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					Integumentary System
         Fall 2010
   C. Matthews MSN, RN
       Ignatiavicius references are for 6th ed   .
RESPONSE TO ALTERED INTEGUMENTARY FUNCTION
Unit 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 client‟s 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.
Introduction: Skin in our Culture
• Defining „beauty‟

• Language

• Costs

• Every RN

      4. Psychosocial Integrity: Discuss psychosocial impact of client’s altered dermatological condition.
                                      C. Matthews MSN, RN
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)




          4. Psychosocial Integrity: Discuss psychosocial impact of client’s altered dermatological condition.
                                          C. Matthews MSN, RN
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)




       4. Psychosocial Integrity: Discuss psychosocial impact of client’s altered dermatological condition.
                                       C. Matthews MSN, RN
Multiple layers within the integumentary
system form a wall of protection
http://www.chinapictures.org/photo/travel/great-wall-of-china/31222141525419/

Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun
exposure, environmental toxins, etc.).



                                   C. Matthews MSN, RN
Anatomy review


• See illustration – Iggy‟s text (6th ed. -
  page 461 and/or Lilly text (6th ed.) page
  864

• FYI
  http://www.middlesexcc.edu/faculty/Barbara_Bogner/pr
  eworkshop5.html


                     C. Matthews MSN, RN
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.).



                                  C. Matthews MSN, RN
Functions:
• Protective Barrier
     – Injury
     – Microbial Invasion
     – Fluid & Electrolyte Balance
     – Temperature control
•   Excretion
•   Sensation
•   Vitamin D
•   Identity
                    Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention.
                    Psychosocial Integrity: 4. Discuss psychosocial impact of client’s altered dermatological condition.
                                                    C. Matthews MSN, RN
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


                     C. Matthews MSN, RN
                                      KP‟s

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


            Physiologic Integrity: 6. Develop plan of care for client with impaired skin
                                            integrity.
                             C. Matthews MSN, RN
                          Thorough History

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




        Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span .
                                         C. Matthews MSN, RN
Assessment: Subjective Data
 – Past Medical History                                                                                          Chart 26 -2
                                                                                                                 page 466
    • Trauma
    • Surgery
    • Prior skin disease
    • Jaundice
    • Delayed wound healing
    • Allergies
    • Sun exposure
    • Radiation treatments


      Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span.
                                       C. Matthews MSN, RN
Assessment: History
 Medications
 –    Prescription
 –    OTC
 –    Herbals
 –    Name
 –    Length of usage




     Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
              Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.
                                                        C. Matthews MSN, RN
Assessment: History
• Surgery                                                                     • C/O symptoms
  – Cosmetic                                                                  • Known exposure to
  – Biopsy                                                                           carcinogens, chemical
• Diet                                                                               irritants, allergens
• Health Practices                                                            •      Family
  – Hygiene, products                                                                   – Alopecia (bald)
  – Sunscreen, SPF                                                                      – Psoriasis
                                                                                        – Skin cancer
  – Complementary &
    alternative medicine



     Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
     Health Promotion and Maintenance: 3. Identify healthy behaviors by the client and family (screening exams, limiting risk taking behaviors).
                                                        C. Matthews MSN, RN
Assessment: History
•     Changes

    – Skin condition
    – Hair condition
    – Nail condition
    – Mucous membranes




          Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span.
                                           C. Matthews MSN, RN
      Assessment
• Privacy
• Carefully describe:
  –   Obvious changes in color and vascularity
  –   Presence or absence of moisture
  –   Edema
  –   Skin Lesions
  –   Skin integrity
• Document properly



   Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span.
                                    C. Matthews MSN, RN
Parameters of General Skin Assessment
  • color, temperature, moisture, elasticity,
    turgor, texture, and odor.


