direct contact w/ something they're allergic to (hypersensitive) Epidermis becomes inflamed and damaged by repeated contact w/ physical and chemical irritants Common causes are detergents, soaps, industrial chemicals, plants (poison ivy) *Clinical Manifestations*: -Lesions appear first at the point of contact -Burning, pain, pruritus, & edema -Papules *Assessment*: Subjective data: tried a new soap, travelling recently, working with plants or flowers Objective data: Erythema (redness), papules, scratch marks, edema *Diagnostic Tests*: Health hx ID skin testing Elevated IgE levels and Eosinophila- both tests r/t abnormalities to T-cell function *Medical Management*: Identify cause Cortecosteriods and Antihistamines Desynthesization (allergy shots) *Nursing Interventions & Pt Teaching*: Protect the skin Wet dressing using Burrow's solution Aseptic technique A cool environment & cold compressess may be applied to vasoconstrict Fingernails should be cut to the tip Clothing should be lightweight *Prognosis*: Removal of offensive agent normally results in full recovery

Scabies

*Etiology and Pathophysiology*: Caused by the human itch mite More common in females Mite penetrates the skin and makes burrow May lay eggs, transmittd through prolonged contact *Clinical Manifestations*: Wavy, brown, thread-like, microscopic lines on the body, especially the hands, arms, body folds, & genetalia *Assessment*: Subjective data: severe pruritus, skin excoriation from scratching Objective data: wavy, brown lines on the body . severe erythema from scratching -Common areas for rash: webbing between the fingers, wrists, elbows, arm pits, waistline *Diagnostic Tests*: Skin scraping which may yeild the mite *Medical Management*: Crotamiton (Eurax) and a 4%- 8% solution of sulfur in petrlantum may be prescribed *Nursing Interventions & Pt. Teaching*: -Restore skin integrity -Improve hygiene -Apply medications *Prognosis*: good w/ adequate tx

Eczema

*Etiology and Pathophysiology*: Chronic inflammatory disorder of the integument Allergen causes hitamine to be released, & an atigen-atibody reaction occurs -allergy association w/chocolate, wheat, eggs, and OJ *Clinical Manifestations*: Papular and vescular lesions appear and are surrounded by erythema. Vesicles generally rupture, discharging a yellow, tenacious exudate that dries & encrusts. Lesions become infected, skin loses its pigment and become shiny with dry scales. *Assessment*: Subjective data: c/o of pruritus and scratching. Children are generally fussy & irritable, anorexia is common, skin sensitive to touch Objective data: vesicles & papules found on the scalp, forehead, cheek, neck, and surfaces of the extremities. Erythematous and dry. Tiny cracks in epithelium allow fluid to escape and further promote dryness *Diagnostic Tests*: -Health hx -Hereditary -Dietary patterns -Skin testing to identify specific substance of hypersensitivity *Medical Managment*: -Hydration of the skin is key to tx -Soak the affected area in warm water for 15-20 minutes, then apply occlusive ointment (petrolatum and corticosteriods) *Nursing Interventions & Pt. Teaching*: -Tx of symptoms -Administer therapeutic bath & occlusive preparations -Use wet dressings to maximize hydration -Nurse provides emotional outlet, encourage pts to share emotions & use open-ended questions *Prognosis*: Chronic

Folliculitis, Furuncles, Carbunvles and Felons

*Etiology and Pathophysiology*: Folliculitis: infection of hair follicles--> S. aureus bacteria -often occurs in men and women who shave -stye resulting from infected eyelash Furuncle: Inflammation that begins deep in the hair follicles and spreads to surrounding skin Carbuncle: cluster of furuncles Felon (own class): Infection of soft tissue under and around an area as the fingernail *Clinical Manifestations*: -Edematous, erythematous, painful, & pruritic -Exact area may become shiny -Lesion may begin to present w/ pointed head &point up, in a furuncle or carbuncle the center turns yellow -Carbuncles have 4 or 5 cores that sponataneously rupture-pain stops *Assessment*: Subjective data: tenderness, pain with movement -ask family hx of DM or wearing improperly fit clothing Objective data: noting erythema, edema, pt often overweight & may have poor hygeine *Diagnostic Tests*: -Physical exam, health hx, inspection of the area *Medical Management*: -Preventing the spread of infection -Topical antibiotics *Nursing Interventions & Pt Teaching*: -Warm soaks, 2-3x daily -Good medical asepsis -Teach: do not touch exudate, meticulous hand hygiene, b4 and after contact w/ lesions. Each patient needs own toilet items, bath linens-not to be shared. Use bacteriostatic soap/shampoo *Prognosis*: -Full recovery when they follow the tx plan. F/U with PCP

