VNSG 1500: Unit 1 Integumentary Disorders/Problems

Objective 6: Nursing Assessment of the Skin

  • A. Health History

  • B. Physical Assessment

A&P Review of Integumentary System

  • Skin is the largest organ of the body.

  • Functions:

    • 1st line of defense against infection

    • Protects underlying tissues/organs from injury

    • Receives sensory input from the environment and relays it to the brain

    • Helps to maintain body temperature

    • Excretes salt, water, and organic wastes

    • Protects the body from excessive water loss

    • Synthesizes Vitamin D

Layers of Human Skin

  • Epidermis

  • Dermis

  • Subcutaneous tissue

  • Muscle

Epidermal Appendages

  • Stratum corneum

  • Sebaceous

  • Eccrine gland

  • Capillary loop

  • Epidermis

  • Sweat gland

  • Superficial vascular plexus

  • Papillary dermis

  • Reticular dermis

  • Hair follicle

  • Apocrine sweat gland

  • Proximal matrix

  • Distal matrix

  • Subcutaneous adipose tissue

  • Proximal Nail Fold

  • Cuticle

  • Nail Bed

  • Nail Plate

  • Hyponychium

  • Distal phalanx

Normal Bacterial Flora of Skin

  • The number of normal flora differs depending on the location and types of skin.

  • Relatively moist and shaded skin, such as skin of genital areas, is rich in normal flora.

  • Types of Normal Bacterial Flora include:

    • Gram-positive and gram-negative staphylococci

    • Pseudomonas sp.

    • Streptococcus sp.

    • Candida albicans

Risk Factors for Integumentary Disorders

  • Exposure to chemical and environmental pollutants

  • Exposure to radiation

  • Race and age

  • Exposure to the sun or use of tanning beds

  • Lack of personal hygiene habits

  • Use of harsh soaps or other harsh products

  • Some medications, such as long-term glucocorticoid use

  • Nutritional deficiencies

  • Emotional stress

  • Repeated injury or irritation

  • Genetic predisposition

  • Systemic illnesses (Ex.: Diabetes)

  • Impaired immune system

Assessment of Integumentary System: Health History Questions

  • When did the rash or lesion first appear?

  • Can you think of any event or different food you ate or substance you were using just before it appeared?

  • What is your usual dietary pattern? What do you eat and drink?

  • Have you noticed if anything makes it worse?

  • What seems to make it better?

  • Have you been using any chemicals lately for household cleaning or in pursuit of your hobbies?

  • Have you been out in rural areas or in the woods lately?

  • Have you been traveling? Did you visit a tropical area?

  • Have you had any recent exposure to animals?

  • What drugs are you taking? Do you take any over-the-counter medications?

  • Are you using any street drugs? What route of administration?

  • Have you ever had a drug reaction?

  • Have you ever had radiation therapy?

  • Do you have a history of any skin disorders in your family?

  • Does anyone in the family currently have similar symptoms, such as a rash?

  • Do you have any allergies?

  • Are you experiencing itching? Pain? Fever?

  • Have you had any gastrointestinal problems that began about the same time that the rash or lesion appeared? What about a runny or stuffed-up nose? Cough?

  • Has the skin condition affected your social life or work?

Physical Assessment of Skin/Hair/Nails

  • General appearance of skin surface: texture, elasticity, thickness

  • Condition of areas between skin folds

  • Type of lesions and distribution, size, and appearance; photograph or measure and document measurements

  • Appearance of skin adjacent to lesions; note whether reddened areas blanch when mild pressure is applied

  • Localized or generalized skin edema

  • Characteristics of secretions: color, viscosity, amount

  • Odor: description of odor; strong or faint; source—local or generalized

  • Temperature changes: location of hot spots or cold areas of the skin

  • Assess for temperature, texture, and moisture of skin by palpating skin

Physical Assessment of Skin/Hair Nails General Tips

  • Assess skin under good lighting (Don’t do it in the dark!)

  • Remember to account for differences in the shade of skin: skin lesions/rashes may look different on different skin colors

  • Pallor in a dark-skinned person presents as an ashen-gray tone to the skin. In a brown-skinned person, pallor gives the skin a yellow-brown color.

  • Jaundice is best assessed in dark-skinned people by looking at the sclera of the eye

  • Older adults will have normal variations from younger people

  • Skin turgor is assessed by lifting a fold of skin on the forearm, chest, or abdomen between two fingers and seeing how fast it falls back into place. Skin that takes longer than 1 to 2 seconds to return to place is called “poor skin turgor” and indicates dehydration.

