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Integumentary System

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Integumentary System Fall 2010 C. Matthews MSN, RN Ignatiavicius references are for 6th ed. Primary Lesions Bulla 1cm Elevated Serous fluid filled Plaque (psoriasis ... – PowerPoint PPT presentation

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Title: Integumentary System


1
Integumentary System
  • Fall 2010
  • C. Matthews MSN, RN
  • Ignatiavicius references are for 6th ed.

2
RESPONSE TO ALTERED INTEGUMENTARY FUNCTIONUnit
Outcomes Upon completion of this unit of study,
the student will be able to
  •  Safe Effective Care Environment
  • 1. Identify factors that influence injury and
    disease prevention ( sun exposure, environmental
    toxins, etc.).
  • 2 . Perform thorough dermatological assessment
    throughout the life span.
  • Health Promotion and Maintenance
  • 3. Identify healthy behaviors by the client and
    family ( screening exams, limiting risk taking
    behaviors).
  • Psychosocial Integrity
  • 4. Discuss psychosocial impact of clients
    altered dermatological condition ( acne, burns,
    rashes, tumors).
  • Physiologic Integrity
  • 5. Discuss nursing implications for medications
    prescribed for clients with dermatologic
    disorders.
  • 6. Develop plan of care for client with impaired
    skin integrity.
  • 7. Explain the eight parameters of assessing a
    lesion.
  • 8. Describe common lesions and rashes utilizing
    proper terminology.
  • 9. Describe pre-op and post care of clients
    receiving dermatological surgical procedures.
  • 10. Select nursing diagnoses most likely to be
    utilized with clients with integumentary
    problems.
  • 11. Discuss etiology, clinical manifestations,
    and interventions for viral, bacterial, fungal,
    and parasitic skin disorders.

3
Introduction Skin in our Culture
  • Defining beauty
  • Language
  • Costs
  • Every RN

4
Costs
  • - Skin care and tx
  • skincare market including both mass and prestige
    to reach 7.2 billion by 2010
  • (The US
    Market for Skin Care Products, 2005)
  • In the U.S., 2.5 million pressure ulcers are
    treated each year in acute care facilities, and
    the cost of treating these potentially deadly
    wounds has been estimated at 11 billion a year.
    (Groch, 2006)

5
Costs
  • quadriplegic actor Christopher Reeve died at
    the age of 52 from complications reportedly
    associated with an infected pressure ulcer. Once
    established, these wounds are notoriously hard to
    treat and are associated with adverse health
    outcomes and high treatment costs (Groch, 2006)

6
Multiple layers within the integumentary system
form a wall of protection
  • http//www.chinapictures.org/photo/travel/great-wa
    ll-of-china/31222141525419/
  • Safe Effective Care Environment 1. Identify
    factors that influence injury and disease
    prevention ( sun
  • exposure, environmental toxins, etc.).

7
Anatomy review
  • See illustration Iggys text (6th ed. - page
    461 and/or Lilly text (6th ed.) page 864
  • FYI http//www.middlesexcc.edu/faculty/Barbara_Bog
    ner/preworkshop5.html

8
Skin Layers

  • http//www.brighterblooms.com/planting-directions/
  • Safe Effective Care Environment 1. Identify
    factors that influence injury and disease
    prevention
  • (sun exposure, environmental toxins, etc.).

9
Functions
  • Protective Barrier
  • Injury
  • Microbial Invasion
  • Fluid Electrolyte Balance
  • Temperature control
  • Excretion
  • Sensation
  • Vitamin D
  • Identity

10
Topics
  • Assessment
  • Safety and preventive measures
  • Nursing Implications for Pharmacologic Management
  • Nursing Implications for Nonpharmacologic
    Management
  • Nursing Implications for Surgical Management
  • Nursing Management of Clients with Alterations -
    Integument

11
KPs
  • Assessment
  • A. Parameters of General Skin Assessment
  • B. Lesions
  • C. Cultural/Ethnic variations
  • D. Diagnostic Testing

12
Thorough History
  • Dx Tx realm of practice
  • Difficult due to similarities in lesions and sx
  • Differential dx requires clues

13
Assessment Subjective Data
  • Past Medical History
  • Trauma
  • Surgery
  • Prior skin disease
  • Jaundice
  • Delayed wound healing
  • Allergies
  • Sun exposure
  • Radiation treatments

Chart 26 -2 page 466
14
Assessment History
  • Medications
  • Prescription
  • OTC
  • Herbals
  • Name
  • Length of usage

15
Assessment History
  • Surgery
  • Cosmetic
  • Biopsy
  • Diet
  • Health Practices
  • Hygiene, products
  • Sunscreen, SPF
  • Complementary alternative medicine
  • C/O symptoms
  • Known exposure to carcinogens, chemical
    irritants, allergens
  • Family
  • Alopecia (bald)
  • Psoriasis
  • Skin cancer

16
Assessment History
  • Changes
  • Skin condition
  • Hair condition
  • Nail condition
  • Mucous membranes

17

Assessment
  • Privacy
  • Carefully describe
  • Obvious changes in color and vascularity
  • Presence or absence of moisture
  • Edema
  • Skin Lesions
  • Skin integrity
  • Document properly