Systemic Lupus Erythematosus

*Etiology and Pathophysiology*: Inflammatory condition w/ skin manifestations that can lead to the autoimmune disease Inflammation of almost any body part, multisystem inflammatory disorder Body produces antibodies against itself Incurable Decreased number of T-suppressor cells, & remaining have decreased/limited function 10 % of cases are men *Clinical Manifestations*: Oral ulcers, arthalgias or arthritis, vasculitis, rash, necphritis , pericarditis, synovitis, organic brain syndromes, peripheral neuropathies, anemia, leukopenia, thrombocytopenia, coagulopathies, immunosuppression, and dermatitis *Diagnostic Tests*: Positive results for one or more diagnostic tests along w/ at least 3 other criteria lead to diagnosis of SLE: -Butterfly rash, Alopcia, Phtosensitivity, Oral ulcers, Polyarthralgias & polyarthritis, neurologic signs, hematologic disorders, positive ANA *Medical Management*: -Relief symptoms -Alleviation of exacerbations -Prevention of outward complications - NSAIDs, anitmalarial drugs, corticosteriods, antineoplatics, anti-infectives *Nursing Interventions & Pt. Teaching*: - Skin care -balance between rest and activity -recognition of signs of exacerbation & infection -stress reduction -balanced nutrition Education: r/t helping the pt live a normal life, focus on activity level, prevention of infection, and potential complications *Prognosis*: No cure , depends on nature and severity survival rate is variable

Acne Vulgaris

*Etiology and Pathophysiology*: Inflammatory papulopustular skin eruption that involves sebaceous glands, occurs primarily in adolescents Exact cause is unknown Stress, hormone fluctuations, medications, grease & oil-containing cosmetics, & sweat Acne develops when oil glands become occluded *Clinical Manifestations*: -found on the face, neck, upper chest, shoulders, & back -tenderness & edema in the area, followed by comedo (blackhead) *Assessment*: Subjective data: asking adolescent how it affects lifestyle/ self-image Objective data: noting the presence of edema. Comedones (blackheads) are found on the skin of the face, back, or chest *Diagnostic Tests*: Inspection of lesions & health hx that supports diagnosis Blood tests: ALT, AST-needed for Acutane *Medical Management*: Topical systemic of interlesional medications Cleanse, dry, reduce inflammation, reduce bacterial count, or reduce sebum production Acutane *Nursing Interventions & Pt. Teaching*: -self-esteem may be hindered with acne -keep hands & hair away from face, wear clothes that do not restrict affected areas, wash the hair daily, & wash the skin 2-3 x daily w/ medicated soap -3 weaks of tx required b4 noticable improvement *Prognosis*: good however lasting psycological effects can occur from scarring

Pediculosis

*Etiology and Pathophysiology*: LICE-parasitic disorder of the skin -poor living conditions, hygiene -Transmitted by close contact -3 Types: Capitis, Corporis, Pubis *Clinical Manifestations*: -Nits or lice can be seen on the body -Pinpoint, raised macules, pinpoint hemorrhages, & severe pruritus confirm the diagnosis -Excoriation common *Assessment*: Subjective data: c/o of pruritus, tenderness & difficulty wearing clothes Objective data: erythema, petechiae, and skin excoriationin the affected area look for gray, shiny, oval bodies -They are killed & must be picked off using a nitt comb *Diagnostic Tests*: Physical exam Health hx *Medical Management*: OTC: Permethrinor pyrethrin Perscription: benzyl alcohol, malathion, lidane *Nursing Interventions & Pt. Teaching*: -Applying meds to rid of lice -stress the nature of transmission -anything that came in contact must be washed-furniture, clothing, etc *Prognosis*: good w/ proper tx

Psoriasis

*Etiology and Pathophysiology*: Noninfectious skin disorder Hereditary, chronic, poliferative disease involving the epidermis & can occur at any age Normal skin regeneration is 28 days, w/ psoriasis it may decrease to 7 days Severe scaling occurs from rapid cell division *Clinical Manifestations*: -Lesions appear raised, erythematous, circumscribed, silvery scaling plaques. Primary lesion is papular *Assessment*: Subjective data: mild pruritus, expression of feelings of depression, frustration, lonliness, increased self-conciousness about appearance Objective data: dull erythematous, sharply outlined plaques covered w/silvery scales in the elbows, knees, and scalp *Diagnostic Tests*: No specific tests Observation of pt and signs displayed *Medical Management*: -Slowing poliferation, topical steriods & keratolytic agents -Photochemotherapy, involves the use of drug enhanced by exposure to light (UV light) -methotrexate and Vit D *Nursing Interventions & Pt. Teaching*: -Proper administration of the therapeutic modality -The patients emotional needs are as important as the physical needs *Prognosis*: Chronic disease, fewer than half have a prolonged remission