                                                                            Wilkinson page
                                                                            366 - 370




                Physiologic Integrity: 7. Explain the parameters of assessing a lesion.
                               C. Matthews MSN, RN
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)                             Iggy -
                                                      Chart 26-3

     • Mongolian spots                                pg. 476




            Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span .
                                             C. Matthews MSN, RN
Assessment: Inspection
• Inspection of hair                                                                               Malnutrition
  – Distribution                                                                                   Anorexia nervosa
  – Texture                                                                                        Anxiety
  – Quantity                                                                                       Hygiene
• Inspection of nails                                                                              Depression
     • Iggy page 474-475; Wilkinson 370
  – Grooves                                                                                        Hormones
  – Pitting                                                                                        Living conditions
  – Ridges                                                                                         Circulatory status
  – Curvature                                                                                      Chronic disease
  – Shape
                        Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span.
          Physiologic Integrity: 11. Discuss etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and parasitic skin disorders.

                                                           C. Matthews MSN, RN
 Lesion Description                                                                                                                        Page 467- 472


   • Size                                                                                                  • Configuration
             – Metric                                                                                               – Annular
   •        Shape                                                                                                      • “relating to, or
             – Circumscribed                                                                                             forming a ring”
             – Irregular                                                                                            – Linear
             – Round                                                                                                – Concentric rings
   •        Texture                                                                                                 – Clustered
             – Rough                                                                                                – Diffuse
             – smooth
                                                                                                           •       Effect of pressure




Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span. Physiologic Integrity: 7. Explain the eight parameters of assessing a lesion. 8. Describe
common lesions and rashes utilizing proper terminology

                                                                              C. Matthews MSN, RN
 Lesion Description                                                                                                          Page 467-472




 • Distribution
           – Asymmetric vs. Symmetric
           – Confluent
              • “flowing or coming together; also : run together”
           – Diffuse
           – Localized
           – Solitary
           – Zosteriform
              • “resembling shingles”
           – Satellite
Safe Effective Care Environment: 2.Perform thorough dermatological assessment throughout the life span. Physiologic Integrity: 7. Explain the eight parameters of assessing a
lesion. 8. Describe common lesions and rashes utilizing proper terminology

                                                                          C. Matthews MSN, RN
          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
Pause for photos




    C. Matthews MSN, RN
                                                                                                                Table 26-4, page

Assessment: Palpation                                                                                           472




 – Edema                                                          Fever
 – Moisture                                                       C-V status
                                                                  Respiratory status
 – Temperature                                                    Hormones
 – Turgor                                                         Hydration
                                                                  Rash/ Lesion
 – Texture
                                                                  Nutritional status




     Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span.
                                      C. Matthews MSN, RN
Skin problems common in Florida
• Skin cancer
• Sunburn
• Insects
• Plants
• Water sports



                 C. Matthews MSN, RN
Skin cancer

• http://www.cdc.gov/cancer/skin/statistics/
 state.htm

     Iggy text, page 509-512




                         C. Matthews MSN, RN
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 > 60 (damage is cumulative)


        Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
                               Health Promotion and Maintenance: 3. Identify healthy behaviors by the client and family.
                                                             C. Matthews MSN, RN
Non-melanoma Skin Cancers
• Basal Cell Carcinoma
  –   Most common type of skin cancer
  –   Easily treated
  –   Doesn‟t metastasize
  –   Middle age to older adults
  –   Symptoms
       • Small slow growing papule
       • Semi translucent or “pearly”
       • Erosion/ulceration of center




          Safe Effective Care Environment: 2. Perform thorough dermatological assessment throughout the life span.
                                           C. Matthews MSN, RN
Basal Cell Carcinoma

Medical Tx

      • Excision
      • Cryosurgery
      • Radiation
      • Topical chemotherapy



    See illustration, page 510




                     Physiologic Integrity: 8. Describe common lesions and rashes utilizing proper terminology.
                                              C. Matthews MSN, RN
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




      Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                       C. Matthews MSN, RN
Squamous cell carcinoma
Medical Tx

   • Excision
   • Radiation
   • Moh‟s surgery
                         (see slide #33)
   • 5 FU or methotrexate intralesional
        – (see slide #34)




     Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.

                                                             C. Matthews MSN, RN
Diagnostic & Surgical Therapy
• Simple Excision
• Excision
  – Moh‟s micrographic surgery
     • Microscopically controlled removal of lesion
     • Removes tissue in thin layers
     • Can see all margins of specimen
     • Preserves normal tissue
     • Produces smallest wound



          Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures.