18
Parameters of General Skin Assessment
  • color, temperature, moisture, elasticity, turgor,
    texture, and odor.

Wilkinson page 366 - 370
19
Assessment Inspection
  • Consider Cultural and Ethnic variations
  • Dark skin (Iggy page chart 26-3 page 476)
  • rates - skin cancer
  • http//www.cdc.gov/cancer/skin/statistics/race.htm
  • wrinkles
  • Difficult to assess flushing cyanosis jaundice
  • Rashes difficult to observe
  • Pseudofolliculitis
  • Keloids (page 509)
  • Mongolian spots

Iggy - Chart 26-3 pg. 476
20
Assessment Inspection
  • Inspection of hair
  • Distribution
  • Texture
  • Quantity
  • Inspection of nails
  • Iggy page 474-475 Wilkinson 370
  • Grooves
  • Pitting
  • Ridges
  • Curvature
  • Shape

Malnutrition Anorexia nervosa Anxiety Hygiene
Depression Hormones Living conditions Circulatory
status Chronic disease
21
Lesion Description
Page 467- 472
  • Configuration
  • Annular
  • relating to, or forming a ring
  • Linear
  • Concentric rings
  • Clustered
  • Diffuse
  • Effect of pressure
  • Size
  • Metric
  • Shape
  • Circumscribed
  • Irregular
  • Round
  • Texture
  • Rough
  • smooth

22
Lesion Description
Page 467-472
  • Distribution
  • Asymmetric vs. Symmetric
  • Confluent
  • flowing or coming together also run together
  • Diffuse
  • Localized
  • Solitary
  • Zosteriform
  • resembling shingles
  • Satellite

23
Inspection
  • See slides 129 - 133 at the end of the slide show
  • See Iggy text illustrations on pages 467-472 for
    primary and secondary lesions

24
Pause for photos
25
Assessment Palpation
Table 26-4, page 472
  • Edema
  • Moisture
  • Temperature
  • Turgor
  • Texture

Fever C-V status Respiratory status Hormones Hydra
tion Rash/ Lesion Nutritional status
26
Skin problems common in Florida
  • Skin cancer
  • Sunburn
  • Insects
  • Plants
  • Water sports

27
Skin cancer
  • http//www.cdc.gov/cancer/skin/statistics/state.ht
    m

Iggy text, page 509-512
28
Skin cancer - most common cancer!
  • Risk factors
  • Fair skin
  • Blue/green eyes
  • Blond/red hair
  • History chronic sun exposure
  • Family history
  • Living near the equator
  • Very high/low altitudes
  • Working outdoors
  • Age gt 60 (damage is cumulative)

29
Non-melanoma Skin Cancers
  • Basal Cell Carcinoma
  • Most common type of skin cancer
  • Easily treated
  • Doesnt metastasize
  • Middle age to older adults
  • Symptoms
  • Small slow growing papule
  • Semi translucent or pearly
  • Erosion/ulceration of center

30
Basal Cell Carcinoma
  • Medical Tx
  • Excision
  • Cryosurgery
  • Radiation
  • Topical chemotherapy

See illustration, page 510
31
Non-Melanoma Skin Cancer
  • Squamous cell
  • Less common than BCC
  • High cure rate with early detection
  • Can be aggressive, metastasize be fatal
  • Common on lips, mouth, face and hands
  • Pipe, cigar, cigarette smoking
  • Symptoms
  • Firm nodule
  • Scaling/ulceration
  • Opaque

32
Squamous cell carcinoma
  • Medical Tx
  • Excision
  • Radiation
  • Mohs surgery
  • (see slide 33)
  • 5 FU or methotrexate intralesional
  • (see slide 34)

33
Diagnostic Surgical Therapy
  • Simple Excision
  • Excision
  • Mohs micrographic surgery
  • Microscopically controlled removal of lesion
  • Removes tissue in thin layers
  • Can see all margins of specimen
  • Preserves normal tissue
  • Produces smallest wound

34
Drug Therapy Topical Fluorouracil (5-FU)
  • Selective toxicity for sun damaged cells
    (cytotoxic)
  • Indications
  • Premalignant skin disease (esp. actinic
    keratosis)
  • Systemic absorption minimal
  • It causes painful eroded area within 4 days and
    must use 1-2 times daily 2-4 weeks.
  • Healing up to 3 weeks after med stopped
  • Is photosensitizing - avoid sunlight during
    treatment
  • Will look worse before it gets better

Lilley 6th ed. page 871 - 872
35
Non-Melanoma Skin Cancers
  • Actinic Keratosis (AKA Solar keratosis)
  • Most common precancerous lesion
  • Premalignant form of squamous cell carcinoma
  • Symptoms
  • Hyperkeratotoc papules/plaques on sun exposed
    areas
  • Varied appearance
  • Irregular shape
  • Flat
  • Indistinct borders
  • Overlying scale

36
Actinic Keratosis (AKA Solar keratosis)
  • Medical Tx
  • Cryosurgery
  • (see slide 37)
  • 5 FU
  • Surgical removal
  • Retin A
  • Chemical peels

37
Cryosurgery
  • Subfreezing temps for surgery (liquid nitrogen)
  • Lesion becomes red swollen, blisters, then
    scabs falls off in 1-3 weeks
  • Minimal scarring
  • Indications
  • Genital warts
  • Seborrheic keratosis
  • Actinic keratosis

