N433 Chronic leading up to final

skin functions

• protection

• temperature regulation

• vitamin D metabolism

• sensation

• excretion and fluid balance

skin: normal aging changes

• thinning and dryness of skin

• wrinkling, decreased elasticity

• increased fragility and potential for injury

• uneven pigmentation

• benign and malignant lesions

• reduced healing ability

• diminished hair

braden scale

identify patients at risk for pressure injury

• sensory perception

• moisture

• activity/mobility

• nutrition

• friction and shear

score 6-23

18 or less indicates risk

nursing care of skin conditions

• administration of topical and systemic medications

• wound care and dressing changes

• providing patient hygiene

• address educational, emotional, and psychosocial needs

skin infections overview

microorganisms enter body through hair follicles or through small breaks in the skin

causes: weakened immune system, another disease, medical treatment

risk factors: older age, poor circulation, diabetes, weakened immune system, immobility, malnourishment, obesity, excessive skin folds

clinical manifestations: rashes, swelling, redness, pain, pus, itching

diagnosis: exam, skin cultures, biopsies, blood tests

treatment and nursing interventions for skin infection

treatment

• topical creams and lotions

• medication

• procedures

nursing intervetions

• establish a baseline of wound/skin appearance

• perform wound care and administer medications as ordered

• Encourage adequate nutrition that facilitates wound healing — protein and fluids

• client teaching

bacterial skin infections: cellulitis

• painful, erythematous infection of dermis and subcutaneous tissues

• warmth, edema, advancing borders

bacterial skin infections: impetigo

• large vesicles or honey-crusted sores

• contagious, personal hygiene items should not be shared

bacterial skin infections: folliculitis

inflammation of hair follicles

bacterial skin infections: furuncles and carbuncles

• painful, firm, fluctuant abscesses originating from a hair follicle

• NEVER squeeze or pop

viral skin infection: shingles

• caused by reactivation of varicella zoster virus

• dermatomal distribution

• painful blistering rash

• can leave post-herpetic neuralgia — burning sensation and neuropathic pain

treatment: antivirals, pain mngmt

pt teaching

• avoid sharing clothes and towels

• loose-fitting clothes

• cover lesions while rash is weeping

• avoid scratching

• hand washing

viral skin infection: herpes simplex

• lifelong viral infection usually aquired and transmitted asymptomatically through body fluids, skin-to-skin, skin-to-mucosa, mucosa-to-mucosa contact

• dormant until PNS is triggered

• type 1: face, oral cavity, lips, skin

• type 2: painful anogenital lesions

treatment: antivals (no cure)

fungal skin infections

• proliferate in warm, moist, dark environments

• cleanse incontinent episodes as soon as they occur, keep perineum as dry as possible

• separate skin flds with gauze or other dressings

• avoid tight-fitting clothes, shoes, and communal washing

• wear clean, dry, cotton clothing

• avoid synthetic underwear and wet bathing suits

• avoid excessive heat and humidity

• risk increased by antibiotics

• treatment: antifungal agents

parasitic skin infections: lice

• may infest anyone

• most common in head and behind ears

• treatment: includes shampoo and combing of hair with fine-tooth comb dipped in vinegar to remove nits

• do not share combs, hats, ect

• disinfect clothing

• frequently vacuum furniture and floors

• treat family members

parasitic skin infections: scabies

• may take 4 wks for symptoms to appear and several weeks to disappear

• may spread through contact

• wash clothing and treat contacts

treatment

• warm, soapy bath — allow skin to cool

• persiciption scabicide lindane

• crotamiton

• 5% permethrin

psoriasis

immune disorder causing chronic inflammation of the skin

• epidermal cells produced at abnormally rapid rate

• more skin cells made that are shed → thick, raised red patches covered with silvery flaking scales