                                           C. Matthews MSN, RN
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




                    Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.

                                                          C. Matthews MSN, RN
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




              Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                               C. Matthews MSN, RN
Actinic Keratosis
(AKA Solar keratosis)
Medical Tx:
      • Cryosurgery
                            (see slide #37)
      • 5 FU
      • Surgical removal
      • Retin A
      • Chemical peels



        Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.

                                              C. Matthews MSN, RN
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




          Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures.
                                              C. Matthews MSN, RN
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




         Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                          C. Matthews MSN, RN
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%




          Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).

                                                          C. Matthews MSN, RN
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)




                 C. Matthews MSN, RN
A B C D‟s of Melanoma
Asymmetry
Border irregular, edges ragged
Color varied pigmentation
    • Tan, brown, black, red
Diameter > 6mm
Melanoma
Medical Tx
Depends on site, stage, age and
  general health of client
– Surgery
– Chemotherapy
– Biologic Therapy
   • Interferon, interleukin
– Radiation therapy




          Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures.
                                              C. Matthews MSN, RN
Pause for Photos
           Prevention/Education
• Sunscreen
• Limit exposure
• Hat/clothes/sunglasses
• Shade
• Inspect skin regularly



 Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
 Health Promotion and Maintenance: 3. Identify healthy behaviors by the client and family.
                                                                        C. Matthews MSN, RN
Sunburn: Education
(Protect, Protect, Protect)

• Same precautions as for skin cancer.
• Don‟t 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!

Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
                                                         C. Matthews MSN, RN
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


        Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                           C. Matthews MSN, RN
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




         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.
                                        C. Matthews MSN, RN
 Insects/Pests/Parasites
• Spiders
• Fire Ants
• Lice/Scabies
• Mosquitoes
• Scorpions
• “Sand fleas”
• Chiggers
     • AKA harvest mites or red bugs
         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.

                                                 C. Matthews MSN, RN
Spider bites

• http://assets.aarp.org/external_sites/adam
 /html/2/19570.html

• http://www.badspiderbites.com/brown-
 recluse-spider-bite/



                                               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.

                                    C. Matthews MSN, RN
      Infestations: Pediculosis
      – Head, body or pubic lice (“crabs”)
      – Parasite excrement and eggs on skin
      – Nits in hair
         • Waxy, don‟t fall off easily
• Symptoms
                • Tiny red points to papular wheal-like lesions
                • Pruritis – check hairline
                • Secondary excoriation


 Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span. 11. Identify etiology, clinical manifestations, and interventions for viral,
 bacterial, fungal, and parasitic skin disorders.
                                                                          C. Matthews MSN, RN
Pediculosis

Medical tx

     • Pyrethrins (Rid), Permethrin (Nix) or if all other
       agents fail…Benzene 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.

                                                            C. Matthews MSN, RN
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




Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span. 11. Identify etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and
parasitic skin disorders.

                                                                                C. Matthews MSN, RN
Scabies
Medical tx


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



         11. Identify etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and parasitic skin disorders .
                                                  C. Matthews MSN, RN
Drug Therapy: Antiparasitics
 – Pediculicides
    • Pyrethrins (RID)
    • Permethrin (NIX)
 – Scabicide & Pediculicide
    • Lindane (Kwell, Scabene)
                 – Cream, lotion
                 – Shampoo
                      nit comb
                 – Adverse effects
                      Rash, rare CNS toxicity




  Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders. 11. Identify etiology, clinical
  manifestations, and interventions for viral, bacterial, fungal, and parasitic skin disorders.
                                                             C. Matthews MSN, RN
Plants that irritate skin:
• Poison ivy/ oak
  – http://www.aad.org/public/publications/pamp
    hlets/skin_poison.html
• “nettles”
• Cacti
• Sawgrass
• Plants w/ milky sap

       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.

                                                 C. Matthews MSN, RN
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.




            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.

