Chapter 12

•A precancerous lesion that may become a squamous cell carcinoma •Directly related to years of overexposure to UV light -rough, scaly, sandpaper like patches, pink to reddish-brown on an erythematous base, may be single or multiple they may be painless or mildly tender

Actinic Keratosis

perfume detergents, fabric softners, heat, sudden temperature changes, pressure, sweating, restrictive clothing, fatigue, exercise and anxiety

Aggravators of Pruritus

•The most common malignant skin cancer •Occurs mainly in older age groups but is occurring more and more in younger persons •Slow-growing and metastasis is rare -occurs more in light-skinned people

Basal Cell Carcinoma

triggered by extensive sun exposure, especially burns, chronic irritation, and chronic ulceration of the skin

Basal Cell Carcinoma Risk Factors

bony deformities that also develop from long-standing squeezing together of the first (great) and second toes

Bunions

-present on the skin of healthy persons of any age -grows especially well in areas that are moist, warm and dark such as skinfolds, axilla and groin and under pendulous breasts, also found in corners of the mouth associated with chronic moisture of angular cheilitis

Candidiasis (Candida Albicans)

-Postherapetic neuralgia, a chronic, often debilitating pain condition that can last months or even years -Eye involvement which occurs in 10-25% of zoster episodes and can result in prolonged or permanent pain, facial scarring, and loss of vision

Complications of Herpes Zoster

•Need for grafting or amputation, sepsis, or even death and may lead to legal action by the individual or his or her representative against the caregiver •Pressure ulcers cause suffering, pain, discomfort and distress that is not always recognized or adequately treated by nursing staff

Consequences of Pressure Ulcers

cone-shaped and develop on the top of the toe joints from the rubbing of the shoe on the joint

Corns

growths of compacted skin that occur as a result of prolonged pressure, usually from ill-fitting, tight shoes

Corns and Calluses

•Recognized as a geriatric syndrome and efforts at prevention have always been considered and essential nursing intervention, particularly in long-term care •Hospitals will no longer receive reimbursement to care for a patient who has acquired pressure ulcers under the hospital's cares •Estimated annual costs for pressure ulcer treatment are $9-$11.6 billion per year in the US

Cost and Regulatory Requirements of Pressure Ulcers

A permanently flexed toe with a claw-like appearance; the condition is a result of muscle imbalance and pressure from the big toe slanting toward the second toe

Hammer Toe

doesn't occur in a dermatome pattern and is reccurent, lesions eventually rupture, crust over and resolve, scarring may result

Herpes Simplex

-Shingles is a viral infection frequently seen in older adults -Caused by reactivation of latent varicella-zoster virus within the sensory neurons of the dorsal root ganglion decades after initial VZV infection is established -Always occur on a nerve pathway or dermatome, when the eye is affected it is always a medical emergency

Herpes Zoster

-obese, malnourished, receiving antibiotic or steroid therapy, or have diabetes

Increased risk for yeast infection

•One or more lesions are present on nearly all adults older than 65, more common in men -A waxy, raised, verrucous lesion, flesh-colored or pigmented in various sizes -Have a stuck on appearance

Keratoses

•A neoplasm of the melanocytes -accounts for less than 5% of skin cancer cases -it causes most skin cancer deaths -One of the most common cancers in people under 30 years of age, it is more than 10 times more common in white Americans than in African Americans and slightly more common in men than in women -high mortality rate because of its ability to metastasize quickly

Melanoma

Xerosis (dry skin), pruritus, seborrheic keratosis, herpes zoster and cancer

Most common skin problems in older adults

is the most common nail disorder, characterized by degeneration of the nail plate with color changes to yellow or brown and opaque, brittleness and thickening of the nail

Nail Fungus or onychomycosis

Diabetic nail care can never be delegated to the LPN or CNA

Nursing Interventions for Diabetic Patient

-Nutritional intake should be monitored as well as serum albumin, hematocrit, and hemoglobin levels -The type of dressing selected is based on the condition of the ulcer; the presence of granulation, necrotic tissue and slough; the amount of drainage; microbial status and the quality of the surrounding skin -Keep the wound warm at all time, keep clean and moist, protect from further injury, promptly absorb exudate and fill dead space with a biofriendly material, do not subject tissue to caustic products

Nursing Interventions for Pressure Ulcers

Damage comes from prolonged exposure to UV light from the environment and tanning booths

Photo Damage

-An injury to the skin and/or underlying tissue resulting from pressure or in combo with shear, usually over a bony prominence -As tissue is compressed, blood is diverted and blood vessels are forcibly constricted by the persistent pressure on the skin and underlying structures; thus cellular respiration is impaired and cells die from ischemia and anoxia

