Skin Disorders of the Elderly

C. Cough with fever D. "I will tell my client that transmission-based precautions are not necessary after the first dose of oral antiviral therapy for herpes zoster is taken." C. Perform a head-to-toe skin assessment and document the findings

A 45-year old client is receiving subcutaneous injections of a biologic therapy for plaque psoriasis. Which condition will the nurse immediately report to the provider? A. Missed injection B. Increased pruritis C. Cough with fever D. New plaques on leg Which statement, made by the student nurse, requires further teaching by the nurse preceptor? A. "I will always remove crusts from bacterial lesions before apply topical antimicrobials." B. "I will avoid using adult briefs for my bedridden incontinent client who has a perineal yeast infection." C. "If signs and symptoms of a systemic infection are present, I will contact the health care provider to discuss ordering blood cultures." D. "I will tell my client that transmission-based precautions are not necessary after the first dose of oral antiviral therapy for herpes zoster is taken." The nurse is performing an assessment on a female client and notices a large, irregularly shaped mole on her upper back. The client expresses concern about the cosmetic appearance of the lesion. That is the priority nursing intervention? A. Refer to a dermatological health care provider B. Ask if there are any other lesions that bother her C. Perform a head-to-toe skin assessment and document the findings D. Teach about the importance of avoiding excessive sun exposure and tanning beds

C. Place the child in a bath with colloidal treatment B. Urinary Retention

A nurse is providing teaching to the guardian of a child who has contact dermatitis. Which of the following information should the nurse include? A. Use fabric softener dryer sheets when drying the child's clothing B. Apply a warm, dry compress to the rash area C. Place the child in a bath with colloidal treatment D. Leave the child's hands uncovered during the night A nurse is caring for a client who has contact dermatitis and a prescription for diphenhydramine. For which of the following adverse effects should the nurse monitor? A. Elevated blood glucose levels B. Urinary Retention C. Increased salivation D. Insomnia

A. Apply an occlusive dressing after application. C. Wear gloves after application to lesions on the hands. D. Avoid applying in skin folds.

A nurse is proving information about a new prescription for corticosteroid cream to a client who has mild psoriasis. Which of the followed instructions should the nurse include? (SATA) A. Apply an occlusive dressing after application. B. Apply three to four times per day. C. Wear gloves after application to lesions on the hands. D. Avoid applying in skin folds. E. Use medication continuously over a period of several months.

C. Altered tissue integrity C. Topical steroids C. Wash skin with tepid water

An older adult has a stage 3 pressure injury over the sacral region. Which diagnosis should the nurse use to guide care? A. Risk for infection B. Risk for altered skin integrity C. Altered tissue integrity D. Altered skin integrity The nurse notes that an older adult has a large area of skin atrophy on the left forearm. What should the nurse consider as the reason for this skin change? A. Topical antibiotics B. Silver nitrate dressings C. Topical steroids D. Systemic antibiotics An older patient has a Braden Scale score of 15. What should the nurse add to the patient's plan of care? A. Massage reddened skin areas B. Restrict oral protein intake C. Wash skin with tepid water D. Restrict vitamin C and zine intake

A. Skin integrity will remain intake B. Administer a psoralen medication before the treatment. B. Calcium

An older patient's plan of care includes frequent position changes, application of skin lotion, and assistance with ambulation 3 times daily. Which goal was used when selecting these interventions? A. Skin integrity will remain intake B. Demonstrate safety with ambulation C. Pressure injury will demonstrate signs of healing D. Explain the importance of activity and exercise A nurse is teaching a client who has a history of psoriasis about photochemotherapy and ultraviolet light (PUVA) treatments. Which of the following should the nurse include in the teaching? A. Apply vitamin A cream before each treatment. B. Administer a psoralen medication before the treatment. C. Use this treatment every evening. D. Remove the scales gently following each treatment. A nurse is educating a female client on the use of calcipotriene topical medication for the treatment of psoriasis. Which of the following lab values should the nurse monitor? A. Potassium B. Calcium C. Sodium D. Chloride

Unstageable

Assessment Of Pressure Injuries: · _______________: Unable to determine the depth of tissue damage due to necrotic tissue covering wound bed. Skin loss is full thickness, and the base of the wound is covered with slough/eschar, which covers wound bed

Stage IV Pressure Ulcer

Assessment Of Pressure Injuries: · _________________________: skin loss is full thickness with exposed or palpable muscle, tendon, or bone (or supporting structions) § Injury to the tissue that goes through the fascia § Usually has undermining or tunneling (sinus tracts may develop) § Slough or eschar are often present in the wound § Includes structural visibility involvement: muscle, bone, tendon/ligament § May have osteomyelitis or septic arthritis § TREATMENT: · Debridement/cleaning: normal saline or wound cleanser. If necrotic tissue is present, debridement must be done · Dressing: pack with calcium alginate or ribbon gauze. Covered with adhesive foam or silicone gel adhesive (fragile skin)

Suspected Deep Tissue Injury

Assessment Of Pressure Injuries: · _____________________________: the intact skin are is purple/maroon § Blood filled blisters may be present § Before the changes occurred, the skin may have been painful § Other changes that may have proceeded the skin changes include that the area may have felt more firm, boggy, mushy, warmer, or cooler

Stage III Pressure Ulcer

Assessment Of Pressure Injuries: · _______________________________________: skin loss is full thickness (fat visible). Injury to the skin that goes into the SQ tissue and may be necrotic § Goes to the underlying fascia, but not through. Bone, tendon, and muscle are NOT exposed § May have undermining or tunneling § Deeper crater § TREATMENT: · Debridement/cleaning: normal saline or wound cleanser. If necrotic tissue is present, debridement must be done · Dressing: pack with calcium alginate or ribbon gauze. Covered with adhesive foam or silicone gel adhesive (fragile skin)

Stage I Pressure Ulcer

Assessment Of Pressure Injuries: · ______________________________________________: skin is intact, but the area is red and does not blanche when pressed § Harder to determine in AA: skin darker/lighter than normal, skin warmth/coolness, firm/boggy, pain/itching, may be red/blue/purple § Reversable damage with the removal of pressure and shear force § Irregular erythema § Induration § Boggy or firm § TREATMENT: transparent film or spray (fragile skin); skin protectant or barrier cream; changes PRN when soiled

Stage II Pressure Ulcer

Assessment Of Pressure Injuries: · _____________________________________________________: skin is not intact. There is partial-thickness loss of the epidermis or dermis (or both). § May be characterized as a shallow ulcer, blister, crater or abrasion § Red-pink wound bed, with no exposure of subQ tissue § Bruising is NOT present § TREATMENT: · Debridement/cleaning with normal saline or wound cleanser · Thin foam dressing changed depending on amount of drainage

very high risk

Assessment Of Pressure Injury Risk: · Norton Scale § Developed in 1962 § Scale of 5 to 20 § Larger number = less risk § 10 to 14 = high risk § Less than 10 = _________________ § Ease of use makes it popular · Braden Scale § Looks at incontinence, functional ability, friction and shear risk, and nutrition § Score from 6 to 23 § Higher score = less risk § Under 17 = at risk for developing skin breakdown

DRY AND CLEAN. Apply topical powers PRN (you only use a light dusting, NOT HEAVY AMOUNTS.)