  • When checking the temperature of the skin, the back of the hand should be used.

Types of Lesions: Macule/Patch

  • Nonpalpable (can’t be felt by touch), flat area with a change in skin color

  • Macule = <1 cm in diameter

  • Patch = >1 cm in diameter

  • Examples:

  • Freckles: Small, flat, circular spots that appear on skin exposed to the sun, resulting from increased melanin production.

  • Petechiae: Tiny, circular, non-raised patches that appear on the skin or in mucous membranes as a result of localized hemorrhage.

  • Measles: A highly contagious viral disease characterized by a distinct red, flat rash that starts on the face and spreads to the rest of the body.

  • Flat mole (nevus): A common skin growth that is typically flat or slightly raised, with a consistent color ranging from brown to black.


Types of Lesions: Papule/Plaque

  • Elevated, palpable (can be felt by touch), solid mass

  • Papule = <0.5 cm in diameter

  • Plaque = >0.5 cm in diameter

  • Papule Examples:

  • Warts: Small, benign growths on the skin caused by the human papillomavirus (HPV).

    Moles (Nevi): Common skin growths composed of clusters of melanocytes; can be flat or raised, and vary in color.

    Lipoma: A benign tumor composed of fatty tissue, typically soft and movable beneath the skin.

    Basal Cell Carcinoma: A common type of skin cancer that appears as a small, waxy bump or flat, flesh-colored or brown lesion.

  • Plaque Examples:

    Psoriasis: A chronic autoimmune skin condition characterized by raised, red, scaly patches. Common on elbows, knees, and scalp.

  • Actinic Keratosis: A rough, scaly patch on the skin that develops from years of sun exposure. It is considered precancerous and can lead to squamous cell carcinoma.

Types of Lesions: Vesicle (blister)/Bulla

  • Circumscribed, elevated, palpable mass containing serous fluid

  • Vesicle = <0.5 cm diameter

  • Bulla = >0.5 cm diameter

  • Examples: Varicella, Herpes Zoster, 2nd degree burns, Poison Ivy

Types of Lesions: Wheal

  • Firm, edematous, irregularly shaped area; diameter variable

  • Examples: Hives, mosquito bites

Types of Lesions: Pustule

  • Elevated, superficial lesion filled with purulent fluid

  • Examples: Acne, impetigo

Objective 7: Common Diagnostic Studies for Skin Disorders

  • A. Skin Biopsy

  • B. Patch Testing

  • C. Skin Scrapings

  • D. Tzanck Smear

  • E. Wood Light

  • F. Clinical Photographs

  • G. Wound Culture

Diagnostic Tests: Skin Biopsy

  • Collection of a small piece of skin tissue for histopathologic study

  • Methods include punch, excision, and shave

  • Pre-procedure nursing interventions: verify consent has been obtained, cleanse site as ordered

  • Post-procedure nursing interventions:

    • Put dressing on biopsy site

    • Monitor biopsy site for bleeding/infection

    • Educate patient to keep dressing dry and in place for at least 8 hours and to clean the area daily and use antibiotic ointment as prescribed

    • Educate patient about s/s of infection to watch for

Diagnostic Tests: Patch Testing

  • Used for allergy testing

  • Patient wears patches over allergens for 48 hours, and then skin is assessed after 72 hours

  • Reaction of skin to allergens indicates allergy to the substance

    • Weak positive: redness, fine elevation, or itching

    • Moderate positive: fine blisters, papules, severe itching

    • Strong positive: blisters, pain, and ulceration

Diagnostic Tests: Skin Scrapings

  • Used to test suspected fungal lesions

  • Scalpel blade moistened with oil to collect skin scrapings

  • Skin scraping is then examined under a microscope for spores

  • Scabies can also be visualized this way

Diagnostic Tests: Tzanck Smear

  • Used to examine skin cells from blistering skin conditions (Herpes)

  • Collects secretions from blisters, apply to glass slide, stain, and view with microscope

Diagnostic Tests: Wood Light Exam

  • Special ultraviolet light

  • Can be used to detect some bacterial or fungal skin infections

  • Can also detect skin pigment disorders such as vitiligo (skin devoid of melanin will increase in whiteness with UV light)

Diagnostic Tests: Clinical Photographs

  • Used to document wound assessment and progress resulting from the treatment of wound