38
Malignant Melanoma
  • 1/3 of all melanoma occur in existing nevi or
    moles
  • Any sudden or progressive change in size, color
    or shape of a mole should be checked

39
Malignant Melanoma
  • Can metastasize anywhere
  • Most deadly of skin cancers
  • Causes
  • UV radiation
  • Skin sensitivity
  • Genetic
  • Hormonal
  • Sun exposure
  • Mutation of gene (B-RAF) 70

40
Malignant Melanoma
  • 4 Types occur different areas of body
  • Superficial Spreading Melanoma (SSM)
  • Most common type
  • Most curable
  • Frequently from preexisting moles
  • Lentigo Maligna Melanoma (LMM)
  • Acrallentiginous melanoma (ALM)
  • Nodular melanoma (NM)

41
A B C Ds of Melanoma
  • Asymmetry
  • Border irregular, edges ragged
  • Color varied pigmentation
  • Tan, brown, black, red
  • Diameter gt 6mm

42
Melanoma
  • Medical Tx
  • Depends on site, stage, age and general health of
    client
  • Surgery
  • Chemotherapy
  • Biologic Therapy
  • Interferon, interleukin
  • Radiation therapy

43
Pause for Photos
44
Prevention/Education
  • Sunscreen
  • Limit exposure
  • Hat/clothes/sunglasses
  • Shade
  • Inspect skin regularly

45
Sunburn Education(Protect, Protect, Protect)
  • Same precautions as for skin cancer.
  • Dont let clouds or cool air fool you Florida
    sun is damaging then too.
  • Get out of the sun before you turn red!
  • Cool skin off. Immediately!
  • Hydrate!

46
Sunburn
  • Superficial burn
  • Illustration page 522
  • Excessive exposure to ultraviolet rays injures
    dermis.
  • Dilated capillaries red, tender, edema,
    blisters
  • Large area h/a, nausea, fever

47
Sunburn
  • Redness pain begin within a few Hours.
  • Intensity may increase before subsiding.
  • 3-5 days to heal
  • Tx cool bath soothing lotions topical
    corticosteroids fluids

48
Insects/Pests/Parasites
  • Spiders
  • Fire Ants
  • Lice/Scabies
  • Mosquitoes
  • Scorpions
  • Sand fleas
  • Chiggers
  • AKA harvest mites or red bugs

49
Spider bites
  • http//assets.aarp.org/external_sites/adam/html/2/
    19570.html
  • http//www.badspiderbites.com/brown-recluse-spider
    -bite/

50
Infestations Pediculosis
  • Head, body or pubic lice (crabs)
  • Parasite excrement and eggs on skin
  • Nits in hair
  • Waxy, dont fall off easily
  • Symptoms
  • Tiny red points to papular wheal-like lesions
  • Pruritis check hairline
  • Secondary excoriation

51
Pediculosis
  • Medical tx
  • Pyrethrins (Rid), Permethrin (Nix) or if all
    other agents failBenzene hexachloride (Kwell)
  • Contact screening
  • http//www.cdc.gov/lice/head/faqs_treat.html

11. Identify etiology, clinical manifestations,
and interventions for viral, bacterial, fungal,
and parasitic skin disorders. Physiologic
Integrity 6. Develop plan of care for client
with impaired skin integrity.
52
Infestations Scabies
  • Skin reactions due to eggs, feces, mite parts
  • Transmitted by direct contact
  • Symptoms
  • Severe itching especially at HS
  • Usually not on face
  • Presence of burrows esp. interdigital webs
    flexor surface of wrists
  • Redness, swelling, vesiculation

53
Scabies
  • Medical tx
  • Topical Scabicide
  • Antibiotics for 2ndary infection
  • Treat those in close proximity
  • Clothing linens hot water and detergent

54
Drug Therapy Antiparasitics
  • Pediculicides
  • Pyrethrins (RID)
  • Permethrin (NIX)
  • Scabicide Pediculicide
  • Lindane (Kwell, Scabene)
  • Cream, lotion
  • Shampoo
  • nit comb
  • Adverse effects
  • Rash, rare CNS toxicity

55
Plants that irritate skin
  • Poison ivy/ oak
  • http//www.aad.org/public/publications/pamphlets/s
    kin_poison.html
  • nettles
  • Cacti
  • Sawgrass
  • Plants w/ milky sap

56
Plants in FL that irritate skin
  • Poinsettia, Croton
  • Milky sap can cause skin irritation
  • Oleander
  • Touching the plant is not dangerous, but
    prolonged contact can irritate the skin.
  • Poison Ivy , Brazilian Pepper
  • Touching the leaves or oil from the plant can
    cause an itchy rash with blisters.