Atopic Dermatitis · Dermatitis (atopic): A chronic skin condition causing intense itching and a red, raised rash. In severe cases, the rash looks like small blisters. § REMEMBER: atopic dermatitis, contact dermatitis, and eczema are all inflammatory reactions to an irritation. VERY SIMILAIR. (unlike psoriasis, which is AUTOIMMUNE) · Treatment: § Avoidance therapy if possible § KEEP THE AREA _____________________________________________________ § Steroid therapy: hydrocortisone, betamethasone, prednisone · Monitor for adrenal suppression · Warm, moist dressings over topical creams ONLY if prescribed.; avoid using occlusive dressings over rash after applied topicals § Antihistamines: diphenhydramine, cetirizine, fexofenadine · Monitor for urinary retention, photosensitivity · Take at bed time due to drowsiness; avoid driving § Topical immunosuppressants: tacrolimus, pimecrolimus (per textbook only, flemmer did not mention these in lecture) · Used for eczematous dermatitis · Monitor for erythema, burning · Avoid occlusive dressings and if infection is present · Discontinue when rash clears · Avoid light and tanning beds

with tighter weaves (if you can see through fabric, the sun can get through it)

Cancerous lesions: · Open sore that does not heal for 3 weeks · Spot or sore that burns, itches, stings, crusts or bleeds · Mole or spot that changes in size or texture · develops irregular boarders · pearly, multicolored, or translucent · Risk factors for Skin Cancer: § Overexposure to sun: working outdoors § Genetics § One or more precursor lesions that resemble unusual moles § Living at lower latitudes § Arsenic exposure, chemical carcinogens · Prevention of Skin Cancer: § Avoid sun exposure between 11am-3pm § Use sunscreens with appropriate strength for skin type (usually at least SPF 30) § Use sunscreen while driving/ in a car, after swimming/sweating/drying off § Wear a hat (w/ 3in brim or baseball hat), opaque clothing, and sunglasses (wraparound frames) when in the sun § Wear clothes with ___________________________________________ § Keep a body map of skin spots, scars, and lesions to detect changes § Examine skin monthly for lesions § Eat diet high in antioxidants (fruits, veggies, green tea) § Indications to seek medical advice: · Change in color of lesions (darkens, spreads) · Change in size (sharp border becomes irregular, or flat becoming raised) · Redness or swelling of the skin around a lesion · A change in sensation, like itching or tenderness · Change in character of a lesion, like oozing, crusting, bleeding, or scaling

§ A: Asymmetrical. One half is different from other half of lesion § B: Borders are ragged, irregular, notched, or blurred § C: Color is varied in the same lesions § D: Diameter is larger than 6mm and enlarging § E: Evolving. Changes in shape, size, color, elevation, new symptoms, itching, bleeding, crusting

Cancerous lesions: · Open sore that does not heal for 3 weeks · Spot or sore that burns, itches, stings, crusts or bleeds · Mole or spot that changes in size or texture · develops irregular boarders · pearly, multicolored, or translucent · Types of Skin Cancers: § Squamous Cell Carcinoma § Nodula Basal Cell Carcinoma § Melanoma · ABCDE: A- B- C- D- E-

use the LEAST amount/dose of steroid. Large, long-term doses can cause loss of subQ tissue, increased fragility/thinness, and very significant changes in skin.

Common Disorders: Pruritis · Pruritis: itching; often associated with skin irritation. It can be very distressing and debilitating. Itching can be localized or generalized and occur with or without a skin rash. § May or may not occur with skin disease (LIVER DISEASE). § Pruritic conditions are common in elderly, such as scabies. · chemical or physical agents can activate nerve fibers directly or stimulate the release of chemical mediators (histamine), which then act on itch receptors · It can be associated with medical conditions, such as diabetes. · Pruritis is a subjective symptom (similar to pain). § May be worse at night. § Some conditions can make it worse, like poor skin hydration, increase in skin temperature, emotional stress or perspiration. · Nursing Interventions for Pruritis: § Increase patient comfort and prevent skin injury with loss of tissue integrity. Patients often scratch itchy areas, which further stimulates the itch receptors and causes the "itch-scratch-itch" cycle § Itchy lesions can be treated by treating the underlying cause. Systemic diseases, like liver(buildup of bilirubin) or venous(lack of blood) disorders, can cause itchy skin lesions. § Keep fingernails trimmed short and file rough edges. Teach family and UAP to trim nails. (careful with diabetic patients to not break skin while cutting nails) § Wear mittens at night to prevent scratching during sleep § Use a cool sleeping environment, cool showers, or MOISTURIZES/LOTIONS (NON-FRAGRANT, NO ALCOHOL; APPLY AFTER A SHOWER!) to promote sleep. Herbal teas and antihistamine drugs can be used to help sleep § If antihistamines are prescribed, monitor the patient's response (diphenhydramine can have worse side effects in older adults) § Topical steroids may be prescribed (apply to damp skin with NO OCCLUSIVE DRESSING). Goal is to _______________________________________________________________

MOISTURIZES/LOTIONS (NON-FRAGRANT, NO ALCOHOL; APPLY AFTER A SHOWER!) to promote sleep. Herbal teas and antihistamine drugs can be used to help sleep

Common Disorders: Pruritis · Pruritis: itching; often associated with skin irritation. It can be very distressing and debilitating. Itching can be localized or generalized and occur with or without a skin rash. § May or may not occur with skin disease (LIVER DISEASE). § Pruritic conditions are common in elderly, such as scabies. · chemical or physical agents can activate nerve fibers directly or stimulate the release of chemical mediators (histamine), which then act on itch receptors · It can be associated with medical conditions, such as diabetes. · Pruritis is a subjective symptom (similar to pain). § May be worse at night. § Some conditions can make it worse, like poor skin hydration, increase in skin temperature, emotional stress or perspiration. · Nursing Interventions for Pruritis: § Increase patient comfort and prevent skin injury with loss of tissue integrity. Patients often scratch itchy areas, which further stimulates the itch receptors and causes the "itch-scratch-itch" cycle § Itchy lesions can be treated by treating the underlying cause. Systemic diseases, like liver(buildup of bilirubin) or venous(lack of blood) disorders, can cause itchy skin lesions. § Keep fingernails trimmed short and file rough edges. Teach family and UAP to trim nails. (careful with diabetic patients to not break skin while cutting nails) § Wear mittens at night to prevent scratching during sleep § Use a cool sleeping environment, cool showers, or ____________________________________________________________ § If antihistamines are prescribed, monitor the patient's response (diphenhydramine can have worse side effects in older adults) § Topical steroids may be prescribed (apply to damp skin with NO OCCLUSIVE DRESSING). Goal is to use the LEAST amount/dose of steroid. Large, long-term doses can cause loss of subQ tissue, increased fragility/thinness, and very significant changes in skin.

topical hydrocortisone for mild, possibly systemic, IM, IV prednisone for more severe

Contact Dermatitis · Signs and Symptoms: § Localized eczematous eruption with well-defined, geometric margins that are consistent with contact by irritant or allergen § Usually seen in acute form but may become chronic if exposure is repeated § Allergy to plants (poison ivy/oak) occurs as linear streaks of vesicles or papules · Care for Contact Dermatitis: § Obtain history: Attempt to identify causative agent. (changes in soap/detergent/fabric softener/etc, new foods, jewelry, new clothes). § DON'T SCRATCH IT. It will break skin, introduce bacteria, then you have a secondary infection. Then you have to get an antibiotic to treat the infection plus other meds to help with contact dermatitis irritation. · CUT NAILS. Possibly wear mittens at night to prevent nighttime scratching § Avoidance therapy (once cause is identified) to reverse reaction and clear the rash. For example, if new soap causes contact dermatitis, the patient shouldn't use it. If jewelry with nickel in it causes reaction, DON'T WEAR IT! § Steroid therapy (__________________________________________________________) to suppress inflammation. Patients taking oral prednisone experience adrenal suppression as a side effect, and they should taper the dose down when discontinuing. · Teach the patient that the steroid doesn't cure the disease. It just reduces symptoms and promotes comfort. · Cool/moist dressings over topical steroids can increase absorption. Be very careful about this, the patient should not do it unless the doctor tells them to. · Occlusive dressings should be avoided with steroid creams · IF there are big blisters, they may not get topical steroids because you don't want to pop the blisters. § Avoid applying oil-based ointments and pasts to sweaty skinfolds because it can cause folliculitis. WATER SOLUBLE creams are better for these areas § Lotions and gels prevent matting of hair and are appropriate for hairy areas, like the scalp. § Antihistamines provide some relief but may not keep patient totally comfortable. Sedative effects may be better tolerated if dose is taken at bedtime. Older adults are at risk for falls, especially with polypharmacy. § Cool moist compresses and luke-warm baths can promote comfort. Colloid oatmeal, tar extracts, cornstarch, or oils added to baths may relieve itching.