  • May also be used to track suspicious moles that are changing

Diagnostic Tests: Skin/Wound Cultures

  • Use of a sterile applicator and appropriate culture tube to collect a small sample of skin or wound culture

  • Once the organism has been cultured, colonies can be tested for sensitivity to certain antiinfective agents

  • Always obtain skin/wound culture samples before instituting antibiotic therapy

Objective 8: Common Therapeutic Management of Skin Care and Wounds

  • A. Skin Care

  • B. Wound Care & Dressings

    • Surgical Wound Care

    • Drain Care

    • Dehiscence/Evisceration

Skin Care

  • Protecting the skin: maintain acidic pH of skin, help maintain skin’s moisture

  • Use mild soaps

  • Avoid deodorant soaps and laundry detergents

  • Consider all skin lesions as potentially infectious; use gloves when providing wound care

Wound Care Types of Dressings

  • Passive: protect wound and maintain a moist environment (Tegaderm)

  • Interactive: can absorb some drainage and maintain the moisture of the wound bed while keeping peri-wound skin dry (Hydrocolloids, alginates, hydrogels)

  • Active: improve the healing process and decrease healing time (Skin grafts)

  • Wicker: used with sinus tracts or undermining, absorb drainage

  • Filler: used for deep wounds

  • Cover: may be used for superficial wounds or as a secondary dressing over deep wounds

Wound Care: Autolytic Debridement

  • Uses body’s own enzymes to break down necrotic tissues on the wound bed so that the wound can heal

  • Must use an occlusive dressing that will keep the wound moist

  • May produce a foul odor as dead tissue breaks down

Assessing for Wound Infection

  • Symptoms and Signs

    • ACUTE WOUNDS

      • Localized infection

        • Classical findings:

          • New or increasing pain

          • Erythema

          • Local warmth

          • Swelling

          • Purulent discharge

          • Delayed healing

          • Abscess

      • Spreading infection

        • As for localized infection PLUS:

          • Extension of erythema

          • Lymphangitis

          • Crepitus in soft tissues

          • Wound breakdown/dehiscence

          • Malodour

Things That Delay Wound Healing

  • Poor circulation

  • Poor nutrition: not enough protein in diet, patient may have low lab values for Prealbumin and Albumin

  • Poorly controlled Diabetes Mellitus

  • Wound Infection

Promoting Wound Healing

  • Prevent infection: adhere to good hand hygiene, practice clean/sterile technique during dressing changes

  • Tight blood sugar control for diabetics

  • Promote good circulation to the wound

  • Teach patient to eat protein and Vitamin C

Surgical Wound Care: Assess for

  • Approximation of wound edges

  • Integrity of sutures or staples

  • Redness, warmth, swelling, unusual tenderness, discharge

  • Assess skin around wound for reaction to tape or other adhesives

Dehiscence vs. Evisceration

  • Can result from too much strain placed on the wound:

    • Trapped fluid building up inside the wound (hematoma or infection)

    • Patient moving too vigorously or coughing

    • Obesity

    • Poor skin integrity due to age, nutrition, corticosteroid use

  • Most likely to occur with abdominal wounds

  • Patient may state they felt a popping sensation or something giving way. There may be a gush or serosanguinous fluid.

  • Nursing Priorities:

    • Assess for protrusion of intestines or other abdominal viscera

    • Place patient in Low Fowler’s position and instruct to lie still

    • Cover any protruding organs with sterile saline dressing

    • Notify the surgeon immediately

JACKSON-PRATT DRAIN CARE

  • (Information regarding drain care)

Objective 9: Pressure Injuries

  • A. Pathophysiology

  • B. Prevention

  • C. Assessment and Staging

  • D. Nursing Management/Treatment

Pressure Ulcers: Pathophysiology

  • Caused by sustained pressure, friction, or shear on the skin, which limits the blood flow.

  • Restricted blood flow causes cell injury and death.