Burns

*Etiology and Pathophysiology*: Thermal: flames, scalds, and thermal energy Non-Thermal: electricity ,chemicals, and radiation Burns Effect depends on 2 Factors: 1. Extent of the body surface burned, temperature of agent, type of agent 2. Depth of the burn injury Extent of the burn is measured in total body surface area TBSA Burns exceeding 20 % result in massive evaporative water losses and fluid loss into the interstitial spaces 3 Stages: Stage 1 Emergent, Stage 2 Intermediate or acute, Stage 3 Long-term rehabilitation *Assessment*: Includes 1) depth of the burn 2) causitive agent 3) temperature and duration of contact 4) skin thickness Rule of Nines: Determines TBSA burned Divides the body into multiples of nine, Entire head is 9%, anterior and posterior aspects of the arms are 9%, legs are 9% anterior and 9% posterior, chest and back 18% each, perineum is 1% Note: the rule of nines does not take into account the different levels of growth and is not accurate for children Subjective data: causitive agent, temperature and duration, patients age, able to communicate-rate pain score 0-10. Objective data: depth of the burn, skin thickness, percentage of TBSA, specific location, other injuries sustained Factors determining major, moderate, minor: 1) % of TBSA burned, 2) victims age 3) specific location 4) cause of the burn 5) other diseases present 6) depth of the burn 7) injuries sustained during the burn *Diagnostic Tests*: -Physical exam -Blood assessments: electrolytes, CBC, ABG, serum chemistries, done to determine severity of dehydration. In Inhalation burns carboxyhemoglobin level is elevated. Fatalities occur with CO2 poisoning

Tinea Capitus Tinea Corporis Tinea Cruris Tinea Pedis

*Etiology and Pathophysiology*: Tinea capitis-ringworm of the scalp Tinea corporis-ringworm of the body Tinea cruris-jock itch, found in the groin area Tinea pedis-athletes foot, most common *Clinical Manifestations*: Tinea capitis- erythematous, round lesion with pustules around the edges, temporary alopecia occurs at the site , & infected hairs turn blue-green under a Wood's lamp (UV light) Tinea corporis- flat lesions that are clear in the center with erythematous borders Tinea cruris- red brown lesions that migrate out of the groin area Tinea pedis-produces more skin maceration than others *Assessment*: Subjective data: symptoms of extreme pruritus & tenderness from excoriation of the area Objective data: Tinea capitus-inspection and locatation of a round, scaled lesion that has pustules around the edges of the scalp, involved area is erythematous and no hair. Tinea corporis-lesions are flat w/ clear centers and erythematous borders on nonhairy body parts. Tinea cruris- groin area reveals brown red lesions that radiate outward w/ skin excoriation and scratching. Tinea pedis- fissures between toes and soft skin accompanied by vascular lesions and thick toenails *Diagnostic Tests*: Visual inspection and for tinea capitus, use of Wood's lamp Thorough health hx *Medical Management*: Use of topical or oral antifungal drugs (Fulvicin, Tinactin, Desenex) Treatment lasts from 2-6 wks *Nursing Interventions & Pt Teaching*: 1) protect the involved area from trauma & irritation by keeping clean and dry 2) alliviate fungus through proper application of medications and warm compress Tinea pedis should be treated with warm soaks, using burrows solution (5% aluminum subacetate)-has antiseptic properties relieves itching, & aids in reduction of bactercidal and fungal growth Patient Education: teach proper skin care & comfort measures, review meds to be taken, procedures for pt to do at home, ephasizing fungal infections may take months to cure *Prognosis*: Good, few complications result when treatment is followed