Occlusive dressings

Contact Dermatitis · Signs and Symptoms: § Localized eczematous eruption with well-defined, geometric margins that are consistent with contact by irritant or allergen § Usually seen in acute form but may become chronic if exposure is repeated § Allergy to plants (poison ivy/oak) occurs as linear streaks of vesicles or papules · Care for Contact Dermatitis: § Obtain history: Attempt to identify causative agent. (changes in soap/detergent/fabric softener/etc, new foods, jewelry, new clothes). § DON'T SCRATCH IT. It will break skin, introduce bacteria, then you have a secondary infection. Then you have to get an antibiotic to treat the infection plus other meds to help with contact dermatitis irritation. · CUT NAILS. Possibly wear mittens at night to prevent nighttime scratching § Avoidance therapy (once cause is identified) to reverse reaction and clear the rash. For example, if new soap causes contact dermatitis, the patient shouldn't use it. If jewelry with nickel in it causes reaction, DON'T WEAR IT! § Steroid therapy (topical hydrocortisone for mild, possibly systemic, IM, IV prednisone for more severe) to suppress inflammation. Patients taking oral prednisone experience adrenal suppression as a side effect, and they should taper the dose down when discontinuing. · Teach the patient that the steroid doesn't cure the disease. It just reduces symptoms and promotes comfort. · Cool/moist dressings over topical steroids can increase absorption. Be very careful about this, the patient should not do it unless the doctor tells them to. · _____________________________ should be avoided with steroid creams · IF there are big blisters, they may not get topical steroids because you don't want to pop the blisters. § Avoid applying oil-based ointments and pasts to sweaty skinfolds because it can cause folliculitis. WATER SOLUBLE creams are better for these areas § Lotions and gels prevent matting of hair and are appropriate for hairy areas, like the scalp. § Antihistamines provide some relief but may not keep patient totally comfortable. Sedative effects may be better tolerated if dose is taken at bedtime. Older adults are at risk for falls, especially with polypharmacy. § Cool moist compresses and luke-warm baths can promote comfort. Colloid oatmeal, tar extracts, cornstarch, or oils added to baths may relieve itching.

C. Suggest the doctor measure the person's vitamin D level B. Mild soap and warm water is better for me to use D. Aging causes the skin thickness to decrease, which increases the risk for skin breaks and infections

During a home visit, a nurse learns that an older adults spends no time out of doors because of fear of skin cancer. Which action should the nurse take to maintain this person's health status? A. Discuss the importance of performing weightbearing exercises daily B. Recommend attending events for senior citizens scheduled in the evenings C. Suggest the doctor measure the person's vitamin D level D. Change the time for the next home visit to occur in the evening The nurse reviews with an older person the reasons they may experience dry skin during the winter months. Which statement indicates that this person understands ways to prevent skin change from occurring? A. I will continue to drink about 410-ounce glasses of fluid each day B. Mild soap and warm water is better for me to use C. I should continue to take showers with hot water D. A heavy towel that is dragged over my skin is the best way to dry it An older adult is concerned about the number of legwound infections that have been occurring over the last year. What should the nurse explain about this development of these infections? A. Aging adversely affects immune function, increasing the risk for all types of infections B. The reason for skin infections occurring more frequently with aging is unknown C. Bacteria on the skin is not being adequately washed when bathing D. Aging causes the skin thickness to decrease, which increases the risk for skin breaks and infections

Isolate patients with fluid filled blisters/vesicles until they have crusted over and are dry.

Herpes Zoster (Shingles) · Herpes Zoster (Shingles): Caused by the chicken pox virus (varicella zoster). It is caused by reactivation of the varicella-zoster virus (VZV) in patients who had chicken pox. The dormant virus resides in the dorsal root ganglia of sensory nerves § Travels on the dermatone (nerve). It usually reactivates after an illness/stress § Very common in older adults or immunosuppressed people § It is contagious to people who have not previously had chicken pox or been vaccinated against it. Nurses should: __________________________________________________ § MEDICAL EMERGENCY WHEN IN EYE = BLINDNESS

A palpable, solid, marble-like lesion, greater than 1 cm in diameter. These are usually found in the dermal or subcutaneous tissue, and the lesion may be above, level with, or below the skin surface. An example is a lipoma

Non cancerous Lesions · Macule: A circumscribed flat area less than 1 cm of discoloration (often white, red, or brown) without elevation or depression of surface relative to surrounding skin. EX: freckles, flat moles, rubella lesions · Papule: A circumscribed, elevated, solid lesion, less than 1 cm. Examples are elevated moles or warts · Patch: A circumscribed area of discoloration, greater than 1 cm, which is neither elevated or depressed relative to the surrounding skin. They may or may not have some surface changes (scale, fine wrinkles). EX: vitiligo, café au lait spots · Plaque - A well-circumscribed, elevated, superficial, solid lesion, greater than 1 cm in diameter (don't extend into lower skin layers). They are plateau-like patches, such as psoriasis or seborrheic keratosis. · Vesicle - A small, superficial, circumscribed elevation of the skin, less than 0.5 cm, that contains serous fluid. Example is acute dermatitis · Nodule - _______________________________________________________________________ · Bulla - raised, circumscribed lesion greater than 0.5 cm that contains serous fluid. Example is second-degree burn · Wheal - Transient, circumscribed, elevated papules or plaques, often with erythematous borders and pale centers. Examples are urticaria and insect bites · Pustule - A small (< 1 cm in diameter), circumscribed superficial elevation of the skin that is filled with purulent/cloudy material. Can also be described as a vesicle filled with pus. Examples are acne and acute impetigo · Tumor - Solid, firm lesions typically 2 cm that can be above, level with, or beneath the skin surface. Also known as a mass. · Cyst: nodules filled with liquid or semisolid material that can be expressed, such as a sebaceous cyst · Erosion: wider than fissures, but only involve the epidermis. Examples are varicella

A well-circumscribed, elevated, superficial, solid lesion, greater than 1 cm in diameter (don't extend into lower skin layers). They are plateau-like patches, such as psoriasis or seborrheic keratosis.

Non cancerous Lesions · Macule: A circumscribed flat area less than 1 cm of discoloration (often white, red, or brown) without elevation or depression of surface relative to surrounding skin. EX: freckles, flat moles, rubella lesions · Papule: A circumscribed, elevated, solid lesion, less than 1 cm. Examples are elevated moles or warts · Patch: A circumscribed area of discoloration, greater than 1 cm, which is neither elevated or depressed relative to the surrounding skin. They may or may not have some surface changes (scale, fine wrinkles). EX: vitiligo, café au lait spots · Plaque - ____________________________________________________________________ · Vesicle - A small, superficial, circumscribed elevation of the skin, less than 0.5 cm, that contains serous fluid. Example is acute dermatitis · Nodule - A palpable, solid, marble-like lesion, greater than 1 cm in diameter. These are usually found in the dermal or subcutaneous tissue, and the lesion may be above, level with, or below the skin surface. An example is a lipoma · Bulla - raised, circumscribed lesion greater than 0.5 cm that contains serous fluid. Example is second-degree burn · Wheal - Transient, circumscribed, elevated papules or plaques, often with erythematous borders and pale centers. Examples are urticaria and insect bites · Pustule - A small (< 1 cm in diameter), circumscribed superficial elevation of the skin that is filled with purulent/cloudy material. Can also be described as a vesicle filled with pus. Examples are acne and acute impetigo · Tumor - Solid, firm lesions typically 2 cm that can be above, level with, or beneath the skin surface. Also known as a mass. · Cyst: nodules filled with liquid or semisolid material that can be expressed, such as a sebaceous cyst · Erosion: wider than fissures, but only involve the epidermis. Examples are varicella

A circumscribed area of discoloration, greater than 1 cm, which is neither elevated or depressed relative to the surrounding skin. They may or may not have some surface changes (scale, fine wrinkles). EX: vitiligo, café au lait spots

Non cancerous Lesions · Macule: A circumscribed flat area less than 1 cm of discoloration (often white, red, or brown) without elevation or depression of surface relative to surrounding skin. EX: freckles, flat moles, rubella lesions · Papule: A circumscribed, elevated, solid lesion, less than 1 cm. Examples are elevated moles or warts · Patch: ___________________________________________________________________________ · Plaque - A well-circumscribed, elevated, superficial, solid lesion, greater than 1 cm in diameter (don't extend into lower skin layers). They are plateau-like patches, such as psoriasis or seborrheic keratosis. · Vesicle - A small, superficial, circumscribed elevation of the skin, less than 0.5 cm, that contains serous fluid. Example is acute dermatitis · Nodule - A palpable, solid, marble-like lesion, greater than 1 cm in diameter. These are usually found in the dermal or subcutaneous tissue, and the lesion may be above, level with, or below the skin surface. An example is a lipoma · Bulla - raised, circumscribed lesion greater than 0.5 cm that contains serous fluid. Example is second-degree burn · Wheal - Transient, circumscribed, elevated papules or plaques, often with erythematous borders and pale centers. Examples are urticaria and insect bites · Pustule - A small (< 1 cm in diameter), circumscribed superficial elevation of the skin that is filled with purulent/cloudy material. Can also be described as a vesicle filled with pus. Examples are acne and acute impetigo · Tumor - Solid, firm lesions typically 2 cm that can be above, level with, or beneath the skin surface. Also known as a mass. · Cyst: nodules filled with liquid or semisolid material that can be expressed, such as a sebaceous cyst · Erosion: wider than fissures, but only involve the epidermis. Examples are varicella

visible thickened stratum corneum. They appear dry and are usually whitish. They are seen most often with papules and plaques. Examples are exfoliative dermatitis and psoriasis.