Pressure Ulcer

•Older people account for 70% •Higher prevalence and incidence among African Americans in nursing homes than other race groups

Prevalence of Pressure Ulcers

Itchy skin, it is a symptom not a diagnosis or disease and is a threat to skin integrity because of the attempts to relieve it by scratching

Pruritus

•Thinning of the dermis leads to increased fragility of the dermal capillaries and to blood vessels rupturing easily with minimal trauma •Extravasation of the blood into the surrounding tissue, commonly seen on the dorsal forearm and hands

Purpura

Old Age and Fair Complexion

Risk Factors for Actinic Keratosis

•Change in skin, comorbid illnesses, nutritional status, cognitive deficits and reduced mobility •Primary risk factors are immobility and limited activity with positioning that exerts unrelieved pressure on tissue confined between non-pliable surfaces •Tissue tolerance is related to the ability of the tissue to distribute and compensate for pressure exerted over bony prominences

Risk Factors for Pressure Ulcers

•Early identification of risk status is critical so that timely interventions can be designed to address specific risk factors •Braden scale assess the risk of pressure ulcers on the basis of 6 factors: sensory perception, moisture, activity, nutrition, mobility and friction/shear

Risk Factors for Pressure Ulcers

Persons with a history of frequent blistering sunburns, use of tanning beds, skin cancer, or exposure to carcinogenic materials, or with sun sensitivity or a depressed immune system • White individuals with fair skin, freckles and red or blonde hair

Risk Factors for melanoma

•A skin condition that causes intense itching, particularly at night •Caused by a tiny burrowing mite called Sarcoptes scabiei •It is contagious and can spread quickly through close physical contact in a family, child care group, school class or other close communal living facilities such as nursing homes

Scabies

pearly papule with prominent telangiectasias (blood vessels) or as a scarlike area with no history of trauma

Sign of Basal Cell carcinoma

•Lesion begins as a firm, irregular, fleshy, pink-colored nodule that becomes reddened and scaly, much like actinic keratosis but it may increase rapidly in size, may also be hard and warlike with a gray top and horny texture, or may be ulcerated and indurated with raised, defined borders

Sign of squamous cell carcinoma

•Classical multicolor, raised appearance with asymmetrical, irregular border, may appear to be any size but the surface diameter is not necessarily reflective of the size beneath the surface, similar in concept to an iceberg

Signs of Melanoma

Cancer of the skin is the most common of all cancers

Skin Cancer

form between opposing surfaces of the toes from prolonged squeezing, until friction and pressure is relieved they will continue to enlarge and cause increasing pain

Soft Corns

second most common skin cancer •High incidence of metastasis •More prevalent in fair-skinned, older men who live in sunny climates, usually found on head, neck or hands

Squamous Cell carcinoma

itching, tingling, or pain in the affected dermatome several days before the outbreak of the rash

Symptoms of Herpes Zoster

-associated with poor hygiene and immunocompromise, -Appears as irregular, white, flat to slightly raised patches on an erythematous base that cannot be scraped off, infection can extend into throat and cause swallowing to be painful

Thrush

-eliminating the infestation with prescribed lotions and creams -Meds kill the mites but itching may not stop for several weeks -All clothes and linen used at least three times before treatment should be washed in hot, soapy water and dried with high heat

Treatment for Scabies

-Mouth swishing and swallowing with an anti-fungal suspension and/or sucking on antifungal troches, topical ointment to corners of the mouth

Treatment of Thrush

•Use of tepid water temperatures and super-fatted soaps or skin cleansers without hexachlorophene or alcohol should be used •Light mineral oil is effect and more economical than commercial brands of lotions and oils, however oils poured directly into a tub or shower increase the risk for falls

Treatment options for Xerosis

-Use of tricyclic antidepressants, anticonvulsants, steroids, Lidocaine skin patches, and opioids as well as stress reduction techniques and behavioral cognitive therapy -Acyclovir

Treatments of Herpes Zoster

-Extremely dry, cracked and itchy skin -The most common skin problem experienced by older people, it occurs primarily in the extremities, especially the legs but can affect the face and the trunk as well

Xerosis

precancerous lesion

actinic keratosis

ABCD

asymmetry, border irregularity, color, diameter

benign growth that appears mainly on the trunk, face, neck and the scalp as single or multiple lesions

seborrheic keratosis

cool compresses or oatmeal or Epsom salt baths may be helpful

ways to rehydrate the stratum corneum (pruritus)