Common Integumentary Problems of the Adult Paitent

Epidermis

the outermost layer containing epidermal ridges

Dermis

• the middle layer, subdivided into the papillary layer (top) and the reticular layer (bottom)

• it contains blood vessels and dermal papillae

Subcutaneous layer

the deepest layer, primarily composed of fatty tissue

Bacterial infections

• conditions like cellulitis present as spreading redness and swelling on the limbs

• require antibiotics treatment

Fungal infections

• often occur in the skins folds (intertrigo/candidiasis) such as under the breasts or in the groin

• they are treated with antifungual medications like Miconazole Nitrate (found int products like Desenex)

Viral infections and nerve involvement

• shingles (herpes zoster) often follows specifics dermatomes ( areas of skin supplied by single spinal nerve)

Infestations

• scabies is characterized by the presences of a “burrow” (the path the mite takes under the skin) and scattered red papules

abscessess

large, painful, fluid-filled lumps may require incision and drainage to remove infected material

Use this rule to evaluate mole or lessions for potential melanoma

• A: asymmetry: one half does not match the other

• B: Borders: edges are uneven, notched, or blurred

• C: color: the lesion has multiple colors or is dark black

• D: Diameter: the lesion is greater than 6 mm

• E: evolving: there is a change in size, shape, or color

Paronychia

an infection of the tissue adjacent to the nail

Subungual hematoma

• a collection of blood under the nail, usually caused by trauma

• it can be treated by drilling a small hole in the nail to release pressure and blood

What is impetigo

• skin infection that is highly contagious

• commonly on face (mouth or nasal area)

S/S of impetigo and the sequence how it presents

1. it will start out as itchy, painful red and blister or bump… the area doesn’t seem to heal but spreads

2. if it blisters it can rupture, if not blisters spread

3. the lesion will start to leak fluid that is honey-colored (strep) clear or pus (staph)

4. It will leave behind red patches that crust over with yellowish brown crust, a painful swollen lymph node may present near the site because the immune systems recognition of the bacteria in body

Treatment for impetigo

• topical or oral antibiotics

• Remove the crust prior to applying antibiotic ointment with warm water and antibacterial soap (this is where the bacteria live and ointment need to come into contact with the skin to kill the bacteria)

• Not contagious after 48 hours with topical ointment and 24 hours for oral antibiotics

• educate about completing full dose of treatment, especially if the pt has strep impetigo: can develop kidney problems.

How to prevent spreading of imetigo

• touching the sire can spread it to another site on body or others

• meticulous hand hygiene along with placing patient in contact precautions

• prevention of scratching or touching sites on the body and keep the nails short along with performing regular hand hygiene

What is cause of cellulitis

• results from an infection by group A beta-hemolytic streptococci or staphylococcus aureus

• a break in skin integrity almost always precedes infections

• affects the subcutaneous tissue and dermis

What are signs and symptoms of cellulitis

• a tender, warm, erythematous, swollen area, which is usually well demarcated

• warm, tender streak following the course of a lymphatics vessel

• fever and chills

Diagnosis of cellulitus

• can be made from clinical presentation

• gram stain and culture of skin tissue

• if patient acutely ill, blood cultures may be taken

Treatment of cellulitus

preventing widespread skin destruction requires I.V. or oral antibiotic therapy depending on the severity of the infection

Nursing care for Cellulitis

• monitor the patients vital signs (especially temp) every 4 hours

• assess the patient every 4 hours for an increase in the size of the affected area or worsening of pain

• administer an antibiotic, an analgesic, and warm compresses, as ordered

What is herpes zoster (shingles)

• acute unilateral and segmental inflammation of certain nerve roots

• usually appearing in adults over age 40

• confined to a dermatome (area of skin innervated by sensory fibers from a single spinal nerve)

• sever neuralgic pain occurs in peripheral areas fed by the nerves arising in the inflamed ganglia

What is the cause and S/S of herpes zoster

• cause: results from varicella-zoster virus, a herpsvirus that also causes chicken pox

• S/S: onset is fever and malaise, within 2-4 days, severe deep pain, pruritus, and paresthesia ( burning, itching, prickling, or tingling sensations) or hyperesthesia (increased sensitivity to touch) develop- usually on the trunk and occasionally on the arms and legs

• Pain may be continuous or intermittent

Diagnosis of herpes zoster

• Dermatomic distribution of lesions is usually sufficient to confirm the diagnosis

• unusual cases, a Tzanck smear, biopsy, and viral culture may be needed to confirm the diagnosis

nursing care and treatment for herpes zoster

• relief of itching and neuralgic pain require calamine lotion or another topical antipruritic and pain medication (if bacteria have infected ruptured vesicles, treatment includes a systemic antibiotic

• Promote patient comfort

• if lesions are severe and widespread, apply wet dressing (if rupture apply cold compress)

• watch an immunosuppressed patient closely for signs and symptoms of dissemination (generalized lesions) and central nervous system infection (headache, weakness, fever, and stiff neck)

Postherpetic Neuralgia

• most common complication of shingles

• condition affects nerve fibers and skin, causing burning pain that lasts long after the rash and blisters of shingles disappear

• certain anti-seizure medications, including gabapentin and pregabalin (lyrica), can lessen the pain of postherpetic neuralgia

Intertrigo

• superficial inflammatory skin conditions of the skins flexural surfaces, prompted or irritated by warm temp, friction, moisture, maceration and poor ventialtion

• highest among obese patients

• commonly becomes secondarily infected with Candida

• area affected axilla, infra-mammary creases, abdominal folds, perineum

How to treat Intertrigo

• typically treated topically

• if Candida suspected use anti-fungal cream or powder

• apply thin layer of topical cream two times per day

Scabies

• cause by an infestation of the skin by the human itch mite

• burrows into the upper layer of the skin where it lives and lays its eggs

What are causes of scabies and S/S

• sexually active individuals, presence of many children in the house, poor housing

• S/S: skin rash (caused by sensitization to the protein and feces of the parasite), pruritus (severe itching), scabies rash, burrows in skin (causes by female scabies mite)

Scabies nursing and medical mnagement

• contact precautions

• treatment: administration of scabicidal agent as well as appropriate antimicronial agent if a secondary infection has developed

• restore skin integrity: have patients avoid rubbing and scratching

• education: decontaimination

Abscess

• appears as swollen, pusfilled lump under the surface of the skin, if infection might have high temp and chills

• may be treated with antibiotics (PO) or IV if severe, with systemic symptomology

• may be lanced and drained, and nursing does wound care

• often the wounds are packed with medicated gauze, covered with a wet to dry dressing