Non cancerous Lesions · Secondary Lesions: § Scales: ______________________________________ § Ulcers: deep erosions that extend beneath the epidermis and involved the dermis and sometimes subQ fat. Example is a stage 3 pressure ulcer § Lichenification: palpably thickened areas of epidermis with accentuated skin markings. They are caused by chronic rubbing and scratching. Examples are chronic dermatitis § Fissures: linear cracks in the epidermis that often extend into the dermis, such as athlete's foot. § Crusts: areas composed of dried serum or pus on the surface of the skin, beneath which debris may accumulate. They frequently result from broken vesicles or pustules.

64oz of water daily, cool water for baths, wearing light colored clothes, wearing lightweight clothes, and remaining indoors during the hottest part of the day.

Normal aging changes · Decrease in eccrine, apocrine, and sebaceous glands causing dry skin and less thermoregulation § *Teach older adults the potential for heat exhaustion and heat stroke on hot summer days. Prevention: ______________________________________________ · Exposure to and damage by the sun (actinic damage, affects the aging appearance of skin (accelerates wrinkles) · Male pattern baldness is common in men · Hair thins and turns gray · Eyelid elasticity loss · Changes in pigmentation with accumulation of discoloration (photoaging). · Vascular lesions (cherry angiomas, petechia, telangiectasia) are more common · Onychomycosis (fungal infection) of toenails commonly occurs

ask their doctor to check their vitamin D blood level to ensure adequate calcium absorption. If they live in a colder climate, check blood level during winter months

Normal aging changes · SQ Tissue § Less fat and thermoregulation (less blood vessels) = § Decreased insulation to extremities § Decreased strength in extremities § Adipose tissue redistributes to the waist line and hips · Loss of ability to produce Vitamin D leads to decreased absorption of calcium § Worse in winter months or colder climates where there is reduced exposure to sun § Adequate vitamin D is needed to prevent cancers and reduces fall risk § *Recommend that older adults ______________________________________________________________________________

Increased healing time, more bruising noted

Normal aging changes · Turnover time increases · Barrier function decreases · Decreased Langerhans cell production = increased CA and infection · Melanocytes are decreased = decrease protection against UV · Decreased touch receptors = Reduced sensation and slow reflexes · Dermis: § Decreases in thickness = flatter and thinner (risk for friction, shearing injuries and skin tears) § Decrease in the # of sweat glands =increase in hypothermia and heat stroke § Reduction of 35% of vertical capillary loops § Vessels are more pronounced § Elasticity decreases = wrinkling and sagging § Decreased turgor, increased dehydration § Decreased macrophage production, mast cells and melanocytes = decreased immunity § Decreased cell proliferation = ____________________________________ § Increased pressure ulcer risk due to decreased blood flow and thin skin

Older Adults

Pressure Ulcers · Amount of vertical pressure that can cause tissue death is directly related to the status of the tissue before the injury · Pressure increases 3 to 5 times on bony prominences · POOR circulation = DECREASED injury time · *___________ are at high risk for skin tears and pressure injuries because of age-related skin changes (flattening of dermis cells), skin moisture and irritation from incontinence, or cognitive impairment (can't feel/communicate discomfort)

Tar preparations

Psoriasis · Psoriasis vulgaris: a chronic, lifelong autoimmune disorder affecting the skin with exacerbations/remissions. It results from overstimulation of the immune system (Langerhans' cells) in the skin that activates T-lymphocytes, which target the keratinocytes, causing increased cell division and plaque formation. · Treatment and Nursing Interventions for Psoriasis § Topical Therapy: Topical steroids, Topical tar, UV light § Corticosteroids: clobetasol, triamcinolone, fluocinolone, betamethasone all suppress cell division · FLEMMER SAYS "NO OCCLUSIVE DRESSINGS ON STEROID CREAMS". Textbook says: , "Enhance skin penetration with warm, moist dressings and an occlusive outer wrap of plastic (film, gloves, booties). These can be left in place for up to 8hr daily" · Avoid using high potency steroids on the face, scalp, or skinfolds. When using high potency steroid creams, monitor skin for thinning, striae, or hypopigmentation § _________________________________ suppress cell division and reduce inflammation. They are available as ointments, solutions, lotions, gels, and shampoos · They are messy, cause staining, and have an unpleasant odor · Monitor for skin irritation · They can cause stinging, burning, and stain skin/hair · Apply at night and cover area with old pajamas, gloves, or socks due to odor and staining § Calcipotriene and calcitriol are vitamin D analogs that prevent cell proliferation. Monitor for itching, irritation, erythema, and hypercalcemia (high calcium, muscle weakness, fatigue, anorexia). Limit sun exposure and do not put on face (it increases skin cancer risk) § Tazarotene is a vitamin A drug that slows cell division and reduces inflammation (causes sloughing of skin cells) · Contraindicated during pregnancy; must use birth control · Monitor for localized reactions, burning, inflammation, and desquamation · Avoid sun or artificial UV light § UV Light Therapy: Use lamps or cabinets with UV tubes (NOT TANNING BEDS.). The sun is an inexpensive source, but can cause sunburns · UV therapy is limited by exposure time and effects on surrounding skin. · Therapy is measured in seconds of exposure, and patients have to wear eye protection during it. · Light therapy with lasers can be effective and allow better focus on the lesions and reduce exposure to surrounding skin · Psoralen and UVA therapy (PUVA) involves ingestion of photosensitizing agent 45-60min before UVA light exposure. Therapy sessions are dose every 2-3days, and they must wear dark glasses during treatment and for the rest of the day. Monitor for and report: tenderness, erythema, blisters, edema, skin cancer, cataracts, premature skin aging

Biologic agents, DMARDs (adalimumab, etanercept, ustekinumab, alefacept, infliximab)

Psoriasis · Psoriasis vulgaris: a chronic, lifelong autoimmune disorder affecting the skin with exacerbations/remissions. It results from overstimulation of the immune system (Langerhans' cells) in the skin that activates T-lymphocytes, which target the keratinocytes, causing increased cell division and plaque formation. Treatment Options: · Systemic Therapy: oral apremilast. They are teratogenic and the patient must adhere to strict contraceptive measures. § ________________________________________ may be used to suppress immune function · increased infection risk, so the patient must immediately report s/s of infections · must get TB test prior to using; do not take live vaccines during therapy · do not take during pregnancy/breastfeeding § Cytotoxic medications: methotrexate, acitretin reduce turnover of cells · Monitor LFT and renal function · Methotrexate can cause bone marrow suppression (leukopenia, thrombocytopenia, anemia) · Do not use if pregnant. It decreases effect of oral birth control, so use extra contraceptive measures. · Avoid alcohol § Cyclosporine and azathioprine: immunosuppressants that are nephrotoxic, increase infection risk, and require strict BP monitoring due to right of HTN · Emotional Support! Patient's self esteem can suffer, so encourage expression of feeling, support groups, etc. Encourage the touching, like hand shaking, placing the hand on a shoulder when explaining a procedure (DON'T WEAR GLOVES DURING THESE INTERACTIONS). Touch, more than any other gesture, communicates acceptance of the person and the skin problem (per IGGY)

1. Curved or linear ridges in the skin. Horizontal white skin lesions (formed by burrowing of the mite into outer skin layers) 2. Shows up in folds, warm moist areas (between fingers, on palms, wrists, groin, armpits) 3. Pruritic lesions, often unbearable at night 4. Blistered in appearance, Can mimic contact dermatitis 5. If allergic, it can cause excoriated erythematous papules, pustules, and crusted lesions

Scabies · Scabies: contagious skin infection caused by mite infestations, transmitted by close contact with infected person or bedding. It is common in those with poor hygiene and living in crowded living conditions. § Scabies mite can carried by pets but it is commonly spread from PERSON-PERSON contact, in homeless and institutionalized older patients · Signs and Symptoms: 1 2 3 4 5 · Diagnosis: they take a skin scrap and look at it under a microscope -> they see mites

Permethrin cream

Scabies · Treatment: scabicides! § _______________________________ (others: lindane, crotamitron, benzyl benzoate), it is applied all over the body overnight, and ALL household members need the cream and linen cleaning. § ALL clothes must be either washed or sealed in a bag for 2 weeks. § Laundering clothes and personal items with hot water and detergent will eliminate mites from linens § Some infestations are so bad that the house must be fumigated § Inform patients that it can take up to 3 months for itching to stop. Itching continues after the bugs are dead

· Pre: Check allergies (lidocaine), get informed consent, you don't have to be NPO · Post: wound care, monitor for s/s of infection, no submersion (baths) until cleared at follow-up appointment.

