Integumentary%20System

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Integumentary System
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

4
Functions

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

5
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

6
KPs

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

7
Thorough History

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

8
Assessment Subjective Data

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

9
Assessment History

• Medications

• Prescription
• OTC
• Herbals
• Name
• Length of usage

10
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

11
Assessment History

• Changes
• Skin condition
• Hair condition
• Nail condition
• Mucous membranes

12

Assessment

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

13
Parameters of General Skin Assessment

• color, temperature, moisture, elasticity, turgor,
  texture, and odor.

14
Assessment Inspection

• Consider Cultural and Ethnic variations
• Dark skin
• rates - skin cancer
• Difficult to assess flushing cyanosis jaundice
• Rashes difficult to observe
• Pseudofolliculitis
• Keloids
• Mongolian spots

15
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
16
Lesion Description

• 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

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Lesion Description

• Distribution
• Asymmetric vs. Symmetric
• Confluent
• flowing or coming together also run together
• Diffuse
• Localized
• Solitary
• Zosteriform
• resembling shingles
• Satellite

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Assessment Palpation

• Edema
• Moisture
• Temperature
• Turgor
• Texture

Fever C-V status Respiratory status Hormones Hydra
tion Rash/ Lesion Nutritional status
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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)

20
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

21
Basal Cell Carcinoma

• Medical Tx

• Excision
• Cryosurgery
• Radiation
• Topical chemotherapy

22
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

23
Squamous cell carcinoma

• Medical Tx

• Excision
• Radiation
• Mohs surgery
• (see slide 33)
• 5 FU or methotrexate intralesional
• (see slide 34)

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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

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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

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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

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Actinic Keratosis (AKA Solar keratosis)

• Medical Tx

• Cryosurgery
• (see slide 37)
• 5 FU
• Surgical removal
• Retin A
• Chemical peels

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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

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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

30
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

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A B C Ds of Melanoma

• Asymmetry
• Border irregular, edges ragged
• Color varied pigmentation
• Tan, brown, black, red
• Diameter gt 6mm

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Melanoma

• Medical Tx

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

33
Prevention/Education

• Sunscreen
• Limit exposure
• Hat/clothes/sunglasses
• Shade
• Inspect skin regularly

34
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!

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Sunburn

• Superficial burn
• Excessive exposure to ultraviolet rays injures
  dermis.
• Dilated capillaries red, tender, edema,
  blisters
• Large area nausea, fever

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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

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Insects/Pests/Parasites

• Spiders
• Fire Ants
• Lice/Scabies
• Mosquitoes
• Scorpions
• Sand fleas

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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

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Pediculosis

• Medical tx

• Pyrethrins (Rid), Permethrin (Nix) or if all
  other agents failBenzene hexachloride (Kwell)
• Contact screening
• l

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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

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Scabies

• Medical tx

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

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Drug Therapy Antiparasitics

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

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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.

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Brazilian Pepper
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Virginia Creeper
Poison Ivy
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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

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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

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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

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Nursing ManagementRN as skin symptomologist

• Dry skin
• Elderly Infants
• Itchy skin
• Broken skin
• Prevention of secondary infections

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Nursing Management Dry skin

• Manifestations
• Interventions
• Elder
• Fewer total baths
• Lotions Mild soaps
• Hydrate!

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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

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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

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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

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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)

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Nursing Management Protect

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

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Nursing Management Psychological support

• Chronic skin conditions
• Emotional stress
• Self concept alterations
• Body image changes

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Nursing InterventionsPsychological support

• Support client
• Allow verbalizations of frustrations
• Reinforce treatment
• Support groups
• Help with camouflage

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Diagnostic Testing

• RN Responsibilities

• Biopsy

• Informed Consent
• Prep site
• Assist with procedure
• Apply dressing
• Post-op instructions
• Properly ID specimen

• Punch
• Incisional
• Excisional
• Shave

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Diagnostic Testing

• Cultures
• Diagnose fungal, bacteria, viral infections
• KOH (Potassium Hydroxide)
• Fungus
• Sample collection
• Skin scraping
• Swabbing
• Meticulous labeling

60
Diagnostic Testing

• Woods Light
• Organisms fluoresce
• Pseudomonas
• Fungus
• Vitiligo
• Mineral oil slides
• Infestations
• Patch test
• Allergen testing

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Dermatological Interventions

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

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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

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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
• y.

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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

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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

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Allergic Conditions

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

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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
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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

69
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

70
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

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Drug Reaction

• Medical Treatment

• Discontinue drug
• Antihistamines, local or systemic
• Corticosteroids if needed

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Allergic Conditions Atopic Dermatitis

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

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Atopic Dermatitis

• Medical Treatment

• Topical corticosteroids
• Phototherapy
• Coal tar
• corticosteroids
• Lubrication of dry skin
• Antibiotics for secondary infections

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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

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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

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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

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Herpes Simplex Virus, Type I

• Medical Tx

• Symptom management
• Moist compresses
• Petrolatum to lesions
• Antiviral agents (Zovirax, Famvir, Valtrex)

www.treatmentsforhealth.com/.../cold-sores/
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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
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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

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Herpes Varicella Virus

• Medical Tx

• Antivirals
• Symptomatic relief

81
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

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Herpes Zoster

• Medical Tx

• Symptomatic
• Wet compresses
• White petrolatum to lesions
• Antiviral agents

83
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

84
Infections Verruca Vulgaris

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

85
Infections Plantar Warts

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

86
Plantar Warts

• Medical Tx

• Liquid nitrogen
• Frequent paring with chemical patches
• Duct tape??????

87
Infections Candidiasis (moniliasis)

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

An opportunistic infection
88
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.

89
Candidiasis

• Medical Tx Anti-fungals

• Nystatin
• Vaginal suppository
• Oral lozenge
• Mycostatin powder, cream
• Keep skin clean dry
• Diagnosis
• culture
• Microscopic exam (KOH)

90
Infections Fungal

• Tinea Corporis
• AKA ringworm
• Symptoms
• Annular
• well defined margins
• erythematous

91
Tinea CorporisAKA ringworm

• Medical Tx

• Cool compresses
• Topical antifungals
• Miconazole, clotrimazole, butenafine

92
Infections Fungal

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

93
Infections Fungal

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

94

Tinea Pedis AKA athletes foot

• Medical Tx

• Topical antifungals
• Keep dry

95
Infections Fungal

• Tinea Unguium
• Symptoms
• Brittle thickened nails
• White/yellow discoloration

96
Tinea Unguium

• Medical Tx

• Topical antifungal cream or solutions
• Griseofulvin (fingernails)
• Lamisil
• Debride toenails

97
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

98
Drug Therapy Antifungals

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

99
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

100
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

101
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

102
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

103
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

104
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

105
Benign Skin Conditions Moles

• Grouping of normal cells
• Manifestations
• Hyperpigmented areas
• Varying form and color
• Treatment
• None necessary
• Cosmetic
• Biopsy for diagnosis

106
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

107
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

108
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

109
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

110
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

111
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

112
Primary Lesions

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

113
Primary Lesions

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

114
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

115
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

116
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

117
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

118
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

119
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

120
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.

121
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)

122
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

123
Emergent Care

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

124
Burns

• What happens.

125
Complications of Emergent Phase

• Cardiovascular
• Arrhythmias
• Hypovolemic shock
• Impaired circulation
• Respiratory
• Upper airway burns
• Inhalation injuries
• Urinary
• Acute tubular necrosis

126
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

127
Drug Therapy Antibiotics

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

128
Rehabilitation Phase

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