  • Risk Factors:

    • Bedrest

    • Immobility

    • Inadequate subcutaneous tissue

    • Poor nutrition

    • Incontinence

    • Poor circulation

    • Advanced age

    • DM, PVD, Stroke, Obesity, Cognitive Impairment

    • Pain meds and sedatives

    • Smoking

Progression of a Pressure Ulcer

  • Grade 1: Non-blanchable erythema (redness) of intact skin. Discoloration of the skin, warmth, oedema, induration, or hardness may also be used as indicators, particularly on individuals with darker skin

  • Grade 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister

  • Grade 3: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia

  • Grade 4: Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss

Pressure Ulcers

  • Suspected Deep Tissue Injury: intact skin with a purple or maroon discoloration. Tissue may be firm, boggy, painful, cool, or warm

  • Unstageable Pressure Ulcer: Wound bed is covered with eschar or slough that obscures the depth of the wound

Pressure Ulcers: Treatment

  • Debridement: removal of eschar or slough

  • Wound care: dressings should keep wound bed moist

  • Measurement: should be measured and documented when first discovered and at least once a week after that

  • Negative pressure wound therapy

  • Hyperbaric oxygen therapy

  • Increase protein intake to promote healing

Pressure Ulcers: Prevention

  • Thorough skin assessment and good skin care

  • Reposition every 2 hours

  • Use positioning devices and padding

  • Special mattresses/air beds

  • HOB a lowest degree possible for patients on bedrest

  • Use draw sheet or lifting device to move patient in bed

  • Keep skin clean and dry

  • Don’t massage bony prominences

  • Good nutrition

Objective 10: Nursing Management of Pruritus

  • A. Pathophysiology

  • B. Medical Management

  • C. Nursing Management

  • D. Gerontologic Considerations

Pruritus, aka “Itching”

  • Pathophysiology: scratching pruritus areas causes histamine to be released, which produces more pruritus

  • Pruritus tends to worsen at night

  • The underlying cause of itching could be several things: allergies, dry skin, cholestasis, or uremia

  • Gerontologic Consideration: pruritus occurs more frequently in older adults as a result of dry skin. They are also more likely to have a systemic illness that causes pruritus.

Pruritus, aka “Itching”: Medical Management

  • Topical creams containing Lidocaine or Prilocaine

  • Topical corticosteroids

  • Oral antihistamines: Diphenhydramine, Hydroxyzine

  • SSRIs (Fluoxetine, Sertraline) for cholestatic itching or uremic itching

  • Skin moisturizers

  • Lotions that contain menthol or camphor

Oral Antihistamines

  • Diphenhydramine (Benedryl), Hydroxyzine (Atarax), Cetirizine (Zyrtec)

  • Side Effects: Drowsiness, Dry Mouth, Dizziness

  • Teaching: take at bedtime to avoid daytime drowsiness

Pruritus, aka “Itching”: Nursing Management

  • Teach patient to take tepid bath rather than hot

  • Don’t rub with towel, but blot dry

  • Use emollient lotion after baths to trap moisture

  • Avoid situations that cause vasodilation: overheating, alcohol intake, hot/spicy foods

  • Use a humidifier if the cause of itching is dry skin

  • Avoid synthetic materials that may irritate skin

  • Keep nails trimmed short to avoid breaking skin

Objective 11: Common Skin Disorders/Infections

  • A. Secretory Disorders

    • Acne Vulgaris

    • Acne Rosacea

  • B. Infections Skin Disorders

    • Bacterial: Impetigo, Folliculitis/Furuncles/Carbuncles

    • Viral: Herpes Zoster

    • Fungal: Yeast, Tinea (Ringworm)

    • Parasitic: Pediculosis & Scabies

  • C. Non-infectious Skin Disorders

    • Contact dermatitis

    • Psoriasis

    • Blistering Diseases

    • TEN & Stevens-Johnson Syndrome

Skin Disorders/Problems: Secretory Disorders

  • Acne Vulgaris

  • Acne Rosacea

Acne

  • Acne is a disorder of the skin characterized by papules and pustules over the face, back, and shoulders.

  • Two Types: Acne Vulgaris and Acne Rosacea

Acne Vulgaris: Etiology

  • The exact cause is unknown but may include hormonal influences on the sebaceous glands, increased sebum production, and proliferation of the enzymes that reduce lipids to irritating fatty acids

Acne Vulgaris: Medical Diagnosis/Management

  • Diagnosis by examination and history

  • Topical Treatments:

    • Retinoic Acid (Retin-A) topical

    • Benzoyl peroxide

    • Antibiotics: Tetracycline, Erythromycin

    • Oral contraceptives

    • Isotretinoin (used to be Accutane) for severe cystic acne (SERIOUS SIDE EFFECTS ASSOCIATED WITH THIS DRUG)

      • Mandatory effective contraception while on this drug and up to 8 weeks afterward (teratogenic effects)