Skin Cancer · Diagnostic Studies: § Total body photography and skin surface microscopy: used to evaluate high-risk patients who have many moles. A series of 24 slides are taken and used for comparison in subsequent visits to identify and track changes in nevi § Skin culture & sensitivity (bacterial/fungal/viral) § Tzanck's smear: herpetic/chickenpox § Scrapings: scabies § Wood's lamp examination: fungal; light is purple or violet and normal skin does not fluoresce § Patch testing § Biopsy: skin cancer § Patient education: pre- & post-procedure Biopsy: 1. PRE:____________________ 2. POST:__________________

Melanoma: pigmented cancer arising in melanin producing epidermal cells. Highly metastatic. Genetic predisposition, excessive UV exposure. Approx. 8,700 deaths/year.

Skin Cancer · ____________________________________________________: § S/S: irregularly shaped, pigmented papule or plaque; variegated colors with red, white, or blue tones § Can occur anywhere on body, especially where nevi or birthmarks are present (upper back, lower legs, soles of feet or palms) § Often starts with a pre-existing mole or new lesion that may enlarge, become brown/black/multicolored, develop nodules/plaques, and have a black, irregular outline that spreads. It is often more than 6mm in diameter § Horizontal growth phase followed by vertical growth phase. Rapid invasion and metastasis with high morbidity and mortality

Basal cell carcinoma: basal cell layer of epidermis that originates in lowest layer of epidermis and appears as a small fleshy bump. Metastasis is rare. Genetic predisposition, chronic irritation. Starts as small fleshy bumps.

Skin Cancer · ______________________________________________________________________: § S/S: pearly papule with a central crater and rolled waxy borders. Telangiectasis and pigment flecks visible on close inspection § Sun exposed areas, like head, neck, central face § Metastasis is rare § 50% recurrence rate related to inadequate treatment

Squamous cell carcinomas: CA of the epidermis that originates in the higher levels of the epidermis and appears as a flesh-colored-erythematous, indurated scaly plaque, papule, or nodule (may have ulceration/erosions). Metastasis is common. Can be related to chronic skin damage. Most common skin CA in persons with darker skin.

Skin Cancer · __________________________________________________________________________________: § S/S: firm, nodular lesion topped with a crust or a central area of ulceration § Indurated margins § Fixation to underlying tissue with deep invasion § Common on sun exposed areas like head, neck, lower lip, or sites of chronic irritation or injury (scars, burns) § Rapid invasion with metastasis via lymphatics in 10% of cases

deep skin resection often involving removal of full-thickness skin in the area of the lesion. SubQ and lymph may be removed.

Skin Cancer Treatment: § Electrodesiccation and curettage: removal of cancerous cells using a dermal curette to scrap away cancerous tissue, followed by the application of an electric probe to destroy remaining tumor tissue § Excisional Biopsy: removal of lesion for examination § Wide excision: __________________________________________________________ § Surgical excision · margins of 5 mm are best for curative removal § Mohs: special form of excision usually for basal and squamous cell carcinomas. The tissue is sectioned horizontally in layers, and each layer is examined for histology to determine presence of residual cancer cells · High risk or large BCC § Cryosurgery: cell destruction by the local application of liquid nitrogen to isolated lesions, causing cell death and tissue destruction § Drug therapy: topical or systemic chemotherapy § Biotherapy with interferon, monoclonal antibodies and targeted therapy for melanoma (Ipilimumab) § Radiation therapy is limited to older patients with large, deeply invasive basal cell tumors and those who are poor risks for surgery.

special form of excision usually for basal and squamous cell carcinomas. The tissue is sectioned horizontally in layers, and each layer is examined for histology to determine presence of residual cancer cells · High risk or large BCC

Skin Cancer Treatment: § Electrodesiccation and curettage: removal of cancerous cells using a dermal curette to scrap away cancerous tissue, followed by the application of an electric probe to destroy remaining tumor tissue § Excisional Biopsy: removal of lesion for examination § Wide excision: deep skin resection often involving removal of full-thickness skin in the area of the lesion. SubQ and lymph may be removed. § Surgical excision · margins of 5 mm are best for curative removal § Mohs: _________________________________________________________________________________________ § Cryosurgery: cell destruction by the local application of liquid nitrogen to isolated lesions, causing cell death and tissue destruction § Drug therapy: topical or systemic chemotherapy § Biotherapy with interferon, monoclonal antibodies and targeted therapy for melanoma (Ipilimumab) § Radiation therapy is limited to older patients with large, deeply invasive basal cell tumors and those who are poor risks for surgery.

long term UVR damage that is done to the skin from lifelong exposure to UV radiation. These changes occur on sun-exposed areas, like the face, neck, arms, hands. It includes freckling, loss of elasticity, damaged blood vessels, and general course and weathered appearance

Sun Damage · A tan is a protective response of the body to sun damage, and is often admired as attractive/healthy. But, a tan is a sign of skin damage, and that is the most common cause of skin CA. § UVA rays penetrate deeper into skin and result in premature gaining. They can pass through car windows § UVB rays damage more superficial layers of the skin, and are responsible for causing erythema and sunburn. They contribute to tanning and cumulative skin damage § Photoaging: ______________________________________________________________________________ · There is a cumulative effect of sun damage; it leads to premature aging and increased risk of skin cancer. The person's risk for melanoma doubles if they have had five or more sunburns · More than 90% of nonmelanoma skin cancers are the result of sun exposure. · UV damage is distinct from normal aging process. · Older patients are at increased risk of developing skin related conditions including skin cancer. · Polypharmacy in the older adult increases the risk of drug reactions which may mimic skin diseases. This complicates the accurate dx of derm. problems. Remind older patients to bring a complete Rx list to appts. with PCPs.

1 Digitoxin (antiarrhythmic). 2 Doxepin (antidepressant). 3 Amiodarone (antiarrhythmic). 4 Captopril (Anti-HTN).

Sun Damage · A tan is a protective response of the body to sun damage, and is often admired as attractive/healthy. But, a tan is a sign of skin damage, and that is the most common cause of skin CA. § UVA rays penetrate deeper into skin and result in premature gaining. They can pass through car windows § UVB rays damage more superficial layers of the skin, and are responsible for causing erythema and sunburn. They contribute to tanning and cumulative skin damage § Photoaging: long term UVR damage that is done to the skin from lifelong exposure to UV radiation. These changes occur on sun-exposed areas, like the face, neck, arms, hands. It includes freckling, loss of elasticity, damaged blood vessels, and general course and weathered appearance · Sun Sensitivity Meds: § Antibiotics: Bactrim, Doxycycline, Biaxin (clarithromycin), ciprofloxacin, levofloxacin, ofloxacin, tetracycline, trimethoprim § Antifungals: flucytosine, griseofulvin, voriconazole § Antihistamines: promethazine, cetirizine, diphenhydramine, loratadine, cyproheptadine § Cholesterol Drugs: simvastatin, atorvastatin, lovastatin, pravastatin § Diuretics: furosemide, triamterene, HCTZ, chlorthalidone, chlorothiazide § NSAIDS: Ibuprofen, naproxen, celecoxib, piroxicam, ketoprofen § Phenothiazines: chlorpromazine, fluphenazine, promethazine, thioridazine, prochlorperazine § Retinoids: acitretin, isotretinoin § Sulfonamides: acetazolamide, sulfadiazine, sulfathiazole, sulfamethoxazole, sulfapyridine, sulfasalazine, sulfaoxazole § Glipizide, glyburide 1 2 3 4