Herpes Simplex

*Etiology and Pathophysiology*Herpesvirus 1. Type 1 (HSV-1): most common, cold sores (fever blisters), assosiated w/ febrile conditions, self-limiting (clears up on its own) 2. Type 2 (HSV-2): causes lesions in genital area (genital herpes) -Transmitted by direct contact with open lesion -primary mode of transmission for HSV-2 is through sexual contact -Type 1 associated with oral lesions but can manifest anywhere on the body -Lesions appear 2 days-2 weeks after exposure & present for 2-3 weeks, most painful in the 1st week -severe consequences in pregancy: miscarraige/premature delivery linked, may be fatal to newborn when transmitted during childbirth. Women who have active herpes lesions at childbirth have C-section *Clinical Manifestations*: Type 1: characterized by a vesicle at the corner of the mouth, lips or on the nose, cold sores typically occur after an acute illness or infection Type 2: genital herpes, produces various types of vesicles that rupture & encrusts, causing ulcerations -cervix most common in women -penis most common in men Flu-like symptoms occur 3-4 days after rupture of vesicles (HA, fatigue, myalgia, fever, anorexia) -experience difficulty voiding -initial outbreak is most severe *Assessment*: Subjective data: C/O fatigue, puritus, & burining pain in the mouth for HSV-1 and genital area for HSV-2, also pain with urination Objective data: HSV-1: edematous and erythematous n face, mainly lips, but may spead to eyes. HSV-2: labia, vulva, penis is edematous & erythematous, rupture of vesicles may develop dried exudate. Lymph nodes may be tender or enlarged *Diagnostic Tests*: Culture from the lesion *Medical Managment*: No cure, treatment focuses on symptoms of relief, Antiviral drugs-acyclovir (Zovirax) can shorten outbreak and lessen severity & pain, initail outbreak is treated for 7-10 days & subsequent 5 days> High dose IV use can produce nephrotoxicity Pt with frequent outbreaks may be prescribed daily suppresive therapy-valacyclovir (Valtrex) Tylenol given for pain relief, pain may require local anesthetic such as lidocaine (Xylocaine) or systemic analgesics such as codiene and asprin *Nursing Interventions & Pt Teaching*: Focus on symptom tx and preventing spread of the disease Lesions should be kept clean and dry wear loose, absorbent underclothing Sitz baths decrease lesion discomfort & enhance urinary and bowel elimination. Warm compress to relieve pain and severe pruritus Type 2 can still be transmitted by viral shedding even during periods of remission Preventing infection is the priority when caring for pt with open skin lesion *Prognosis*: Has no cure healing time for type 1 is 10-14 days, type 2, 7-14 days 75% recurrence rate

Mnemonic for assessing chief complaint: PQRST

*P*roactive and Palliative factors (factors that cause the condition) *Q*uality and Quantitiy (characterisitics and size) of the skin problem *R*egion of the body *S*everity of the signs and symptoms *T*ime (length of time the pt has had the disorder)

Psychosocial Assessment

Body image & self-esteem may be affected Society's reaction has significant effect on pt Personal appearance is prinary concern May need to socially isolate the pt Mentally feel shunned

Inflammatory Disorders of the Skin

-Contact Dermatitis -Dematitits Venenata, Exfoliative Dermatitis, and Dermatitis Medicamentosa -Uticaria -Angioedema -Eczema (Atopic Dermatitis) -Acne Vulgaris -Psoriasis -Systemic Lupus Erythematosus

malignant melanoma

A cancerous neoplasm pigment cells (melanocytes) made, & sometimes the SQ tissue -Melanoma is the most deadly skin cancer -The increased occurance is associated w/ tanning (recreational exposure) bed use -Heredity, large number of moles, hx of skin cancer is a risk factor *Clinical Manifestations*: 1) superficial spreading of melanomas 2) lentigo malignant melanomas 3) nodular melanomas 4) lentiginous melanomas *Assessment*: Subjective data: thorough health hx r/t to skin cancer. Pts at greatest risk have fair complexions, blue eyes, red or blonde hair, & freckles Objective data: location , color, appearance *Diagnostic Tests*: Tissue biopsy *Medical Management*: -Surgical excision, skin grafts, chemotherapy, nonspecific immunotherapy, chemoimmunotherapy, & radiation *Nursing Interventions & Pt. Teaching*: -Pain relief -reduction of anxiety -palliative tx of disease -Discharge insctructions: wound care, medication, cleansing, F/U care. Regular examinations & skin self-assessment *Prognosis*: Individuals w/ lesions less than 1 mm thick have a survival rate of almost 100 % whereas those w/ lesions 3 mm thick or thicker have survivor rates of less than 50%

Squamous cell carcinoma

Arises in the epidermis Firm, nodular lesion topped w/ a crust or central area of ulceration & indurated margins metastasis 10% by way of lymphatic system

stage 2: intermediate or acute (diuretic)