      • Avoid Vitamin A supplements while on this drug

      • The most common side effect is cheilitis (inflammation of the lips)

Acne Vulgaris: Nursing Management

  • Wash face gently with mild soap. Scrubbing and harsh soaps increase inflammation

  • Avoid squeezing pimples

  • Try to keep hands off face as much as possible

  • Give support to teens dealing with body image issues due to acne

Acne Rosacea: Etiology and Risk Factors

  • Etiology: Cause is not really known

  • S/S: Facial redness, pimples, dilation of capillaries on face (“spider veins”)

  • Risk Factors:

    • Age: usually develops between 30-60 years of age

    • Gender: more common in women than men

    • Fair Skin

    • Ethnicity: Northern or Eastern European heritage

    • Sun Exposure

    • Hx of Acne Vulgaris

Acne Rosacea: Medical Diagnosis/Management

  • Diagnosis by examination and history

  • Topical Treatments: Metronidazole cream

  • Avoidance of triggers: sun exposure, caffeine, alcohol, stress, spicy foods

  • Nursing Management

    • Treatment will most likely be lifelong

    • How to apply topical medication

    • Use gentle soaps, fragrance- free skincare/make-up products

    • Use sunscreen with SPF of 15 or higher

Skin Disorders/Problems: Bacterial

  • Impetigo

  • Folliculitus/Furuncles/Carbuncles

Impetigo

  • Superficial skin infection caused by Staph, Strep, or multiple bacteria, tends to occur in skin that has been cut, scraped, or has some other small opening

  • Clinical manifestations:

    • Small red macules that turn into vesicles that rupture and crust over

    • Lesions usually found on the face and extremities

    • Crusts are a yellowish color and easily removed

Impetigo: Medical Management

  • Medical Management:

    • Topical antibiotics: Mupirocin

      • Lesions must be washed and crusts removed before applying antibiotic ointment (gloves should be worn)

    • Systemic antibiotics may be used if widespread or when fever is present

  • Nursing Management:

    • Bathe patient daily with bactericidal soap

    • Practice good hygiene to avoid spread, don’t share linens

    • Avoid contact with other people or keep lesions covered if possible until lesions heal

Bacterial Skin Infections

  • Cellulitis: an infection of the dermis and subcutaneous tissue, usually caused by Staphylococcus. Area is red, swollen, and painful

  • Folliculitis/Furuncles (boils): inflammations of hair follicles. Lesion may contain pus and necrotic tissue.

  • Carbuncles: a collection of faruncles (boils).

  • Treated with systemic antibiotics

  • May use astringent solutions such as Burow solution to help draw out pus

  • May perform Incision & Drainage of the abscess with debridement of any necrotic tissue

Skin Disorders/Problems: Viral Skin Infections

  • Herpes Zoster (Shingles)

Viral Skin Infections: Herpes Zoster (Shingles)

  • Reactivation of dormant varicella vaccine by trauma, malignancy, stress, or local radiation

  • More common in older adults

  • Preventable with vaccination: Shingrix vaccine recommended for immunocompetent adults age 50 and over

  • If a person has never had chicken pox or varicella vaccine, they cannot get shingles.

  • Signs/Symptoms:

    • Fatigue, low-grade fever

    • Aching along nerve pathway (dermatome) with or without redness

    • 3-5 days after onset, small groups of vesicles appear on the skin following the nerve pathway

    • Eventually, vesicles change to painful scaly lesions that itch

    • Pain may persist after healing of lesions, and the patient may develop postherpetic neuralgia that lasts for years

Viral Skin Infections: Herpes Zoster (Shingles) Medical Diagnosis/Management

  • Diagnosis by examination and history

  • Treatment: no cure, the purpose is to shorten the course of illness and manage pain

  • Antivirals: Topical and oral Zovirax (acyclovir), Valacyclovir (Valtrex), or Famciclovir (Famvir)

  • Analgesics

  • Gabapentin (Neurontin)

  • Corticosteroids may be used to reduce inflammation

  • Earlier the condition is treated, the better the chances to decrease the amount & duration of pain

  • Nursing Management

    • Teach about medications

    • Treat pain and itching: cold compresses, Calamine lotion, distraction techniques

    • Monitor for secondary bacterial infection

    • Don’t wait until diagnosis to institute airborne and contact precautions if suspect patient has shingles

    • Patient should be isolated until all lesions have crusted

    • If lesions are localized and can be covered with a dressing and the patient is not immunocompromised, standard precautions are sufficient

Skin Disorders/Problems: Fungal Skin Infections

  • Yeast

  • Tinea

Fungal Skin Infections

  • 2 Types of fungal infections in humans:

    • Fungi that are truly pathogenic in humans (very few)

    • Fungi that are opportunistic and require host to be immunocompromised

  • S/S: itching, swelling, breakdown of tissues, tend to develop in warm, moist areas.