Bactrim, Doxycycline, Biaxin (clarithromycin), ciprofloxacin, levofloxacin, ofloxacin, tetracycline, trimethoprim

Sun Damage · A tan is a protective response of the body to sun damage, and is often admired as attractive/healthy. But, a tan is a sign of skin damage, and that is the most common cause of skin CA. § UVA rays penetrate deeper into skin and result in premature gaining. They can pass through car windows § UVB rays damage more superficial layers of the skin, and are responsible for causing erythema and sunburn. They contribute to tanning and cumulative skin damage § Photoaging: long term UVR damage that is done to the skin from lifelong exposure to UV radiation. These changes occur on sun-exposed areas, like the face, neck, arms, hands. It includes freckling, loss of elasticity, damaged blood vessels, and general course and weathered appearance · Sun Sensitivity Meds: § Antibiotics: ____________________________________________________ § Antifungals: flucytosine, griseofulvin, voriconazole § Antihistamines: promethazine, cetirizine, diphenhydramine, loratadine, cyproheptadine § Cholesterol Drugs: simvastatin, atorvastatin, lovastatin, pravastatin § Diuretics: furosemide, triamterene, HCTZ, chlorthalidone, chlorothiazide § NSAIDS: Ibuprofen, naproxen, celecoxib, piroxicam, ketoprofen § Phenothiazines: chlorpromazine, fluphenazine, promethazine, thioridazine, prochlorperazine § Retinoids: acitretin, isotretinoin § Sulfonamides: acetazolamide, sulfadiazine, sulfathiazole, sulfamethoxazole, sulfapyridine, sulfasalazine, sulfaoxazole § Glipizide, glyburide § Digitoxin (antiarrhythmic). § Doxepin (antidepressant). § Amiodarone (antiarrhythmic). § Captopril (Anti-HTN).

ECZEMA

TEST QUESTION EXAMPLE: "I have this rash and its always here on my hand. It gets better and worse. I have a topical steroid to put on it, and I use it when its bad. It gets worse in winter" THIS IS A HINT THAT IT IS NOT CONTACT DERMATITIS. IT IS MORE LIKELY _____________ and requires a different treatment approach

B. Chemical killing of these parasites is required C. Wash bed linens in cold water to remove lice and eggs F. Lice can infest hair on the head, in the genital region, in the axillae, on eyelashes, and on other body hair (e.g., arms, chest, legs)

The nurse is teaching a client how to treat pediculosis (lice). Which teaching will the nurse include? Select all that apply. A. Use a fine-tooth comb to remove nits B. Chemical killing of these parasites is required C. Wash bed linens in cold water to remove lice and eggs D. Lice do not affect clothing items because they jump off of fabric E. Eggs of lice must be killed to reduce the risk for development of skin cancer F. Lice can infest hair on the head, in the genital region, in the axillae, on eyelashes, and on other body hair (e.g., arms, chest, legs)

saline, non-toxic wound cleaner, or prescribed solution by pouring saline over the wound, squeezing a bulb syringe over the wound, or applying saline soaked gauze to clean the wound.

Treatment of Pressure Ulcers § Wound management for pressure injuries (chart 25-3 IGGY) · If injury is covered, change dressing according to manufacturer's instructions, when dressing seal is compromised, when drainage is on dressing, or when dressing gets contaminated · Measure wound size at greatest length and width with disposable tape measure. For asymmetric injuries, you can outline/trace the wound onto a plastic film weekly or more often · Compare measurements against initial measurement · Assess for necrotic tissue and amount of exudate. Assess/document the condition of the skin surrounding the pressure injury (color, temp, texture, moisture, appearance) · Remove or trim loose bits of tissue (wound specialist) · Clean injury with ____________________________________________________________ · Rinse and dry the injury surface · Collab with wound care for the best dressing for the wound · Avoid positioning the patient on the injury Re-position frequently

(nonabsorbent, waterproof) are useful when the wound has little drainage and needs to be protected from contamination

Treatment of Pressure Ulcers · DRESSINGS: § For a draining, necrotic ulcer, the dressing must remove excess exudate and loose debris without damaging healthy epithelial cells or granulation tissue. · Extensive necrosis and eschar requires sharp surgical or chemical removal before debridement dressings can be effective · Sharp Debridement: using scalpel to remove dead tissue for large, extensive wounds with risk of sepsis or cellulitis. · Mechanical debridement: mechanical entrapment and detachment of dead tissue. This includes wet-dry dressings, whirlpool therapy, and forceful wound irrigation · Topical chemical debridement: topical enzyme preparations to loosen necrotic tissue · Natural chemical debridement: promoting self-digestion of dead tissues by naturally occurring bacterial enzymes § After dead tissues is removed, protect healthy tissue. The ideal healing environment is slightly moist ulcer surface with minimal bacterial colonization (absence of shiny gel-like biofilm on wound) § Hydrophobic dressings _____________________________________________________________ § Hydrophilic dressings (absorbent) draw excessive moisture away from the injury surface to prevent maceration § Frequency of dressing changes depends on the amount of necrosis or exudate. Dry gauze dressings are changed when stroke through occurs § Change synthetic dressings when exudate causes the adhesive seal to break and leakage to occur.

deep, extensive tissue damage present under normal-appearing skin, with separation of the skin layers from the underlying granulation tissue

Treatment of Pressure Ulcers · Determine Pressure ulcer Characteristics, so you know how to treat: § Grade/Stage § Wound bed appearance · Necrotic · Infection · Slough · Eschar: back, brown, gray collagen · Granulation: starts as pale pink, progresses to beefy red as it grows to fill wound. Healthy granulation tissue is moist and has a spongy texture. · Epithelial § Undermining: __________________________________________________ · Tunneling: after ischemia occurs, continued pressure over the area increases destruction under the surface and forms tunnels. It's a "hidden" wound that may have a small opening in the skin with purulent drainage. § Surrounding skin § Pain § Documentation

helps heal wounds by removing infectious materials from the wound and enhancing granulation. It requires a suction tube covered by a sponge that is sealed in place. The foam dressing is changed every 48-72hr. Requires monitoring every 2hr for bleeding. · Contraindications: cancer wounds, anticoagulant use, poor nutrition, radiation treatment, exposed blood vessels/nerves/organs in wound area

Treatment of Pressure Ulcers · Nutrition: adequate intake of vitamins, calories, protein, minerals, and water. Protein deficiency delays healing. Coordinate with the dietician to help the patient eat a well-balanced diet emphasizing protein, vegetables, fruits, whole grains, and minerals · Technology-based therapies: electrical stimulation, negative-pressure wound therapy, hyperbaric O2 therapy, growth factors, skin substitutes § Electrical stimulation: low-voltage current applied to wound area to increase blood vessel growth and promote granulation. It is not used for those with pacemakers, wounds over the heart, or skin cancer involving the wound § Negative-Pressure Wound Therapy (NPWT): ________________________________________________________________ - § Hyperbaric O2 Therapy (HBOT): administering O2 under high pressure, resing the tissue O2 concentration. It is often used for life-threatening injuries like burns or diabetic ulcers. The patient is placed in an enclosed chamber, and the high pressure O2 keeps wounds oxygenated · Preventing Infection: If a wound shows not improvement in 7-10 days or worsens, re-evaluate the treatment plan. Check for s/s of infection (pain, tenderness, redness, purulence, odor, sudden deterioration of ulcer, changes in color/texture of granulation, changes in exudate)

special mattresses/pads, seat cushions

Treatment of Pressure Ulcers · Pressure redistribution to keep pressure over skin below the capillary closing pressure: _____________________________________________________ § A high static support surface (uses water, air, gel) is recommended for those at high pressure risk or those with stage 1-2 ulcers § Dyanamic support surfaces (powered) are useful for immobile patients when repositioning is contraindicated, when the number/severity of pressure injuries limits turning options, or for management of stage 3-4 ulcers § FREQUENT REPOSITIONING (q2h or more) AND SKIN INSPECTION · Keep what is wet wet and what is dry dry · Consult physical therapy to help redistribute pressure, improve QOL, and max function · Drug therapy, antibacterials as prescribed § Topical silver sulfadiazine, triple antibiotic ointment, metronidazole § Antimicrobial wound dressings containing silver, iodine, or PHMB § Systemic antibiotics, like penicillin § Aminoglycosides: gentamicin, tobramycin, streptomycin (risk for kidney impairement)