57
Brazilian Pepper
58
Virginia Creeper
Poison Ivy 5 little fingers Ø 3 little leaves
59
Drug Therapy
  • Topical Corticosteroids
  • Anti-inflammatory, antipruritic
  • Low potency (hydrocortisone)
  • Slower acting
  • Can be used longer without serious side effects
  • Ointment most efficient
  • Higher potency, long term, systemic use is
    different tx

60
CorticosteroidsTriamcinolone (Kenalog)
  • Intralesional
  • Reservoir of med effects lasts several weeks to
    months
  • Indications
  • Psoriasis
  • Alopecia
  • Cystic acne
  • Hypertrophic scars and keloids
  • Systemic
  • Undesirable adverse effects Lilley 6th ed.
    Page 869
  • Short term therapy poison ivy
  • Long term therapy chronic bullous diseases

61
Bases for Topical Medications
  • Powder
  • Promotes dryness
  • Good for antifungals
  • Lotion
  • Cooling and drying with residual powder film
  • Good for pruritic eruptions
  • Cream
  • Emulsion of oil and water
  • Lubrication and protections
  • Ointment
  • Oil with water in suspension
  • Lubrication
  • Most efficient delivery system
  • Paste
  • Mixture of powder and ointment
  • Drying
  • Moisture absorption

62
Water sports
  • Swimmers ear
  • http//swimming.about.com/od/earsandeyes/a/swim_ea
    r.htm
  • Red tide (algal bloom)
  • Sting rays/jelly fish
  • Amoeba in lake water
  • Naegleria fowleri
  • Enters via nasal tissue

63
KP
  • Protect
  • Protect
  • Protect

Pause for Photos
64
Nursing ManagementRN as skin symptomologist
  • Dry skin
  • Elderly Infants
  • Itchy skin
  • Broken skin
  • Prevention of secondary infections

65
Nursing Management Dry skin
  • Chart 27-1 Page 480
  • Manifestations
  • Interventions
  • Elder
  • Fewer total baths
  • Lotions Mild soaps
  • Hydrate!

66
  • Everyday skin care of infant from Yale- New Haven
    Childrens Hospital
  • http//www.ynhh.org/pediatrics/newborn/infant_skin
    _care.html
  • Care of Diaper rash from Mayo Clinic Staff
  • http//www.mayoclinic.com/health/diaper-rash/ds000
    69

67
Nursing Management Itchy skin
  • Control of pruritis
  • Keep cool
  • No rubbing
  • Moisturize
  • Systemic antihistamines
  • Wet dressing
  • Topical steroids
  • Menthol, Camphor, Phenol numb itch receptors
  • Oatmeal baths

68
Nursing Management itch
  • Baths
  • For large body areas
  • Has sedating and antipruritic effect
  • Oilated oatmeal (Aveeno), potassium permangenate,
    sodium bicarb
  • Temp comfortable to client
  • Soak 15-20 mins 3-4 times daily
  • Pat dry, no rubbing
  • apply moisturizers or meds after baths

69
Nursing Management
  • Wet dressings
  • Indications
  • Skin weepy from infection/inflammation
  • Relieves itching
  • Debrides wound
  • Increases penetration of topical meds
  • Relieves discomfort
  • Enhances removal of scabs, crusts, and exudate

70
Wet dressings
  • Procedure
  • Clean solution and gauze
  • Squeeze until not dripping
  • Apply to affected area, avoid normal tissue
  • Leave in place 10-30 minutes 2-4 times a day
  • Discontinue if skin macerates (to soften)

71
Nursing Management Protect
  • Protect intact skin!
  • OOB
  • Turn at least q2h
  • Reposition frequently
  • Alleviate pressure
  • Hydration
  • Mechanical intervention
  • Rx

72
Nursing Management Psychological support
  • Chronic skin conditions
  • Emotional stress
  • Self concept alterations
  • Body image changes

73
Nursing InterventionsPsychological support
  • Support client
  • Allow verbalizations of frustrations
  • Reinforce treatment
  • Support groups
  • Help with camouflage

74
Diagnostic Testing
  • RN Responsibilities
  • Biopsy
  • (Iggy, page 477)
  • Informed Consent
  • Prep site
  • Assist with procedure
  • Apply dressing
  • Post-op instructions
  • Properly ID specimen
  • Punch
  • Incisional
  • Excisional
  • Shave

75
Diagnostic Testing (Iggy, page 476-477)
  • Cultures
  • Diagnose fungal, bacteria, viral infections
  • KOH (Potassium Hydroxide)
  • Fungus
  • Sample collection
  • Skin scraping
  • Swabbing
  • Meticulous labeling

76
Diagnostic Testing (Iggy, page 476-477)
  • Woods Light
  • Organisms fluoresce
  • Pseudomonas
  • Fungus
  • Vitiligo
  • Mineral oil slides
  • Infestations
  • Patch test
  • Allergen testing

77
Dermatological Interventions
  • Phototherapy
  • UVA UVB (UVL)
  • Ultraviolet wavelengths cause erythema,
    desquamation, and pigmentation
  • Enhance with psoralem (photosensitizing)
  • Treatment for
  • Psoriasis
  • Atopic dermatitis
  • Vitiligo

78
Phototherapy
  • Adverse effects
  • Basal or squamous cell Ca
  • Burns
  • Erythema
  • Teach patients to avoid further sun exposure
    photosensitizing drugs
  • Wear eye protections as psoralem absorbed by lens
    of eye

79
Dermatological Interventions
  • Radiation Therapy
  • Indications
  • Cutaneous malignancies
  • Advantages
  • Produces minimal damage to surrounding tissues
  • Adverse effects
  • Permanent hair loss (alopecia) to irradiated
    areas
  • Telangiectasia
  • Atrophy
  • Hyperpigmentation / depigmentation
  • Ulceration
  • BCC and SCC
  • Physiologic Integrity 5. Discuss nursing
    implications for medications prescribed for
    clients with dermatologic disorders. 6. Develop
    plan of care for client with impaired skin
    integrity.