• most common: elbow, knees, legs, palms, soles, scalp, trunk, face

• aggravated by infections, meds, stress, trauma, seasonal and hormonal changes

  • more common in those in warmer climate with sun exposure

• can lead to psychosocial stress, poor self-esteem, financial worries, increase pain and discomfort, infection

psoriasis diagnosis

• clinical manifestations

• serum CRP, ESR

• r/o other disorders

psoriasis treatment

no cure

• topical creams and ointments (corticosteroids, retinoids)

• UV light therapy

• systemic meds to alt immune response (methotrexate)

psoriasis nursing interventions

• baseline skin assessment, monitor for changes, s/s of infection

• medications and treatment — monitor side effects

• pain control

• provide emotional support and referral to counseling fro psychosocial dysfunction

• client teaching

skin cancer

• main cause UV exposure

  • damages skin cell DNA, disrupts cell membrane, mediates immune suppression

• use sunscreen and avoid sun exposure

• Basal cell carcinoma: most common and usually treatable

  • Tumors remain localized

• melanoma: less than 2% of cancer diagnosis

  • majority of skin cancer deaths

  • depth of tissue involved and likelihood of metastasis

skin cancer: diagnosis

observation of physical changes in appearance of skin

biopsy

skin cancer treatment

• dependent on type, location, severity

• surgery

• radiation

• chemo

• photodynamic therapy

• biological therapy

skin cancer teaching

• limit sun exposure

• monthly skin self-exams

• wound care and s/s infection

burn injuries

• approx. 1.1 million people require medical attention of burns every year

• half occur in home environment

• thermal, electrical, chemical, or radiation

• superficial, superficial partial-thickness, deep partial thickness or full thickness

burn injuries: superficial

epidermal layer of skin

• mild erythema

• hypersensitivity

• resolve in 24-72 hours on own

burn injuries: superficial partial thickness

• epidermis and superficial or minimal layers of dermis

• painful d/t nerve ending involvement

• sensitive to touch and even air currents

• cap refill remains normal

• heal 1-2 weeks

burn injuries deep partial thickness

• epidermis and extends to deeper portions of bottom layers of the dermis

• pain varies, decreased sensation

• waxy appearance, weepy blisters

• light pink or cherry red

• cap refill decreased or absent

burn injuries: full thickness

• epidermis, dermis, potentially: tissue, muscle bone

• nerve fibers are destroyed

burn injuries: estimate TBSA burned

rule of palm: size of pt hand (including fingers) = 1%

rule of nines: body surface broken down into 9% or multiples there of

lund and browder: relate to age and assigned to each body part

burn injuries: factors affecting severity

• presence of halation injury

• age

• PMH

• concomitant injury

• anatomical location

major burn injury affects

• impaired function and mobility

• altered appearnace

• inhalation injuries

• burn shock and fluid/elect. imbalance r/t fluid loss

• impaired renal function r/t decreased blood volume

• decreased nutrient absorption and GI motility

• increased metabolic rt and caloric needs

• high infection risk

burn injuries: emergent phase

• airway mngmt

• prevent hypothermia

• pain mngmt

• risk for clotting, impaired nutrition, GI motility, anxiety, depression

nursing interventions

• resp status, BP, HR, urine OPm anxiety size and depth

• 100% humidified O2, intubation

• 2 large-bore IV catheters, LR

• cover wounds with clean, dry sheet

burn injuries: intermediate phase

• wound healing and closure, pain mngmt, optimal nutrition, prevention of infection

• surgical mngmt

nursing interventions

• VS, labs, daily weight, caloric intake, s/s of healing and infection, pain, anxiety, ADLs

• pain and anxiety management

• oral intake

• wound care

• assistance

burn injuries: rehabilitation phase

• longest

• monitor for infection, nutrition status, pain, promote greater mobility, flexibility, comfort, psychosocial health

nursing interventions

• pain level, ROM, compliance with treatment and rehabilitation regimen, readiness for integration into society

• splinting and rehab

• psychological treatment

• community resources