CULTERED

When Assessing Pressure Injuries: § * Assess any wound with every dressing change to compare with documented changes § Labs: · Wound colonization occurs when organisms attach to a wound surface, causing inflammation and impaired wound healing without clinical infection · Wound infection is a state of critical colonization with pathogenic organisms to the degree than the organism growth and spread cannot be controlled by the body's own immune defenses. These are red, indurated, and have moderate-heavy purulent exudate AND SHOULD BE ______________. Wound biopsies may be done

A. Subcutaneous tissue atrophy with aging B. Photoaging B. A sore, rough, scaly, reddened patch on the face

While completing an assessment, the nurse notes that an older adult has a large area of ecchymosis around a 3-inch scratch on the anterior surface of the lower left leg, reported to be caused by walking into an open dresser drawer a few days ago. What should the nurse consider as the reason for the wound's appearance? A. Subcutaneous tissue atrophy with aging B. Use of over-the-counter antihistamines C. Excessive dryness of the skin D. Poor nutritional status An older adult has visibly darker and more weathered skin over the face, arms, and lower legs. What should the nurse suspect as the reason for this skin change pattern? A. Dehydration B. Photoaging C. Low-fat diet D. Vitamin deficiency The nurse plans to teach an older adult on the hazards of sun exposure to the skin. Which finding caused the nurse to implement this teaching? A. Edematous lower extremities with areas of ecchymosis B. A sore, rough, scaly, reddened patch on the face C. Generally red, rough, itchy skin D. Rough, dry skin over the arms and legs

a superfatted, non-alkaline soap

Xerosis: Dry Skin · Nursing Interventions and Patient Teaching for Xerosis: § Limit showers and bath time. Take a complete shower or bath every other day (wash face, armpits, perineum, or soiled areas daily) § Use warm/tepid water, not hot and do not rub skin. (Hot water dehydrates the skin. Rubbing the skin increases dryness and pruritis.) § Avoid soap products that contain harsh chemicals. (Many products can cause sensitization of the skin and lead to a rash). Use _______________________________________ instead of deodorant soap. RINSE THOROUGHLY § If bath oils are preferred, add them at the end of the bath (AVOID FALLS BECAUSE OIL MAKES TUB SLIPPERY.) § Pat skin dry gently. Apply moisturizers liberally. (Moisturizers will help retain water and prevent dry skin). § Use a room humidifier during winter months or when the furnace is in use § Avoid clothing that continuously rubs the skin, like tight belts, nylon stockings, or pantyhose § Maintain a fluid intake of 3L/day unless contraindicate § Do not apply rubbing alcohol, astringents, or other drying agents to the skin § Avoid caffeine and alcohol ingestion

1. Hepatic: biliary cirrhosis, hepatitis, liver failure, cholestasis, pancreatitis 2. Endocrine: hyper/hypothyroidism, hyperparathyroidism 3. Hematological: anemia, lymphoma, myeloma, leukemia 4. Renal: kidney failure, uremia, hemodialysis 5. Neuro: stroke, multiple sclerosis 6. Psych: anxiety, psychosis 7. Infection: scabies, HIV, AIDs 8. Drug use: opioids, chloroquine, stimulants, recreational drugs

Xerosis: Dry Skin · Xerosis is common in the lower legs, hands, and trunk, and it presents as flaky, scaly crusts that are often pruritic. Scratching leads to infection risk and can cause patches of rough/thick skin (lichenification) · Often worse during winter months § It can be the result of other disorders: 1 2 3 4 5 6 7 8 § Can be the result of lifestyle: 1. Frequent bathing with hot water, overuse of harsh soaps or personal care products 2. Vigorous towel drying 3. Skin powders 4. Too much sun exposure 5. Dehydration 6. Drying conditions: winter, desert climates, central heating, air conditioning

Soaps, detergents, disinfectants, juices from meats/fruits, chemicals, dust mites, pets, pollens, molds, dandruff, hot/cold, humidity, sweating, foods, stress, hormones, bacteria (staphylococcusareus), viruses, fungi

· Atopic dermatitis = eczema or atopic eczema.(CHRONIC!!!) § Development of thickened areas of skin along with scaling and desquamation § Itching can be intense § Distribution along face, neck, hands, BENDS OF SKIN, and upper torso, or ALONG SKIN FOLDS § Triggers for Eczema: · ________________________________________________________________________ · IF YOU HAVE ECZEMA, AVOID THESE TRIGGERS.

Acyclovir

· Nursing Interventions for Herpes Zoster (Shingles): § If a nurse is pregnant, she should NOT care for a shingles patient. § START TREATMENT ASAP. § Pain meds = GABAPENTIN (not standard analgesics because its nerve pain). Give it as soon as possible to prevent postherpetic neuralgia (pain continues after lesions resolve). Pain usually lasts for 1-2 days before the blisters show up, so you have to treat it very early! · Gabapentin: it is a controlled substance, so the need to keep it somewhere safe. They will need a short-term drug contract. It can have a hypnotic effect, especially if the person has not taken them before. · It is a controlled substance because it potentates other drugs (opioids), which greatly increases risk for opioid overdose § ___________________________________ can be used, and is started as early as possible. This is to prevent a massive, seriously painful shingles episode § Patient Education: they need to isolate and keep lesions covered; stay away from pregnant people/children; take acyclovir for the full duration

Friction

· Pressure Ulcers are Caused by: § Pressure: unrelieved pressure leads to ischemia, inflammation, and necrosis. Subsequent injury occurs when pressure is removed and abrupt reperfusion occurs to the ischemic vascular bed § Shearing forces: this occurs when the skin itself is stationary but the tissues below the skin shift or move (Vertical stretching and angulation of the SQ tissue); Worse with loose and folded skin. These usually occur when a patient is sitting up and glides downward (skin on sacrum may not slide down at the same pace as deeper tissues) § _____________________: Repeated movement of skin across surfaces. Surfaces rub the skin and irritate/tear the epithelial tissue (dragging patient across bed linen) § Moisture (urine, feces) increases risk for skin damage § Malnutrition makes tissue more prone to breakdown and delays healing.

prealbumin level less than 19.5 (TABLOSKI SAYS LESS THAN 15??), albumin less than 3.5, lymphocyte count less than 1800, serum transferrin less than 219

· Preventing Pressure Ulcers: o Adequate hydration and nutrition: · 30-35 kcal/kg overall (keeps positive nitrogen balance) · 1-1.5 g/kg protein (up to 2g/kg protein with severe nutrient deficits) · 1ml/kcal fluid (2-3L/day) · Inadequate Nutrition: ________________________________________________

BRADEN SCALE

· Preventing Pressure Ulcers: § Ounce of prevention = pound of cure. Use the ___________________ § Identify patients at risk: mental status changes, decreased sensation, stroke, head injury, organic brain disease, Alzheimer's, sedation, impaired mobility, inadequate nutrition (prealbumin level less than 19.5, albumin less than 3.5, lymphocyte count less than 1800), dehydration, incontinence, excessive moisture § Pressure reduction with mattresses/cushions § Barrier creams for incontinence § Frequent repositioning, avoid oversedation

a 30-degree tilt

· Preventing Pressure Ulcers: § Positioning: · Pad contact surfaces with foam, silicone gel, air pads, pressure-reduction properties · Do not keep the HOB elevated above 30 degrees to prevent shearing. The HOB can be elevated to 90 degrees for meals, but should be lowered after · Use a lift sheet to move a patient in the bed (don't slide/drag them) · When positioning a patient on their side, position at _____________________________________________ · Re-position an immobile person at a frequency consistent with assessed needs (usually q2h). Encourage activity and body shifting (ROM q8h) · Do not place a rubber ring or donut under the sacrum · When moving a patient to another surface, use a slide board well lubricated with talc or use a mechanical lift · Place pillows or foam wedges between two bony surfaces · Keep the patient's skin directly off plastic surfaces Keep the patient's heels off the bed surface using bed pillow under ankles or heel-suspension devices

a skin barrier in areas of incontinence

· Preventing Pressure Ulcers: § Skin Care: daily skin inspection, document infection s/s, use moisture on dry skin when it is damp, prevent prolonged moisture (dry skin folds, use absorbent pads, use moisture barriers), DO NOT massage bony prominences, humidify the room § Skin Cleaning: · Clean skin as soon as possible after soiling and at routine intervals · Use a mild, heavily fatted soap or gentle commercial Ph balanced cleanser for incontinence · Use tepid rather than hot water · In the perineal area, use disposable cleaning cloth that contains a skin barrier agent · Gently pat rather than rub the skin dry · So not use powders or talc directly on skin · Hydrate skin with moisturizer, but don't rub red areas. Use petroleum-based formula for protection from moisture After cleaning, apply _____________________________________________

padding any surfaces that come in contact with leg and arm movements, like side rails, wheelchair arms, leg supports, table corners