  • Examples: Candidiasis (yeast), Tinea pedis (Athlete’s foot)

  • Remember that diabetics are at greater risk for fungal skin infections

Tinea: “Ringworm”

  • Fungal infection of the skin, not a worm

  • Contagious: affected children should not share grooming items, headgear, or clothing with other children

  • Can me transmitted from animals such as household pets

  • Gymnasium mats and helmets are another source of infection

  • Treatment: Antifungal ointment, oral antifungals if a problem is widespread or persistent

Fungal Skin Infections: Tinea Pedis (Athlete’s Foot) Medical Diagnosis/Management

  • Diagnosis by examination

  • Treatment:

    • Topical Antifungals: Miconazole, Clotrimazole, Ketoconazole

    • Keep the area dry, clean, and exposed to air and sunlight as much as possible

    • Clean cotton socks, separate toes with gauze or cotton.

    • Systemic antifungal such as Terbinafine (Lamisil) for persistent infections

  • Nursing Management

    • Teach patient to keep feet clean and dry

    • Wear clean cotton socks every day

    • How to apply topical med

    • Disinfect tub/shower after bathing to prevent transmission to others

    • Use own towel

    • Always wear shoes at pool/gym/locker rooms

    • Monitor liver function of patients on oral antifungals

Skin Disorders/Problems: Parasitic Skin Infections

  • Pediculosis Capitis (Lice)

  • Scabies

Scabies

  • A skin infestation caused by the scabies mite

  • Lesions are created as a female scabies mite burrows into the epidermis and deposits eggs & feces.

  • Inflammatory response causes intense itching

  • Maculopapular lesions, denser distribution in folds and creases

  • Transmitted via prolonged contact

  • Can affect people regardless of age, sex, personal hygiene, or socioeconomic status

  • Treatment: Scabicide such as Elimite (Permethin 5%) cream, oral Ivermectin

  • Contact precautions

Pediculosis Capitis (Head Lice)

  • Infestation of the scalp by Pediculosis humanus capitis, a tiny bloodsucking insect

  • Anyone can get head lice no matter age, socioeconomic level, or cleanliness

  • The female louse lays eggs at night on the hair shaft close to the skin; nits (eggs) hatch in 7-10 days

  • Itching is caused by crawling of insects and insect saliva on the skin

  • Signs/Symptoms: itching of the scalp, especially behind ears and at the nape of the neck; visualization of insect or nit

  • Treatment: Pediculicides such as permethrin 1% shampoo and manual removal of nits with a fine-toothed comb; should retreat in 7-10 days in case some nits were missed

  • Lice do not jump or fly, but they can be transmitted through prolonged contact or sharing of combs, hats, hair ornaments

Identifying Head Lice

  • (Includes images of lice and nits)

Skin Disorders/Problems: Non-infectious Skin Disorders

  • Contact Dermatitis

  • Psoriasis

Dermatitis: Contact Dermatitis

  • Contact Dermatitis: allergic response to a substance on the skin

  • Redness, swelling, pruritis, and vesicular lesions

  • Examples: poison ivy, poison oak, certain soaps, latex allergy

  • Atopic Dermatitis (Eczema): autoimmune

    • More common in infancy/childhood

  • Stasis Dermatitis: usually occurs on LE as a result of venous stasis & edema

  • Seborrheic dermatitis (cradle cap): Lesions appear as scaly white or yellowish plaques with mild pruritus.

Dermatitis: Diagnosis/Treatment

  • Diagnosed by inspection and history

  • Treatment:

    • Avoidance of irritants or allergens

    • Skin moisturization

    • Control of inflammation/itching with topical or oral corticosteroids

  • Nursing Management

    • Teach patient to avoid allergens/irritants

    • Teach how to use topical meds

    • Take tepid rather than hot baths to decrease itching

    • Caution patients to avoid becoming overheated and not to puncture vesicles

    • Pat skin dry rather than rub

Psoriasis

  • Psoriasis is a chronic autoimmune skin disease that speeds up the growth cycle of skin cells, causing an overgrowth of skin cells.