80
Dermatological Interventions
  • Laser Therapy (CO2, Argon)
  • Cuts, coagulates, vaporizes tissue
  • No cumulative tissue damage
  • Indications
  • Coagulation of vascular lesions
  • Skin resurfacing
  • Removal birthmarks
  • BCC
  • Keloids
  • Plantar warts

81
Diagnostic Surgical Therapy
  • Skin Scraping
  • Scalpel
  • Surface cells for microscopic inspection
  • Electrodesication electrocoagulation
  • Electrical energy converted to heat
  • Destroys tissue by burning
  • Coagulates bleeding vessels
  • Curettage
  • Remove tissue with circular cutting edge
  • Small skin tumors
  • warts, seborrheic keratosis, BCC, SCC
  • Physiologic Integrity 5. Discuss nursing
    implications for medications prescribed for
    clients with dermatologic disorders. 6. Develop
    plan of care for client with impaired skin
    integrity.

82
Allergic Conditions
  • Contact Dermatitis
  • Delayed hypersensitivity
  • Lesions 2-7 days after antigen exposure
  • Manifestations
  • Red, hive-like papules and plaques
  • Sharply circumscribed
  • Vesicles
  • Pruritic

83
Contact Dermatitis
  • Medical Tx
  • Topical corticosteroids
  • Antihistamines
  • Skin lubrication
  • Elimination of allergen
  • Systemic steroids if severe

http//dermatology.cdlib.org/DOJvol7num1/NYUcases/
contact/joe.html
84
Drug Therapy Antihistamines
  • Compete with histamine receptor site
  • Oral or Topical
  • Cetitizine (Zyrtec)
  • PO tabs, syrup QD
  • Non-sedating
  • Diphenahydramine (Benadryl)
  • PO, IM, topical
  • Indications
  • Urticaria
  • Pruritis
  • Allergic reactions

85
Drug Therapy Antihistamines
  • Adverse effects
  • Anticholinergic
  • Sedation (Benadryl)
  • Use with caution in older adults
  • Indications
  • Urticaria
  • Pruritis
  • Allergic reactions
  • Adverse effects
  • Anticholinergic
  • Sedation (Benadryl)
  • Use with caution in older adults

86
Allergic Conditions Drug Reaction
  • Manifestations
  • Rash of any morphology
  • Red, macular, papular
  • Generalized rash with sudden onset
  • Pruritic
  • Can occur as late as 14 days after drug is stopped

87
Drug Reaction
  • Medical Treatment
  • Discontinue drug
  • Antihistamines, local or systemic
  • Corticosteroids if needed

88
Allergic Conditions Atopic Dermatitis
  • Cause unknown
  • Begins in infancy and declines with age
  • Manifestations
  • Scaly, red to re-brown, circumscribed lesions
  • Pruritic
  • Symmetric eruptions

89
Atopic Dermatitis
  • Medical Treatment
  • Topical corticosteroids
  • Phototherapy
  • Coal tar
  • http//www.psoriasis.org/netcommunity/sublearn03_m
    ild_otc
  • Intralesional corticosteroids
  • Lubrication of dry skin
  • Antibiotics for secondary infections

90
Pause for Photos
91
Dysplastic Nevus Syndrome
  • Abnormal mole pattern
  • Increased risk for melanoma
  • Doubles with dysplastic nevi
  • Atypical moles larger than usual (gt5mm)
  • Irregular borders, possibly notched
  • Various variegated colors
  • Most common on back

92
Infections of the skin
  • Risk factors
  • Imbalance between host and microorganism
  • Broken or damaged skin Trauma
  • Systemic disease such as Diabetes
  • Moisture
  • Obesity
  • Systemic corticosteroids, antibiotics
  • Prevention
  • Proper hygiene
  • Good health

93
Infections Herpes Simplex Virus, Type I
(AKA cold sores/fever blisters)
  • Contagious
  • Dormant Exacerbation
  • Triggers
  • Symptoms -- 1st episode 3-7 days after exposure
  • Painful local reaction
  • Vesicles on erythematous base
  • Fever, malaise

94
Herpes Simplex Virus, Type I
  • Medical Tx
  • Symptom management
  • Moist compresses
  • Petrolatum to lesions
  • Antiviral agents (Zovirax, Famvir, Valtrex)

www.treatmentsforhealth.com/.../cold-sores/
95
Infections Herpes Simplex Virus, Type II
  • Genital
  • Most genital herpes is caused by HSV-2.
    (n.l.m.-n.i.h./ Medline plus)
  • Recurrence more common than oral
  • Does not mean re-infection
  • Symptoms
  • Same as Type I
  • Treatment
  • Same as Type I

Iggy page 1742-1743
96
Infections Herpes Varicella Virus(chicken pox)
  • Highly contagious
  • No chicken pox or vaccination
  • Keep those w/active lesions separated until
    crusted
  • Symptoms
  • Vesicular lesions in successive crops
  • Face , scalp, spreading to trunk and extremities
  • Protect eyes
  • Do not squeeze pustules or crusts
  • Vesicles gt pustules gt crusts gt scars
  • Postherpetic neuralgia
  • Self limiting in children