Begins 48-72 hours after the burn injury, Circulatory overload may result from fluid shift back from the interstitial spaces into the capillaries. *Pathophysiology*: Increased BV ---> Increased CO and Increased renal perfusion--->diuresis -less tissue edema -monitor VS, UO, & LOC Other complications: heart failure, renal failure, hyperkalemia contractures, curlings ulcer -Decreased blood supply to gastric mucosa ischemia, paralytic ileus The acute phase begins when the kidneys excrete large volumes of urine and when fluids shift back to the intravascular compartment, usually 72 hrs after the burn. -may last 10 days-months. -Infection is most common complication and cause of death after 72 hrs. -Curling ulcer (duodenal ulcer that develops 8-14 days after severe burns on the surface of the body; the first sign is usually vomiting of bright red blood.) *Nursing Interventions*: Head to Toe Assessment: 1. Respiratory pattern 2. VS 3. Circulation 4. Intake and output 5. Ambulation 6. Bowel sounds 7. Inspection of the wound itself 8. Mental status Monitor the Pt for signs of acute renal failure such as elevated serum creatinine and BUN. Serum potassium levels may rise sharply in the first 72 hrs. *Primary goal include proper care of the burn wound to promote healing and prevent infection & prevention & treatment of complications* Assessment for infection of the burn wound includes: increased erythema, odor, or a green/yellow exudate. -Adequate nutrition remains a corner stone of burn care during the acute phase, increased amount of protein, calories, and vitamins help repair the damaged tissue. -Monitor nutritional status: daily weight, serum electrolytes, serum albumin, & urinalysis. Skin grafts will not be successful unless nutrition is adequate -Wear PPE with major burns -TransCyte (temporary bioengineered skin substitute, 1st product approved by FDA, provides a temporary covering that protects against fluid loss and reduces risk of infection) -Removal of Eschar (can harbor microorganisms and cause infection) -Daily debridement -CircOlect or Clinitron bed -Chilling may be controlled by keeping room temp 85 F (29.4 C), light or heat lamps for additional warmth. Humidity 40-50 %. -Skin grafts are used ASAP for full-thickness burns (autograft-self, homograft-another person such as a cadaver, heterograft-another species, pig or cow) -grafts applied by Pedicle or Freestanding method -no pressure on the grafts/no walking -Eat by mouth as soon as condition permits, daily caloric intake 2000-6000 cal depending on burn -ROM & positioning

Stage 3: Long-term Rehabilitation phase

Begins at same time as wound Tx Begins upon admission Second outcome is freedom from wound infection In a burn injury, usually the greatest fluid loss occurs w/in the first 12 hrs. Fluid shift and the loss of intravascular fluids may lead to the development of burn shock. Fluid return notes the end of hypovolemic shock and the beginning of the Diurectic state. A burn victim may experience smoke inhalation damage from breathing chemicals produced by the burn. -atelectasis can occur -signs of respiratory difficulty include a hoarse voice or productive cough --Singed nasal hairs --Agitation, tachypnea, flaring nostrils, or intercostal retractions --Brassy cough, grunting, or guttural respiratory sounds --Erythema or edema of the oropharynx or nasopharynx --sooty sputum Goal: promote independence *Patient Teaching*: Provide written instructions that are complete , comprehensive, easy to understand , and realistic The major topics to cover are: -Wound Care -S/S of complications -Dressings -Exercises -Clothing -ADLs -Social skills *Evaluation*: -Can the pt take care of self? -Can the pt ambulate w/out difficulty? -Can the pt and family cope? -Does the pt have contractures? -Does the pt understand the tx process? *Prognosis*: Depends upon size, depth; victims age; the body part involved; the burning agent; hx of cardiac, pulmonary, edocrine, renal, or hepatic disease; and other injuries sustained at the time of the burn.

Argyria

Blue from drinking silver. Damages liver. Never goes away. These people believe it's the fountain of youth (silver prevents bactercidal growth). Slow progression.

Full Thickness (3rd degree) burn

Cause: Contact w/ hot liquids or solids, Flame, Chemicals, Electrical contact Apperance: Dry w/ leathery eschar, charred vessels visible under eschar, No blanching with fingertip pressure Color: White, charred, dark tan, black, red Sensation: Little or no pain, hair easily pulls out

Partial thickness (2nd degree) burn

Cause: contact w/ hot liquids or solids, flash flame to clothing, direct flame, chemicals, UV light Appearance: Large, moist vesicles, Blanches w/ fingertip pressure Color: mottled with dull, white, tan, pink, or cherry red areas Sensation: very painful

Superficial (1st degree) burn

Cause:Flash flame, UV light (sunburn) Appearance:Dry, no vesicles , minimal or no edema, Blanches w/ fingertip Color: Incrased erythema Sensation: painful

Vit D synthesis

Cholesterol compounds in the skin converted to vit D when bare skin is exposed to the sun's UV rays. Is necessary for healthy bone development.