                                                  C. Matthews MSN, RN
Brazilian Pepper




     C. Matthews MSN, RN
                                                 Virginia Creeper

Poison Ivy:
5 little fingers Ø 3 little leaves




                           C. Matthews MSN, RN
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




        Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.
                                                 C. Matthews MSN, RN
Corticosteroids
Triamcinolone (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 6 ed. Page 869                                             th



     • Short term therapy – poison ivy
     • Long term therapy – chronic bullous diseases

     Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.
                                                            C. Matthews MSN, RN
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            Physiologic Integrity: 5. Describe nursing implications for medications
                                                         prescribed for clients with dermatologic disorders.
                                                                              C. Matthews MSN, RN
Water sports
• „Swimmer‟s ear‟
  – http://swimming.about.com/od/earsandeyes/a/swim_ear.htm

• Red tide (algal bloom)
• Sting rays/jelly fish
• Amoeba in lake water
  – Naegleria fowleri
  – Enters via nasal tissue



                                                 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.

                                      C. Matthews MSN, RN
KP                                                                         • Protect
                                                                           • Protect
                                                                           • Protect

       Pause for Photos




Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
                                                          C. Matthews MSN, RN
Nursing Management:
RN as skin “symptomologist”
• Dry skin
  – Elderly; Infants
• Itchy skin
• Broken skin
• Prevention of secondary infections




               Physiologic Integrity: 6. Develop plan of care for client with impaired skin integrity.
                                      C. Matthews MSN, RN
Nursing Management: Dry skin
• Chart 27-1 Page 480
• Manifestations
• Interventions:
  – Elder –
     • Fewer total baths
     • Lotions & Mild soaps
     • Hydrate!



              Physiologic Integrity: 6. Develop plan of care for client with impaired skin integrity.
                                     C. Matthews MSN, RN
• Everyday skin care of infant from Yale-
 New Haven Children‟s Hospital
  – http://www.ynhh.org/pediatrics/newborn/infa
    nt_skin_care.html

• Care of Diaper rash from Mayo Clinic Staff
  – http://www.mayoclinic.com/health/diaper-
    rash/ds00069


               Physiologic Integrity: 6. Develop plan of care for client
                            with impaired skin integrity.
                       C. Matthews MSN, RN
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



                     Physiologic Integrity: 6. Develop plan of care for client
                                  with impaired skin integrity.
                             C. Matthews MSN, RN
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




                 Physiologic Integrity: 6. Develop plan of care for client
                              with impaired skin integrity.
                         C. Matthews MSN, RN
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




                 Physiologic Integrity: 6. Develop plan of care for client
                              with impaired skin integrity.
                         C. Matthews MSN, RN
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”)




                Physiologic Integrity: 6. Develop plan of care for client
                             with impaired skin integrity.
                        C. Matthews MSN, RN
Nursing Management: Protect
• Protect intact skin!
      – OOB
      – Turn at least q2h
      – Reposition frequently
      – Alleviate pressure
      – Hydration
      – Mechanical intervention
      – Rx


 Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
                            Physiologic Integrity: 6. Develop plan of care for client with impaired skin integrity.
                                                      C. Matthews MSN, RN
Nursing Management:
Psychological support
• Chronic skin conditions
  – Emotional stress
  – Self concept alterations
  – Body image changes




   Psychosocial Integrity: 4. Discuss psychosocial impact of client’s altered dermatological condition Physiologic Integrity: 6. Develop plan of
                                                   care for client with impaired skin integrity.
                                                       C. Matthews MSN, RN
Nursing Interventions:
Psychological support:
  –     Support client
  –     Allow verbalizations of frustrations
  –     Reinforce treatment
  –     Support groups
  –     Help with camouflage




  Psychosocial Integrity: 4. Discuss psychosocial impact of client’s altered dermatological condition Physiologic Integrity: 6. Develop plan
                                               of care for client with impaired skin integrity.
                                                     C. Matthews MSN, RN
Diagnostic Testing
Biopsy                                                                    RN Responsibilities
            (Iggy, page 477)

                                                                                   –     Informed Consent
  –   Punch                                                                        –     Prep site
  –   Incisional                                                                   –     Assist with procedure
  –   Excisional                                                                   –     Apply dressing
  –   Shave                                                                        –     Post-op instructions
                                                                                   –     Properly ID specimen




   Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures .
                                         C. Matthews MSN, RN
Diagnostic Testing
    (Iggy, page 476-477)
• Cultures
  – Diagnose fungal, bacteria, viral infections
  – KOH (Potassium Hydroxide)
     • Fungus

• Sample collection
  – Skin scraping
  – Swabbing
  – Meticulous labeling




        Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures
                                              C. Matthews MSN, RN
Diagnostic Testing
      (Iggy, page 476-477)

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


         Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures
                                               C. Matthews MSN, RN
Dermatological Interventions
• Phototherapy
  – UVA & UVB (UVL)
  – Ultraviolet wavelengths cause erythema,
    desquamation, and pigmentation
  – Enhance with psoralem (photosensitizing)
• Treatment for
        • Psoriasis
        • Atopic dermatitis
        • Vitiligo




    Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures
                                                C. Matthews MSN, RN
      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




Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders. Physiologic Integrity: 9. Describe
pre-op and post care of clients receiving dermatological surgical procedures
                                                              C. Matthews MSN, RN
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.
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
          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.

                                                  C. Matthews MSN, RN
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.
Allergic Conditions
• Contact Dermatitis
  – Delayed hypersensitivity
  – Lesions 2-7 days after antigen exposure

• Manifestations
  –   Red, hive-like papules and plaques
  –   Sharply circumscribed
  –   Vesicles
  –   Pruritic




         Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span .
                                            C. Matthews MSN, RN
Contact Dermatitis
Medical Tx

 –   Topical corticosteroids
 –   Antihistamines
 –   Skin lubrication
 –   Elimination of allergen
 –   Systemic steroids if                                                              http://dermatology.cdlib.org/DOJvol7num1/NYUcases/contact/joe.html


     severe




              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.

                                               C. Matthews MSN, RN
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




           Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders .
                                                    C. Matthews MSN, RN
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




     Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders .
                                              C. Matthews MSN, RN
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




       Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                             C. Matthews MSN, RN
Drug Reaction
Medical Treatment
– Discontinue drug
– Antihistamines, local or
  systemic
– Corticosteroids if needed




               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.

                                        C. Matthews MSN, RN
Allergic Conditions: Atopic Dermatitis
    – Cause unknown
    – Begins in infancy and declines with age

  • Manifestations
    – Scaly, red to re-brown, circumscribed lesions
    – Pruritic
    – Symmetric eruptions




        Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                           C. Matthews MSN, RN
Atopic Dermatitis                                                                   Medical Treatment
 – Topical corticosteroids
 – Phototherapy
 – Coal tar
 http://www.psoriasis.org/netcommunity/sublearn03_mild_otc
 – Intralesional corticosteroids
 – Lubrication of dry skin
 – Antibiotics for secondary infections




             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.

                                                 C. Matthews MSN, RN
Pause for Photos
Dysplastic Nevus Syndrome
• Abnormal mole pattern
• Increased risk for melanoma
    – Doubles with dysplastic nevi
•   Atypical moles larger than usual (>5mm)
•   Irregular borders, possibly notched
•   Various variegated colors
•   Most common on back



            Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.

                                             C. Matthews MSN, RN
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

Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
                                                                       C. Matthews MSN, RN
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




     11. Identify etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and parasitic skin disorders.
                                                          C. Matthews MSN, RN
Herpes Simplex Virus, Type I

Medical Tx
–   Symptom management
–   Moist compresses
–   Petrolatum to lesions
–   Antiviral agents (Zovirax,
    Famvir, Valtrex)                                                                    www.treatmentsforhealth.com/.../cold-sores/




           11. Identify etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and parasitic skin disorders
                                                   C. Matthews MSN, RN
Infections: Herpes Simplex Virus, Type II
  – Genital   Iggy page 1742-1743


    “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


              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.

                                                C. Matthews MSN, RN
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 > pustules > crusts > scars
• Postherpetic neuralgia
• Self limiting in children
                                          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.

                                                                         C. Matthews MSN, RN
Herpes Varicella Virus

Medical Tx


  – Antivirals
  – Symptomatic relief




     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.