· Preventing Skin Tears: § Use a lift sheet to prevent shears § Do not use any pulling or sliding movements when assisting older adults with a change in their position § Protect the older adult by ______________________________________ § Keep environment free of hazards and well lit § Avoid harsh soaps § Keep skin moist through adequate hydration § Keep fingernails and toenails cut short and filed to remove rough edges and prevent self-inflicted skin tears § Apply skin-moisturizing creams to arms and legs twice daily § Use paper tape and remove it cautiously, or substitute for tape with gauze or stockinette § Wear long sleeves and long pants to add a layer of protected over the skin § Those who has repeated tears to the skin should consider shin guards

Herpes Zoster (Shingles)

· Signs and Symptoms of _______________________________________________: multiple lesions occur in segmental distribution along the skin area innervated by the nerve § Lesions appear in similar appearance to herpes simplex and progress with weeping and crusting § Grouped lesions present unilaterally along a segment of skin following a nerve § Eruption is preceded by either minor irritation/itching to deep pain and severe discomfort § May be accompanied by fever and malaise § Postherpetic neuralgia is common in older adults, and is pain that persists after the lesions have resolved. § Secondary infection with necrosis is possible in immunocompromised patients

Psoriasis vulgaris

· Signs and Symptoms of ___________________________________________________: § History: family history, age of onset, current flareup, precipitating factors § Thick, flaky, reddened papules or plaques covered by silvery white scales § Borders between lesions are well defined (well circumscribed) § Patches are less red and moister in skinfolds § Lesions are usually distributed bilaterally. Common sites include scalp, elbows, trunk, knees, sacrum § Pitting or crumbling nails

Cellulitis

· Symptoms of ________________: § Inflammation, pain, heat, redness, and swelling (may not be present in the older adults). § Localized are of inflammation may enlarge rapidly if not treated (may originate as a complication of a wound infection, or involve the entire limb) § On rare occasions, blisters are present § It can be accompanied by lymphadenopathy, increased WBCs and fever when severe (but these common symptoms may not be present in the frail older adult) § Microscopic breaks in the skin resulting from dry/irritated skin -> risk for infection · Nursing Interventions: § skin care with proper cleansing to prevent spread of infection § Apply warm compresses to affected areas for comfort § Immobilization and elevation of the limb § Drug therapy usually involves topical therapy, oral drugs, or IV drugs to treat infection

place the torn skin in its approximate normal position (if possible)

· Treating Skin Tears: § Clean with normal saline and pat dry § Gently _______________________________________________ § Apply dressings (silicone non-adhesive thin foam or petroleum-impregnated non-adherent dressing, gauze, and kling wrap) and change per protocol · Steri-strips, gauze for ones with skin flaps (keep it dry if dry) · For more severe, clean it, keep wound moist if moist (zeriform petrolaum gauze, impregnated hydrocolloid guaze) § Document assessment and interventions, photograph if permitted

Cellulitis

· _________________: An acute bacterial infection of the skin and deeper sub-Q tissue that may cause a great deal of pain and distress. It is commonly caused by Staph or Strep bacteria § Most frequently on lower legs and face. § Minor skin trauma usually contributes to the development of cellulitis, and patients can spread the infection to other body parts by scratching/rubbing itchy skin · Predisposing factors: diabetes, obesity, previous hx of cellulitis, peripheral vascular disease or tinea pedis, lower-extremity edema

Skin Tear

· ________________________: A wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. It can be partial or full thickness § Very painful! § May be accompanied by dark purple ecchymosis (senile purpura). And edema because of Sub-Q tissue atrophy. · Example: removal of an adhesive dressing from an IV site can cause a skin tear. § Can occur with dressing, transferring, turning, or lifting. Also, bumping into things.

Pressure Ulcers

· _________________________: a loss of tissue integrity caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period. Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and gas exchange, which eventually leads to cell death. (per IGGY) § Defined as: degenerative change of tissue that results due to the loss of oxygen from pressure and shearing (per PowerPoint). § 90% occur on the lower body (sacral/coccyx), but can occur anywhere § Once formed, pressure injuries are slow to heal, resulting in morbidity and health care costs. § Complications: sepsis, kidney failure, infectious arthritis, and osteomyelitis

Dermatitis (atopic)

· ___________________________: A chronic skin condition causing intense itching and a red, raised rash. In severe cases, the rash looks like small blisters. § REMEMBER: atopic dermatitis, contact dermatitis, and eczema are all inflammatory reactions to an irritation. VERY SIMILAIR. (unlike psoriasis, which is AUTOIMMUNE) · In infants, it usually affects § the cheeks, § the front of the knees § and the back of the elbows · Risk factors: external/internal skin exposure to allergens, stress, genetics

Contact Dermatitis

· ______________________________________: acute or chronic inflammatory rash secondary to contact with an irritant/allergen. Irritants can cause toxic injury to skin. Allergens cause a cell-mediated reaction in the skin. § A cell mediated immune response. § USUALLY A ONE TIME THING. (whereas with eczema, it is chronic) · Signs and Symptoms: § Localized eczematous eruption with well-defined, geometric margins that are consistent with contact by irritant or allergen § Usually seen in acute form but may become chronic if exposure is repeated § Allergy to plants (poison ivy/oak) occurs as linear streaks of vesicles or papules

Seborrheic Keratosis

· _________________________________________: benign neoplasm which is a raised and thickened papulonodular lesion § S/S: raised, crinkly, rough lesions, can be located anywhere but is most common on the back; usually multiple lesions (if it is just one lesion, it is more likely to be melanoma) § NOT MALIGNANT, but it is unsightly and the patient may want them to be removed · Dermatosis papulose nigra: multiple small dark papules on the face and neck that are common in individuals of African American descent · Senile Purpura: aging causes capillaries to thin and become easily damaged, causing these bruised and discolored areas.

Psoriasis vulgaris

· ________________________________________________: a chronic, lifelong autoimmune disorder affecting the skin with exacerbations/remissions. It results from overstimulation of the immune system (Langerhans' cells) in the skin that activates T-lymphocytes, which target the keratinocytes, causing increased cell division and plaque formation. § A scaling disorder related to dermal inflammation. § Abnormal growth of epidermal cells in the outer skin layers. § genetic predisposition (PSORS1 through PSORS13 gene variations) · many environmental factors lead to outbreaks and influence severity of symptoms · Psoriatic lesions can appear after skin trauma, like surgery, sunburn, or excoriation · Patients often improve with more exposure to sunlight · What can aggravate psoriasis? Infection (candida, URIs), hormone changes (puberty, menopause), stress, drugs (lithium, beta-blockers, indomethacin), obesity, cold weather, or other diseases · Psoriatic arthritis can lead to severe joint damage and indicates that it has become a systemic disorder. · Signs and Symptoms of Psoriasis vulgaris: § History: family history, age of onset, current flareup, precipitating factors § Thick, flaky, reddened papules or plaques covered by silvery white scales § Borders between lesions are well defined (well circumscribed) § Patches are less red and moister in skinfolds § Lesions are usually distributed bilaterally. Common sites include scalp, elbows, trunk, knees, sacrum § Pitting or crumbling nails · Exfoliated psoriasis: explosively eruptive and inflammatory form with generalized erythema and redness but no obvious lesions. Fluid loss from this can cause dehydration when severe · Palmoplantar pustulosis (PPP) is a type of psoriasis that forms pustules on the palms of the hands and soles of feet with red hyperkeratotic plaques. The course of disease is cyclic, with new outbreaks occurring after old ones have resolved.

Actinic (solar) Keratoses: PREMALIGNANT lesions (more common in men)

· ________________________________________________________: § S/S: small (1-10mm), sore, red macule or papule with dry, rough, adherent yellow or brown scale. The base may be erythematous. § Associated with yellow, wrinkled, or weather-beaten skin § Thick, indurated _______________ more likely to be malignant § Often distributed on cheeks, temples, forehead, ears, neck, back of hands, and forearms