97
Herpes Varicella Virus
  • Medical Tx
  • Antivirals
  • Symptomatic relief

98
Infections Herpes Zoster(shingles)
  • Activation of varicella zoster virus
  • Frequent occurrence in immunocompromised
  • Potentially contagious to immunocompromised
  • Symptoms
  • Linear patches along dermatome
  • Grouped vesicles on erythematous base
  • Unilateral on trunk
  • Burning pain and neuralgia

99
Herpes Zoster
  • Medical Tx
  • Symptomatic
  • Wet compresses
  • White petrolatum to lesions
  • Antiviral agents

100
Drug Therapy Antivirals
  • Acyclovir (Zovirax)
  • Suppresses chicken pox, herpes simplex 1 2,
    shingles
  • Po, IV, topical
  • Valacyclovir (Valtrex)
  • Herpes zoster (shingles) genital herpes
  • Vaccines
  • Varivax
  • Prevention of chicken pox
  • Given to children gt 12 mo.
  • Zostivax
  • HZU vaccine for adults gt 60 y/o

101
Infections Verruca Vulgaris
  • Human papillomavirus
  • Mildly contagious
  • Symptoms
  • Circumscribed hypertrophic flesh colored papule
  • Treatment
  • Scoop removal
  • Liquid nitrogen therapy
  • Keratolytic agents
  • CO2 laser therapy

102
Infections Plantar Warts
  • (Human papillomavirus)
  • Symptoms
  • Wart on Plantar surface (bottom) of foot
  • Cone shaped with black dots (seeds)

103
Plantar Warts
  • Medical Tx
  • Liquid nitrogen
  • Frequent paring with chemical patches
  • Duct tape??????

104
Infections Candidiasis (moniliasis)
  • Candida albicans (Fungus)
  • 50 are symptom free carriers
  • Immunocompromised gtgt pathogenic
  • Likes warm moist areas
  • Mouth, vagina, skin

An opportunistic infection
105
Infections Candidiasis
  • Symptoms
  • Mouth
  • White, cheesy plaque (milk curds)
  • Vagina
  • Vaginitis
  • Red edematous painful vaginal wall
  • White patches
  • Vaginal discharge
  • Pruritis
  • Painful urination intercourse
  • Skin
  • Diffuse papular erythematous rash
  • Pinpoint satellite lesions around edges
  • Physiologic Integrity 5. Discuss nursing
    implications for medications prescribed for
    clients with dermatologic disorders. 6. Develop
    plan of care for client with impaired skin
    integrity.

106
Candidiasis
  • Medical Tx Anti-fungals
  • Nystatin
  • Vaginal suppository
  • Oral lozenge
  • Mycostatin powder, cream
  • Keep skin clean dry
  • Diagnosis
  • culture
  • Microscopic exam (KOH)

107
Infections Fungal
  • Tinea Corporis
  • AKA ringworm
  • Symptoms
  • Annular
  • well defined margins
  • erythematous

108
Tinea CorporisAKA ringworm
  • Medical Tx
  • Cool compresses
  • Topical antifungals
  • Miconazole, clotrimazole, butenafine

109
Infections Fungal
  • Tinea Cruris
  • AKA jock itch
  • Symptoms
  • Self-defined border
  • In groin
  • Treatment topical antifungal cream or solution

110
Infections Fungal
  • Tinea Pedis
  • AKA athletes foot
  • Symptoms
  • Interdigital scaling
  • Erythema
  • Blistering
  • Pruritis
  • Pain

111

Tinea Pedis AKA athletes foot
  • Medical Tx
  • Topical antifungals
  • Keep dry

112
Infections Fungal
  • Tinea Unguium
  • Symptoms
  • Brittle thickened nails
  • White/yellow discoloration

113
Tinea Unguium
  • Medical Tx
  • Topical antifungal cream or solutions
  • Griseofulvin (fingernails)
  • Lamisil
  • Debride toenails

114
Drug Therapy Antifungals
  • Clotrimazole (Mycelex, Lotrimin)
  • Lozenges- thrush
  • Cream, solution, lotion- athletes foot
  • Intravaginal creams, tablets
  • Miconazole (Monistat, Micotin)
  • Athletes foot
  • Jock itch
  • Ringworm
  • Yeast infections

115
Drug Therapy Antifungals
  • Fluconazole (Diflucan)
  • PO IV
  • Excellent bioavailability
  • Vaginal or systemic candidiasis
  • Ketaconazole (Nizoral)
  • Nystatin (Mycostatin)
  • Tervinafine (Lamisil) for onychomycosis
  • Tolnaftate (Tinactin)

116
Pause for Photos
117
Infections, Bacterial
  • Impetigo
  • Group A beta hemolytic strept or staph
  • Associated with poor hygiene and low
    socioeconomic status
  • Symptoms
  • Vesiculopustular lesions
  • Thick honey colored crust
  • Surrounded by erythema
  • Pruritic
  • Contagious
  • Treatment
  • Systemic antibiotics
  • Saline or aluminum acetate soaks
  • Soap water
  • Removal of crusts
  • Topical antibiotic cream
  • Strept can cause glonerulonephritis if untreated

118
Infections Bacterial
  • Cellulitis
  • Staph aureus or strept
  • Can be primary or secondary infection
  • Symptoms
  • Hot
  • Tender
  • Erythematous
  • Edematous
  • Diffuse borders maybe malaise and fever
  • Treatment
  • Moist heat
  • Immobilization
  • Elevation
  • Systemic antibiotics
  • Hospitalize if severe
  • Can progress to gangrene if untreated

