Chapter 27

1. Chapter 27 Care of Patients with Skin Problems

2. Xerosis (Dryness) • A common problem among older patients • Fine flaking of the stratum corneum • Generalized pruritus • Scratching may result in secondary skin lesions, excoriations, lichenification, and infection

3. Collaborative Management • Nursing interventions aim to rehydrate the skin and relieve itching. • Bathing with moisturizing soaps, oils, and lotions may reduce dryness. • Water softens the outer skin layers; creams and lotions seal in the moisture provided by water.

4. Pruritus (Itching) • Pruritus is caused by stimulation of itch-specific nerve fibers at the dermal-epidermal junction. • Itching is a subjective symptom similar to pain. • “Itch-scratch-itch” cycle. • Cool sleeping environment is helpful. • Fingernails should be trimmed short. • Antihistamines. • Topical steroids.

5. Sunburn • First-degree, superficial burn • Cool baths • Soothing lotions • Antibiotic ointments for blistering and infected skin • Topical corticosteroids for pain

6. Urticaria (Hives) • Urticaria—presence of white or red edematous papules or plaques of varying sizes • Removal of triggering substances • Antihistamines helpful • Avoidance of overexertion, alcohol consumption, and warm environments, which can worsen symptoms

7. Trauma • Phases of wound healing: • Inflammatory phase • Fibroblastic or connected tissue repair phase • Maturation or remodeling phase

8. Process of Wound Healing

9. Process of Wound Healing (Cont’d) • First intention resulting in a thin scar • Second intention (granulation) and contraction—a deeper tissue injury or wound • Third intention (delayed closure)—high risk for infection with a resultant scar

10. Partial-Thickness Wounds • Involve damage to the epidermis and upper layers of the dermis • Heal by re-epithelialization within 5 to 7 days • Skin injury immediately followed by local inflammation

11. Re-epithelialization

12. Full-Thickness Wounds • Damage extends into the lower layers of the dermis and underlying subcutaneous tissue. • Removal of the damaged tissue results in a defect that must be filled with granulation tissue to heal. • Contraction develops in healing process.

13. Pressure Ulcer • Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period. • Mechanical forces that create ulcers: • Pressure • Friction • Shear

14. Shearing Force

15. Identification of High-Risk Patients • Mental status changes • Independent mobility • Nutritional status • Incontinence

16. Pressure-Relieving Techniques • Adequate pressure relief key to prevention of pressure ulcers • Capillary closing pressure • Pressure-relief products and devices • Positioning

17. Wound Assessment • Pressure ulcers and their features are classified and assessed in four stages: • Stage I • Stage II • Stage III • Stage IV

18. Four Stages of Pressure Ulceration

19. Wound Assessment • Location • Size • Color • Extent of tissue involvement • Cell types in the wound base and margins • Exudate • Condition of surrounding tissue • Presence of foreign bodies

20. Wound Contamination/Wound Infection • A wound that is exposed is always contaminated but not always infected. Contamination is the presence of organisms without any manifestations of infection. • Wound infection is contamination with pathogenic organisms to the degree that growth and spread cannot be controlled by the body’s immune defenses.

21. Nonsurgical Management • Dressings: • Mechanical débridement • Natural chemical débridement • Hydrophobic material • Hydrophilic material

22. Nonsurgical Therapy • Physical therapy • Drug therapy • Nutrition therapy • New technologies: • Electrical stimulation • Vacuum-assisted wound closure (VAC) • Hyperbaric oxygen (HBO) • Topical growth factors • Skin substitutes

23. Hyperbaric Oxygen Therapy

24. Surgical Management • Surgical débridement • Skin grafting

25. Community-Based Care • Home care management • Health teaching • Health care resources

26. Bacterial Infections • Folliculitis—superficial infection involving only the upper portion of the follicle • Furuncle (boil)—much deeper infection in the follicle • Cellulitis—generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue

27. Furuncle

28. Cellulitis

29. Herpes Simplex Virus • Type 1 herpes simplex virus (HSV-1)—classic recurring cold sore • Type 2 herpes simplex virus (HSV-2)—genital herpes • Herpes zoster (shingles)

30. Herpes Simplex Virus(Cont’d) • Herpetic whitlow—a form of herpes simplex infection occurring on the fingertips of medical personnel who have come in contact with viral secretions

31. Herpes Zoster/Shingles • Caused by reactivation of the dormant varicella-zoster virus in patients who have previously had chickenpox. • Multiple lesions occur in a segmental distribution on the skin area innervated by the infected nerve. • Eruption lasts several weeks. • Postherpetic neuralgia occurs after lesions have resolved.

32. Fungal Infections (Dermatophyte) • Tinea pedis • Tinea manus • Tinea cruris • Tinea capitis • Tinea corporis • Candida albicans

33. Assessment • History • Laboratory assessment: • Tzanck smear • Swab culture • Potassium hydroxide (KOH) test

34. Interventions • Skin care with proper cleansing • Isolation Precautions • Drug therapy

35. Skin Care • Bathe daily with an antibacterial soap. • Remove any pustules or crusts gently. • Apply warm compress twice a day to furuncles or areas of cellulitis. • Apply Burow's solution to viral lesions. • Avoid excessive moisture. • Ensure optimal patient positioning.

36. Drug Therapy for Skin Disorders • Antibacterial drugs • Antifungal drugs • Anti-inflammatory drugs

37. Cutaneous Anthrax • Infection caused by the spores of the bacterium Bacillus anthracis • Diagnosis based on appearance of the lesions and culture or anthrax antibodies in the blood • Oral antibiotics for 60 days—ciprofloxacin or doxycycline

38. Cutaneous Anthrax

39. Pediculosis • Pediculosis—infestation by human lice: • Head lice—pediculosis capitis • Body lice—pediculosis corporis • Pubic or crab lice—pediculosis pubis • Pruritus most common symptom • Drugs • Laundering of clothing and bed linen

40. Scabies • Scabies is a contagious skin disease caused by mite infestations. • Scabies is transmitted by close and prolonged contact or infested bedding. • Examine skin between fingers and on the palms. • Infestation is confirmed by an examination of a scraping of a lesion under a microscope.

41. Common Inflammations • Contact dermatitis, atopic dermatitis • Interventions include: • Steroids • Avoidance of oil-based products • Antihistamines • Compresses and baths

42. Psoriasis • Lifelong disorder with exacerbations and remissions • Scaling disorder with underlying dermal inflammation; possibly an autoimmune reaction • Psoriasis vulgaris most often seen • Exfoliative psoriasis—an explosively eruptive and inflammatory form of the disease

43. Psoriasis Vulgaris

44. Treatment of Psoriasis • Corticosteroids • Tar preparations • Other topical therapies • Ultraviolet light therapy • Systemic therapy: • Biologic agents • Cytotoxic agents • Immunosuppressants • Emotional support

45. Benign Tumors • Cysts • Seborrheic keratoses • Keloids • Nevi (moles)

46. Skin Cancer • Actinic keratoses • Squamous cell carcinomas • Basal cell carcinomas • Melanomas—highly metastatic; survival depends on early diagnosis and treatment

47. Skin Cancer (Cont’d)

48. Surgical Management of Skin Cancer Surgical management: • Cryosurgery • Curettage and electrodesiccation • Excision • Mohs’ surgery • Wide excision

49. Nonsurgical Management of Skin Cancer • Drug therapy • Radiation therapy

50. Plastic Surgery • Rhytidectomy (face-lift) • Rhinoplasty (reconstruction of the nose)