  • Etiology: Genetic factors, Autoimmune

  • S/S:

    • Red patches with thick, silvery scales which may range from a few spots to large areas of scaly patches

    • Small scaling spots, commonly noted in children

    • Dry, cracked skin which may be accompanied by bleeding

    • Itching, burning, and painful lesions which may be accompanied by soreness

    • Thick, pitted, or ridged nails

    • Swollen joints with stiffness

    • NO CURE, lifelong problem

    • Has episodes of exacerbation and remission

    • Risk Factors: Someone in family with psoriasis

Psoriasis: Medical Diagnosis/Management

  • Diagnosis by examination and history, rule out other skin disorders

  • Mild-Moderate Cases:

    • Steroid creams such as Triamcinolone and sunlight in moderate doses

    • Coal Tar soaps

    • Artificial UV ray therapy

  • Severe Cases:

    • Antiproliferatives: Methotrexate

    • Biologics: Humira, Remicade, Embrel

    • Monoclonal Antibody: Siliq

  • Nursing Management

    • Skin must be kept moisturized: use moisturizer prescribed by dermatologist and air humidifiers

    • Prevent injury to skin, because small cuts and scrapes can cause the development of plaques

    • Some medications such as antiproliferatives and biologics are immunosuppressant, avoiding infection is really important

Skin Disorders/Problems: Blistering Skin Disorders

  • Toxic Epidermal Necrolysis (TEN)

  • Stevens-Johnson Syndrome (SJS)

TEN & SJS

  • Allergic reaction with skin manifestations. It can be caused by an infection, malignancy, or medication or be categorized as idiopathic. Medications that cause the condition include: Antibiotics (esp. Sulfa), Anticonvulsants, NSAIDS, allopurinol, and Meloxicam. TEN is a more severe form of SJS

  • Risk Factors: Someone in family who has had SJS, Female, Older adults

TEN & SJS: S/S

  • The early symptoms of Stevens-Johnson syndrome resemble that of flu and include fever, sore mouth or throat, tiredness, cough, and burning sensation in the eyes. As the condition advances, the symptoms include:

    • Unexplained skin pain

    • Painful red or purplish rash

    • Spreading of rashes

    • Blister formation on the skin and mucous membranes of the mouth, nose, eyes, and genitals

    • Dying of the affected skin

    • Shedding and healing of the dead skin

    • Facial swelling

    • Swollen lips covered in crusty sores

  • Complications: Keratoconjunctivitis, sepsis, multiple organ dysfunction syndrome

TEN & SJS: Management

  • Good, thorough skin assessment daily

  • Review medications to identify possible cause (Remember OTC meds can cause SJS too!)

  • Discontinue medication thought to be causing the condition

  • Supportive IV fluids and nutrition care (may be TPN)

  • Aseptic wound care to avoid infection, possibly in burn center

  • Analgesics for pain

  • Sometimes corticosteroids are still used, but this is controversial due to immunosuppression caused

Objective 12: Skin Growths and Skin Cancer

  • Benign Skin Tumors

    • Cysts

    • Seborrheic & Actinic Keratoses

    • Verrucae: Warts

    • Angiomas

    • Pigmented Nevi: Moles

    • Keloid Scars

  • Malignant Skin Tumors

    • Basal cell and squamous cell carcinoma

    • Melanoma

Benign Skin Tumors

  • Cysts: may contain fluid or solid material, may be surgically removed

  • Seborrheic Keratoses:

    • Wartlike lesions, range in color from tan to black

    • Usually located on the face, shoulders, chest, and back

    • Should be assessed periodically for changes that suggest malignancy

  • Actinic Keratoses

    • Actinic keratoses are considered premalignant (rough and scaly)

    • May transform into squamous cell carcinoma

Benign Skin Tumors

  • Verrucae: Warts, caused by infection with the human papillomavirus

    • Considered benign unless in the genital area: genital warts can be precancerous

    • Contagious and can be spread from skin-to-skin contact

    • Usually not painful unless on the soles of the feet

    • May be removed with topical agents (salicylic acid) or frozen/burned off by a dermatologist

Benign Skin Tumors

  • Angiomas: vascular tumors, appear as flat red patches (port-wine angiomas) or raised, bright red nodular lesions (