119
Drug Therapy Antibiotics
  • Topical - apply lightly
  • OTC
  • bacitracin
  • Polymixin B
  • Prescription
  • Mupirocin (staph)
  • gentamycin (staph),
  • erythromycin (staph strept)
  • clindamycin (Cleocin) (acne)
  • Systemic - culture sensitivity guides
    selection
  • Penicillin
  • Erythromycin
  • Tetracycline

120
Benign Skin Conditions Acne
  • Inflammatory disorder of sebaceous glands
  • Symptoms
  • comedones, inflammatory lesions, papules,
    pustules face, neck, upper back
  • Treatment
  • Comedo extraction
  • Topical Benzoyl Peroxide
  • Peeling and irritating agents (retinoic acid)
  • Antibiotic therapy - long term
  • Phototherapy
  • Sun exposure
  • If severe - isotretinoin (Accutane) CAUTION!
    Teratogenic

121
Drug Therapy Acne Preparations
  • Benzoyl peroxide (Benzac, Desquam-X, PanOxyl,
    etc)
  • Apply 1-4x day
  • Effects seen 4-6 weeks
  • Adverse effects
  • Erythema, tenderness, dryness, pruritis, burning
  • Erythromycin (Eryderm, T-Stat, Erygel)
  • Macrolide antibiotic
  • Adverse effects
  • Erythema, tenderness, pruritis, burning

122
Drug Therapy Acne Preparations
  • Isotretinoin (Accutane)
  • Pregnancy Category X
  • Proven teratogen
  • 2 contraceptive methods
  • Tretinoin (Retinoic acid, Vitamin A acid,
    Retin-A)
  • Stimulates epidermal cell turnover -gt skin
    peeling
  • Adverse effects
  • Red edematous blisters, crusted skin, altered
    skin pigmentation
  • Avoid sun, use sunscreen
  • Apply to dry skin

123
Benign Skin Conditions Moles
  • Grouping of normal cells
  • Manifestations
  • Hyperpigmented areas
  • Varying form and color
  • Treatment
  • None necessary
  • Cosmetic
  • Biopsy for diagnosis

124
Benign Skin Conditions
  • Psoriasis
  • Chronic dermatitis due to rapid turnover of
    epidermal cells
  • Family predisposition
  • Manifestations
  • Sharply demarcated scaling plaques of
  • Scalp
  • Elbows
  • Knees
  • Palms, soles, and fingernails possible
  • Treatment
  • Retard growth of epidermal cells
  • Topical corticosteroids
  • Tar
  • Anthralin topical
  • Sunlight, UV light
  • Alefacept (Amevive) injection
  • Antimetabolites (methotrexate) or systemic
    retinoids for difficult cases

125
Benign Skin Conditions
  • Seborrheic Keratoses
  • Irregularly shaped flat topped papules or plaques
  • Warty surface
  • Appearance of being stuck on
  • Increase in pigmentation
  • No association with sun exposure
  • Treatment
  • Removal
  • Curettage
  • cryosurgery

126
Benign Skin Conditions Lipoma
  • Encapsulated tumor of adipose tissue
  • Most common 40-60 years of age
  • Manifestations
  • Rubbery, compressible, round mass
  • Variable in size
  • Most common on trunk, back of neck, forearms
  • Treatment
  • Biopsy
  • Excision if indicated

127
Benign Skin Conditions Vitiligo
  • Unknown cause
  • Genetic connection
  • Complete absence of melanocytes
  • Non-contagious
  • Manifestations
  • Complete loss of pigment
  • Variation in size an location
  • Symmetric and permanent
  • Treatment
  • Exposure to UVA and psoralens
  • Depigmentation of pigmented skin in extensive
    disease
  • Cosmetics and stains

128
Benign Skin Conditions Lentigo
  • (see fig. 26-7, Iggy page 465)
  • AKA liver spots
  • Increased number of melanocytes
  • Related to aging and sun exposure
  • Manifestations
  • Hyperpigmented brown to black flat lesion
  • Usually in sun exposed areas
  • Treatment
  • Liquid nitrogen
  • Possible reoccurrence in 1-2 years
  • Cosmetics

129
Primary Lesions
  • Macule (freckles, petecchia, measles)
  • Flat
  • Change in color
  • lt 1cm
  • Papule (wart, mole)
  • elevated,
  • Solid
  • lt1cm
  • Vesicle (chicken pox, herpes zoster, 2nd burns)
  • Elevated
  • Fluid filled
  • lt1cm

130
Primary Lesions
  • Bulla
  • gt 1cm
  • Elevated
  • Serous fluid filled
  • Plaque (psoriasis, keratosis)
  • Elevated
  • Solid lesion
  • gt1cm

131
Primary Lesions
  • Wheal (insect bite)
  • Firm
  • Edematous
  • Irregular shape
  • Diameter variable
  • Pustule (acne, impetigo)
  • Elevated
  • Purulent fluid
  • Varied size

132
Secondary Lesions
  • Fissure (athletes foot)
  • Linear crack from epidermis to dermis
  • Scale (excess dead flaking of skin)
  • Drug eruption
  • Scarlet fever
  • Scar
  • Increased connective tissue
  • Surgical incision
  • Healed wound