                                                         C. Matthews MSN, RN
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


        Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                           C. Matthews MSN, RN
Herpes Zoster
Medical Tx

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




    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.

                                                          C. Matthews MSN, RN
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 > 12 mo.
   • Zostivax
      – HZU vaccine for adults > 60 y/o

           Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.
                                                    C. Matthews MSN, RN
Infections: Verruca Vulgaris
  – Human papillomavirus
  – Mildly contagious
• Symptoms
  – Circumscribed hypertrophic flesh colored papule
• Treatment
  –   Scoop removal
  –   Liquid nitrogen therapy
  –   Keratolytic agents
  –   CO2 laser therapy


            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.

                                                  C. Matthews MSN, RN
Infections: Plantar Warts
  (Human papillomavirus)
• Symptoms
  – Wart on “Plantar” surface (bottom) of foot –
  – Cone shaped with black dots (“seeds”)




       Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.

                                        C. Matthews MSN, RN
Plantar Warts
Medical Tx
  – Liquid nitrogen
  – Frequent paring with chemical patches
  – Duct tape??????




      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.

                                                      C. Matthews MSN, RN
Infections: Candidiasis (moniliasis)
  – Candida albicans (Fungus)
  – 50% are symptom free carriers
  – Immunocompromised >> pathogenic
  – Likes warm moist areas
     • Mouth, vagina, skin

                                                                                 An opportunistic
                                                                                 infection



  Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
                                                              C. Matthews MSN, RN
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.
   Candidiasis
 Medical Tx: Anti-fungals
              • Nystatin
                          – Vaginal suppository
                          – Oral lozenge
     • Mycostatin powder, cream
     • Keep skin clean dry
• Diagnosis
                                      culture
                                      Microscopic exam (KOH)



   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.

                                                                             C. Matthews MSN, RN
Infections: Fungal
• Tinea Corporis
        – AKA ringworm
  – Symptoms
     • Annular
     • well defined margins
     • erythematous




           Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                            C. Matthews MSN, RN
Tinea Corporis
AKA ringworm

Medical Tx

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




                                                                                                                                                                                         .
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

                                                                                C. Matthews MSN, RN
Infections: Fungal
• Tinea Cruris
  – AKA jock itch
  – Symptoms
     • Self-defined border
     • In groin
  – Treatment topical antifungal cream or solution




        Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                         C. Matthews MSN, RN
Infections: Fungal
• Tinea Pedis
         – AKA athletes foot
  – Symptoms
     • Interdigital scaling
     • Erythema
     • Blistering
     • Pruritis
     • Pain



         Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                            C. Matthews MSN, RN
  Tinea Pedis
            AKA athletes foot


Medical Tx
• Topical antifungals
• Keep dry




  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.

                                                                        C. Matthews MSN, RN
Infections: Fungal
• Tinea Unguium
  – Symptoms
     • Brittle thickened nails
     • White/yellow discoloration




       Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.

                                                                      C. Matthews MSN, RN
   Tinea Unguium
     Medical Tx

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




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
                                                                        C. Matthews MSN, RN
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




 Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders .

                                                                        C. Matthews MSN, RN
Drug Therapy: Antifungals
 – Fluconazole (Diflucan)
    • PO & IV
    • Excellent bioavailability
    • Vaginal or systemic candidiasis
 – Ketaconazole (Nizoral)
 – Nystatin (Mycostatin)
 – Tervinafine (Lamisil) for onychomycosis
 – Tolnaftate (Tinactin)




   Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders .

                                            C. Matthews MSN, RN
Pause for Photos




    C. Matthews MSN, RN
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
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
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


Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.
                                                         C. Matthews MSN, RN
  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


                          C. Matthews MSN, RN
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




   Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.
                                                         C. Matthews MSN, RN
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 -> skin peeling
    • Adverse effects
             – Red edematous blisters, crusted skin, altered skin
               pigmentation
    • Avoid sun, use sunscreen
    • Apply to dry skin



   Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.
                                                      C. Matthews MSN, RN
Benign Skin Conditions: Moles
  Grouping of normal cells
• Manifestations
  – Hyperpigmented areas
  – Varying form and color
• Treatment
  – None necessary
  – Cosmetic
  – Biopsy for diagnosis



                   C. Matthews MSN, RN
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
                               C. Matthews MSN, RN
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

   Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures.
                                         C. Matthews MSN, RN
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


     Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                           C. Matthews MSN, RN
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
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
                              C. Matthews MSN, RN
  Primary Lesions
• Macule (freckles, petecchia, measles)
  – Flat
  – Change in color
  – < 1cm
• Papule (wart, mole)
  – elevated,
  – Solid
  – <1cm
• Vesicle (chicken pox, herpes zoster, 2nd burns)
  – Elevated
  – Fluid filled
  – <1cm


             Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                                C. Matthews MSN, RN
Primary Lesions
• Bulla
   – > 1cm
   – Elevated
   – Serous fluid filled
• Plaque (psoriasis, keratosis)
   – Elevated
   – Solid lesion
   – >1cm




          Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                             C. Matthews MSN, RN
Primary Lesions
• Wheal (insect bite)
  –   Firm
  –   Edematous
  –   Irregular shape
  –   Diameter variable
• Pustule (acne, impetigo)
  – Elevated
  – Purulent fluid
  – Varied size

         Safe Effective Care Environment: 2. perform thorough dermatological assessment throughout the life span.
                                            C. Matthews MSN, RN
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



      Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures.
                                            C. Matthews MSN, RN
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
Physiologic Integrity: 9. Describe pre-op and post care of clients receiving dermatological surgical procedures
                                                             C. Matthews MSN, RN
      References:
„ Chickenpox in Pregnancy. (2009). March of Dimes Foundation. Retrieved 9/25/09 from
    http://www.marchofdimes.com/professionals/14332_1185.asp
„   Common Poisonous Plants of Florida (Florida Poison Information Center/Tampa) @
    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/News%20columns/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/GeneralDermatology/3982
References:
„ Hembree, D. (July 21, 2008) 10 Poisonous Plants in Florida and Safety Precautions @
    http://www.associatedcontent.com/article/875395/10_poisonous_plants_in_florida_and_pg2.html?cat=11
„   “Herpes simplex” (May, 2009). Medline Plus Medical Encyclopedia. Retrieved 6/15/09 from
    http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001324.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/medlineplus/mplusdictionary.html




                                            C. Matthews MSN, RN
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.mindbranch.com/Skincare-Products-R567-0199/
„   Scorpion Sting Treatments. (2008). Orkin. Retrieved 6/17/09 from
    http://www.orkin.com/other/scorpions/scorpion-sting-treatments




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


  Safe Effective Care Environment: 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).
                                                            C. Matthews MSN, RN
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.




                              C. Matthews MSN, RN
Classification: Extent of Burn

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




                    C. Matthews MSN, RN
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


                  C. Matthews MSN, RN
Emergent Care
• A,B,C‟s
• Fluid Therapy
• Wound Care
• Pain management
• Prevention of infection




                 C. Matthews MSN, RN
    Burns
What happens….




  C. Matthews MSN, RN
Complications of Emergent Phase
• Cardiovascular
  – Arrhythmias
  – Hypovolemic shock
  – Impaired circulation
• Respiratory
  – Upper airway burns
  – Inhalation injuries
• Urinary
  – Acute tubular necrosis




                     C. Matthews MSN, RN
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
                             C. Matthews MSN, RN
Drug Therapy: Antibiotics
• Silver Sulfadiazine (Slivadene)
   – Burn treatment
   – QD or BID
   – “frosting”

   – Adverse effects
      • Pain
      • Itching
      • Burning




  Physiologic Integrity: 5. Describe nursing implications for medications prescribed for clients with dermatologic disorders.
                                               C. Matthews MSN, RN
Rehabilitation Phase
• Prevent and minimize contractures and
  scarring!
• Cosmetic / reconstructive therapy
• Psychological support if needed




        Psychosocial Integrity: 4. Discuss psychosocial impact of client’s altered dermatological condition
                                            C. Matthews MSN, RN