Paronychia

Disorder of the nails Nails become soft or brittle, the shape changes Nails are painful as they loosen and seperate from the tissue Wet dressings or topical antibiotics may be used

Structures of the skin

EPIDERMIS -Outermost layer (stratified squamous) -cells packed tightly -has no ditinct blood supply -Divided into layers: ---Stratum germinativum: deep innermost layer of epidermis, only layer able to undergo cell division and reproduction. recieves blood supply and nutrition from underlying dermis through diffusion ---Stratum corneum: Flat & the cell structure is filled with a protein called keratin. Keratin makes cells dry, tough, waterproof ---Melanocytes: highly specialized cells that give skin pigment of melanin (black or dark brown hair that is naturally inhair, skin, eyes). Melanin is responsible for skin color. Higher concentations result in darker skin tones. Melanin levels are detemined genetically. DERMIS -or corium/true skin -well supplied with blood vessels & nerve, contains glands & hair follicles -composed of connective tissue , cells scattered among collagen & elastic fibers -recieves its strength from collagen & flexibility from elastic tissue fibers -cells are bathed in interstitial fluid (tissue fluid) -small fingerlike projections calle papillae located in the upper portion of the dermis that project into the lower portion of the dermis. SUBCUTANEOUS (superficial fascia) LAYER -connects the skin to the msucle surface -composed of adipose tissue & loose connective tissue -Functions are: storing water & fat, body insulation, protection for the organs, providing a pathway for nerve & blood vessels

Hypertrichosis (hirsutism)

Ecessive growth of hair in masculine distribution Can be hereditary or results of hormonal dysfunction TX involves removal by electrolysis, dermabrasion, chemical depilation, shaving, tweezing, rubbing w/ pumice

Stage III Pressure Injury

Full-thickness tissue loss SQ fat is sometimes visible

Stage IV Pressure Injury

Full-thickness tissue loss & SQ layer with exposed bone, tendon, cartilage, or muscle Pt is at risk for osteomyelitis Pt needs protein intake

Unstageable Pressure Injury

Full-thickness tissue loss, wound base covered by slough (yellow, tan, gray, green, or brown), and eschar in the wound bed Stable eschar on the heels provides a natural biologic cover: do not remove it

Viral Disorders of the Skin

Herpes Simplex Herpes Zoster Pityriasis Rosea

Alopecia

Loss of hair Can be caused by aging, drugs, anxiety, disease processes Unless r/t aging usually not permanent Body image & self-esteem are threatened

Skin

Major organ and outer covering of the body essential for life First line of defense against infection and injury

Kidney Failure Apperance:

Pale/gray, premature aging, anemic, produce many unprocessed toxins

Parasitic Diseases of the Skin

Pediculosis Scabies

Psychosocial Assessment and Decreasing Pt anxiety

Provide the pt with consistent info r/t his/her care plan Include the family in the treatment plan Provide positive feedback Refer the pt to a support group

Appendages of the skin

SUDORIFEROUS (sweat) GLANDS -3 million sweat glands -cools the bodys surface -sweat is composed of water, salts, urea, uric acid, ammonia, sugar, lactic acid, & absorbic acid (Foods that affect smell: garlic, ginger, onions, asian foods) CERUMINOUS (ear wax) GLANDS -modified sudoriferous glands -secrete cerumen, wax-like substance, located in the external ear canal -protects ear canal from foreign body invasion -too much can cause impaction and infection SEBACEOUS (oil) GLANDS -secrete sebum through hair follicles -lubricates skin and hair -sebum inhibits bacterial growth -in a dry climate these glands work harder HAIR & NAILS -hair is composed of modified dead epidermal tissues -mainly keratin -surrounding the hair follicle is a band of muscle tissue called arrector pili -cold and fear caused these muscles to contract creating goosebumps -within the nails the keratin is mor compressed/compact than hair -part of the root, lunula, looks like a white crescent, remainder is called the nail body apperaing pink from blood vessels beneath it

Hypotrichosis

The absence of hair or decrease in hair growth Skin disease, edocrine problems, and malnutrition are associated factors Tx involves identifying and treating the cause

Stage 1: Emergent phase

The onset of the injury until the patient stabalizes Is the scene safe? Hypovolemic shock is a major concern for up to 48 hours after a major burn -Potassium (K), BUN, Creatinine, Hct increase, GFR decrease, -s/s of hypovolemic shock: hypotension, <UO, tachycardia, rapid/shallow breathing, restlessness 1. The primary concern is to stop the burning process, Stop, Drop, Roll Technique 2. Provide an open airway 3. Control the bleeding 4.Remove all noninherent clothing and jewelry 5. Cover the victim with a clean sheet or cloth 6. Transport the victim to the hospital -Electrical burns have an entry and exit points. Most result in cardiac arrest. -Assess ABCs (airway, breathing , circulation) -Carbon Monoxide poisoning: likely if the pt was in a closed area. CO displaces O2 from Hgb. Not detectible from Pulse ox. Early S/S: HA, N, V unsteady gait, Pt turned red, finger nail beds turned blue, may be agitated or confused. Tx: 100% oxygen -Moderate- Severe burns: 1) Establish airway 2) initiate fluid therapy 3) Insert foley catheter to determine hourly urinary output; IV fluid are given to maintain renal perfusion 4) Insert NG tube to prevent aspiration 5) Administer analgesics in small frequent doses 6) Maintain airway and fluid status, and monitor VS The first 72 hours require diligent medical care!!