133
Secondary Lesions
  • Ulcer
  • Crater
  • Loss of epidermis, dermis
  • Pressure ulcers, chancre
  • Atrophy
  • Thinning of epidermis/dermis
  • Ages skin, striae
  • Excoriation
  • Missing epidermis
  • Scabies, abrasion, scratch

134
References
  • Chickenpox in Pregnancy. (2009). March of Dimes
    Foundation. Retrieved 9/25/09 from
    http//www.marchofdimes.com/professionals/14332_11
    85.asp
  • Common Poisonous Plants of Florida (Florida
    Poison Information Center/Tampa) _at_
    http//www.poisoncentertampa.org/poisonous-plants.
    aspx
  • Culbert, D. (April 14, 2005). Florida scorpions.
    UF/IFAS Okeechobee County Extension Service.
    Retrieved 6/17/09 from http//okeechobee.ifas.ufl.
    edu/News20columns/Florida.Scorpions.htm
  • Groch, J. (August 23, 2006). Guidelines for
    Preventing Pressure Ulcers Seen as Suboptimal.
    MedPage Today. Retrieved 6/12/09 from
    http//www.medpagetoday.com/Dermatology/GeneralDer
    matology/3982

135
References
  • Hembree, D. (July 21, 2008) 10 Poisonous Plants
    in Florida and Safety Precautions _at_
    http//www.associatedcontent.com/article/875395/10
    _poisonous_plants_in_florida_and_pg2.html?cat11
  • Herpes simplex (May, 2009). Medline Plus
    Medical Encyclopedia. Retrieved 6/15/09 from
    http//www.nlm.nih.gov/MEDLINEPLUS/ency/article/00
    1324.htm
  • Lilly, L.L., Harrington, S, Snyder, J. (2005)
    Pharmacology and the Nursing Process. (4th ed.)
    Mosby Elsevier. St. Louis, MS.
  • Medical Dictionary (2009) Merrium Webster Inc.
    Retrieved 6/15/09 from http//www.nlm.nih.gov/medl
    ineplus/mplusdictionary.html

136
References
  • The Medical News. Brain eating amoeba in lake
    kills sixth victim. (October 2007). Retrieved
    6/16/09 from http//www.news-medical.net/news/2007
    /10/07/30863.aspx
  • The US Market for Skin Care Products. (May,
    2005). Retrieved 6/12/09 from http//www.mindbranc
    h.com/Skincare-Products-R567-0199/
  • Scorpion Sting Treatments. (2008). Orkin.
    Retrieved 6/17/09 from http//www.orkin.com/other/
    scorpions/scorpion-sting-treatments

137
Burns
The Following Content Burns will be
covered in future classes! Save this information
for future use.
  • Thermal burns
  • Flame, flash, scald
  • Chemical burns
  • Necrotizing substances
  • Acids
  • Alkali
  • Cleaning agents, drain cleaners, lye
  • Electrical burns
  • Intense heat from electrical current

138
Classification Depth of Burn
  • See page 522 in Iggy text
  • ABA by depth of destruction
  • Partial thickness burn
  • Epidermis and dermis involved
  • Full thickness burn
  • burns reach through the entire dermis and
    sometimes into the subcutaneous fat. (Iggy,
    page 522)
  • Possibly involves muscles, tendons, and bones
  • Skin cannot heal on its own.

139
Classification Extent of Burn
  • Total Body Surface Area (TBSF)
  • (Iggy page 531)
  • Berkow method
  • http//www.umobile.edu/main/notes/Burn.pdf
  • Rule of 9s
  • (Iggy page 531)

140
Classification Location of Burns
  • Severity related to location
  • Complication risks related to location
  • Face, neck, chest
  • Respiratory complications
  • Hands, feet, joints, and eyes
  • Compromise ADLs
  • Circumferential burns of extremities
  • Circulatory compromise

141
Emergent Care
  • A,B,Cs
  • Fluid Therapy
  • Wound Care
  • Pain management
  • Prevention of infection

142
Burns
  • What happens.

143
Complications of Emergent Phase
  • Cardiovascular
  • Arrhythmias
  • Hypovolemic shock
  • Impaired circulation
  • Respiratory
  • Upper airway burns
  • Inhalation injuries
  • Urinary
  • Acute tubular necrosis

144
Acute Phase
  • Fluid therapy
  • Lactated Ringers per Parkland (Baxter) formula
  • Wound care
  • Topical silvadene, sulfamylon, bacitracin, or
    bactroban
  • PREVENT INFECTION
  • Excision and grafting
  • Remove necrotic tissue
  • Apply split thickness auto graft skin
  • Porcine skin, cadaver skin, clients own skin,
    skin culture
  • Nutritional therapy
  • Increased fluids, proteins, vitamins A, C, E.
  • Zinc, iron, folate
  • Physical therapy
  • Prevent contractures
  • Physical and psychological comfort

145
Drug Therapy Antibiotics
  • Silver Sulfadiazine (Slivadene)
  • Burn treatment
  • QD or BID
  • frosting
  • Adverse effects
  • Pain
  • Itching
  • Burning

146
Rehabilitation Phase
  • Prevent and minimize contractures and scarring!
  • Cosmetic / reconstructive therapy
  • Psychological support if needed
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