Assessment of the skin

Thorough assesment helps identify many diseases that result if the skin is penetrated by an outside organism Obtain a careful health hx: -Ask the pt about: 1) recent skin lesions 2) where the lesion first appeared 3) how long the lesions have been present -Explore all complaints of: pain, pruritus (symptom of itching), tingling or burning, -Ask the pt about personal skin care: 1) recent skin color changes 2) exposure to the sun 3) hx of skin cancer Assess the skin: -under natural lighting, use senses of sight, touch, and smell. -inspect and palpate dark skin Observe the color of the skin. Color depends on: -amount of hgb in the blood -amount of melanin in the epidermis -amount of substances, bilirubin, urea, or other chemicals in the blood -O2 sat of the blood -quality & quantity of blood circulating in the superficial blood vessels skin lesion assessment includes a description of the appearance (size, shape, and color), degree of moisture present, drainage, and location

Basal cell carcinoma

Type of skin cancer Scaly mole-like lesion Contact w/ certain chemicals, sun overexposure, & radiation tx Metastasis is rare, but underlying tissue destruction can progress to include vital structures This type of cancer reoccurs in 40-50 % of Pt. treated

Angiomas

When a group of blood vessels dilate & form a tumor-like mass Example: birthmark Tx: involves electrolysis or radiation

Medications to review (table 3.3 p. 69)

acyclovir (Zovirax) Antihistamines, including: diphenhydramine (Benadryl), hydroxyzine (Vistaril) Calamine Lotion fluconazole (diflucan)

Chicken pox is

airborne and contact. If you have the disease or the vaccine, then you can go to droplet.

Disorders of the Appendages

alopecia, hypertrichosis (hirsutism), hypotrichosis, & paronychia

ABCDs of melanoma

asymmetry, border, color, diameter

Verruca (Wart)

can be contagious TX depends on type, location, & number Cauterization, solid CO2, , liquid nitrogen, & preperations of salycylic acid

Beau's lines

depressions in the nails. Acute illness, and high fever can cause changes in the fingernails and enamel on teeth in children.

Crust (table 3.1 p. 59-63)

dried serum, blood or purulent exudate; slightly elevated; size varies; brown, red, black or tan; itchy Examples: scab on abrasion, eczema

Tumor (table 3.1 p. 59-63)

elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter Examples: neoplasms, benign tumor lipoma, hemangioma

Cyst (table 3.1 p. 59-63)

elevated, circumscribed, ecapsulated lesion, in SQ layer, filled w/ liquid or semisolid material (sebum) Examples: sebaceous cyst, cystic acne, boil

*Vesicle* (table 3.1 p. 59-63)

elevated, circumscribed, not into dermis; filled with serous fluid <1 cm in diameter Examples: Varicella (chickenpox), herpes zoster (shingles) *common*

Papule (table 3.1 p. 59-63)

elevated, firm, circumscribed. <1 cm in diameter (viral) Examples: warts, elevated moles, linchen planus

Nodule (table 3.1 p. 59-63)

elevated, firm, curcumscribed lesion, deeper in dermis than a papule, 1-2 cm in diameter Examples: erythema nodosum, lipomas

Plaque (table 3.1 p. 59)

elevated, firm, rough lesion with flat-topped surface, >1 cm in diameter Examples: psoriasis, seborrheic keratosis, actinic keratosis

Wheal (table 3.1 p. 59-63)

elevated, irregularly shaped area of cutaneous edema; solid transient; variable in diameter Examples: insect bites, uticaria, allergic reactions, TB tests

Pustule (table 3.1 p. 59-63)

elevated, superficial lesion simliar to vesicle filled with purulent fluid Examples: impetigo, acne, small pox

Telangiectasia (table 3.1 p. 59-63)

fine, irregular red lines, produced by capillary dilation Examples: Telangiectasia in rosacea (spider veins)

Hypoxic Appearance:

fingernails, lips are blue, rest of body tends to be pale

Clubbing

fingertips widen and become round and spoon out, often caused by low O2 or long-term cyanosis. (broadening) of the fingertips indicates decreased O2

*Macule* (table 3.1 p. 59-63)

flat, circumscribed, changed in color, <1 cm in diameter, (not fluid filled) Examples: freckles, flat moles, *measles*, scarlet fever, petechiae (pinpoint hemmorages, pressure, can occur w/ sepsis) *common*

Patch (table 3.1 p. 59-63)

flat, nonpalpable, irregularly shaped macule, >1cm in diameter Examples: vitiligo, Port-wine stains (birthmarks), mongolian spots, cafe-au-lait spots (birthmarks)

Keloid (table 3.1 p. 59-63)

irregularly shaped, elevated, progressively enlarging scar; grows beyond the boundries of the wound; caused by excessive collagen formation during healing Examples: formation after surgery, some burns (blacks & red heads more prone)

Scale (table 3.1 p. 59-63)

heaped-up kertinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size Examples: flaking of the skin with seborrheic dermatitis after scarlet fever, or flaking of the skin after a drug reaction; dry skin

Pressure ulcers are caused by

inadequate perfusion

Tumors of the Skin

keloids, angiomas, verruca (wart), nevi (moles), basal cell carcinoma, squamous cell carcinoma, malignant melanoma *A change in the size , color, border, surface, or elevation of the skin lesion is concerning and should be reported*

Fungal Infections of the Skin

known as dermatophytoses Tinea Capitus Tinea Corporis Tinea Cruris Tinea Pedis

Dark skin

large amounts of melanin accounts for darker skin color increased melanin forms natural sun sheild Dark skin is pre-disposed to certain skin conditions; pseudofolliculitus, keloids, and mongolian spots

Fissure (table 3.1 p. 59-63)

linear crack or break from the epidermis to the dermis, may be dry or moist Examples: athletes foot, cracks in the corner of the mouth, anal fissure

Stage I Pressure Injury

localized area intact nonblanchable redness

Suspected deep tissue pressure injury

localized purple or maroon area discolored intact skin or blood filled painful, firm, mushy, boggy, or warm to cool compared to adjacent tissue

Ulcer (table 3.1 p. 59-63)

loss of epidermis and dermis; concave; varies in size Examples: Pressure sores, stasis ulcers

Erosion (table 3.1 p. 59-63)

loss of part of the epidermis depressed, moist, glistening, follows rupture of vesicle or bulla Examples: varicella, variola after rupture, small pox, tinea pedis, diaper rash

Excoriation (table 3.1 p. 59-63)

loss of the epidermis, linear hollowed out crusted area Examples: abrasion or scratch, scabies Severe: Peristomal dermatitis caused by stool or urine that is irritant to the skin i.e. ileostomy, yeast (bright red) common with diabetics-keep glucose 100-150

Nursing Interventions for Pressure Injuries

ongoing assessement & evaluation of improvement healing is a long term process, make sure plan of care is consistent over time and evalute effectiveness

Keloid

overgrowth of collagenous scar tissue at the site of a wound of the skin Raised, hard, & shiny Management: corticosteriod injections, cryotherapy, laser surgery, radiation, or surgical removal

Stage II Pressure Injury

partial-thickness loss of dermis shallow open injury injuries manifest as intact or open (ruptured) serum-filled blisters

Functions of the skin (Box 3.1 p. 57)

protects temperature regulation prevents excessive water loss insulates body aids in excretion of waste products Vit D synthesis provide the brain with sensory information r/t to pain, hot and cold, touch, pressure, and vibration

Gum recession

recession caused by poor hygiene, brushing too hard, genetics, aging. If gums are pale-not a lot of blood flow-anemic. Gums should be pink in everyone.

person covered in tumors (Neurofibromatosis?) appearance:

risk for infection. People that have skin folds that can't be cleaned in between, they smell (i.e. removal of a cast), cause is genetic, grows on nerves.

Lichenfication (table 3.1 p. 59-63)

rough, thickened epidermis 2ndary to persistent rubbing, itching or skin irriation; often involves flexor surface of extremity Examples: chronic dermatitis

Bed Bugs (not in book)

small like apple seed feed at night on exposed skin blood spots on sheets dark, rusty spots on mattress musty odor multiple red spots from bites

Baldness

stress, genetics, trichomania, autoimmune, culture, thyroid issues, protein intake, gastric bypass surgery-loss of protein, hormones, etc

Skin is subjected to

temperature variances humidity environmental changes risk for exposure to pathogens trauma ecchymosis (bruising) daily wear and tear

Scar (table 3.1 p. 59-63)

thin to thick fibrous tissue that replaces normal skin after surgery or laceration to the dermis -put sunscreen on to prevent permanent color change Examples: healed wound or surgical incision

Atrophy (table 3.1 p. 59-63)

thinning of skin surface & loss of skin markings; skin translucent & paper-like Examples: straie, aged skin, stretch marks

Jaundice appearance:

yellow, cirrhosis of the liver, issues with gallbladder, itchy bc of bile salt accumulating on the skin.