Skin Diseases and Disorders (DOC)

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                    S TRUCTURE AND F UNCTION OF S KIN
  Largest organ of the body
  In adult, equals 16% of total body weight
  Normal function is to separate the internal environment from the external environmental skin diseases
  and infection

                    E PIDERMIS
  Surface of the skin
  Made of epithelial cells
  Renewed every 15-30 days
  Thickness varies with your age, sex, and location on the body of the skin
  Consists of many layers
  Contains Melanin (shield to protect from UV light) and Keratin (water-repellant protection)

                    D ERMIS
  Deeper layer of skin
  Has connective tissue, blood vessels, nerve endings, hair follicles, sweat and oil glands

                    S KIN C OLOR
  Melanin- yellow to brown pigment- located in the epidermis. People with more melanin have darker
  pigmented skin.
  Carotene- yellow or orange pigment- abundant in Asians and babies with jaundice.
  Influenced by:

                    S KIN T EXTURE
  How soft, hard, scaly, cracked, dry…..the skin appears
  Norms: smooth and firm
  Depends mostly on touch

                    H AIR AND N AILS
  Located in the dermis layer
Composed of dead cells
Provide protective functions
Growth is influenced by hormones and nutrition

                  D RYNESS /M OISTURE
Changes in seasons can affect moisture level of skin

                  S KIN D ISEASE /D ISORDER F ACTS
1 in every 3 people in US suffer from a skin disease
The prevalence of skin disease exceeds that of obesity, HTN , or cancer
Has medical, financial and emotional toll on patients.
 May not seek medical help b/c they don’t feel like needs treatment or can’t afford treatment. Will most
likely be long term treatment. Can cause emotional embarrassment.

                  S KIN L ESIONS
Primary lesions
         Variation of color present at birth
         Allergic reactions
         Environmental agents such as sunburn
Secondary Lesions
         Change in tone of skin resulting from primary lesion
         Scratching causing further injury
         Keloid- exaggerated connective tissue response of injured skin (thick and raised scar)

                  A SSESSMENT AND S KIN L ESIONS
Color- norm= tan/brown suspicious= mixtures of colors
Palpation- mobility, tenderness, depth
Shape- norm= round, suspicious= uneven
Arrangement- grouped or disseminated
Emotional reaction

                  T HERAPEUTIC B ATHS
Somewhat like a whirlpool
Soothe, decrease bacteria count, clean, hydrate, loosen scales, and relieve itching of skin
If they are completely submerged, need to have a mat so they won’t fall. Medications can make it
20-30 minutes is good time frame
Temperature 110-115 degrees
Try to avoid getting water into the eyes due to meds.
Blot the skin to dry, do not rub- could cause damage to the skin

Topical agents- creams, oils, lotions, shampoos……have localized effect (must wear gloves)
Systemic agents- reserved for moderate to severe cases. Most can only be used for limited time.
         Examples: antihistamines, prostaglandins (anti-itch mediators), antimicrobials (antibacterial and
         antifungal), corticosteroids (decreases inflammation)

Watch your face- don’t show your emotions
Many skin conditions are painful
Annoying- can be life-long and can go to remission and can then flare up again

                 D ECUBITIS U LCERS
“pressure ulcer” or “bed sore”
Ischemic lesions of the skin and underlying tissue
Common locations: bony prominence (heels, greater trochanter, sacrum) and any area that is subjected to
external pressure, friction, or shearing forces
Contributing factors:
         Being left in a position for an extended period time (turn or reposition every 2 hours)
         Pressure on a tissue between a bony prominence and the external surface distorts capillaries and
         impeded blood flow.
         Causes platelets to clump and causes microthrombi
         Micro thrombi impede blood flow causing ischemia and hypoxia
         Hypoxia then causes necrosis of the tissue
    1. Stage 1: nonblanchable erythema of intact skin
    2. Stage 2:Partial thickness skin loss involving epidermis and/or dermis. Abrasion, blister or shallow
    3. Stage 3: full thickness skin loss involving subcutaneous tissue
    4. Stage 4: full thickness skin loss with extensive destruction
    1. Positioning: turn at least every 2 hours and document! Allows adequate blood flow to tissues.
    2. Massage: promotes blood flow to the tissues
          3.   Clean, dry, unwrinkled bed: waste can cause chemical irritation *moisture can damage skin
               (urine, perspiration, wound drainage)
          4.   Therapeutic bed covers, mattresses, and beds
                        Sheep skin
                        Egg crate
                        Air mattresses
                        Specialty beds
          5.   Pharmacological agents:
                        Skin Prep
                        Proteolytic enzymes

                       B ACTERIAL S KIN I NFECTIONS

                 Inflammation of hair follicle
                 Small white headed pimple
                 Common on face, scalp, thighs, legs, and groin area
                 Usually occurs after hair follicle is damaged by friction or shaving
                 This damage makes follicle more susceptible to infection
                 Usually staphylococcus aureus
                 Treatment: warm compress and antibacterial ointments
                 Collection of pus that presents as painful fluid-filled lump or hard nodule
                 Common areas: buttocks, groin, face, armpits and near waistline (friction areas)
                 Caused by staphylococcus aureus
                 Start as red pimple, then turn into fluid-filled bump
                 Treatment: warm compress (need to open and drain) topical bactroban or oral antibiotics
                 When furuncles spread and form multiple tunnels
                 Collection of connecting furuncles
                 If become uncontrolled may lead to severe infection, sepsis, and possible death
                 Prevention: hygiene, hand washing with antibacterial soap, and do not “pop” them
                 “fingertip infection”
                 Infection in top portions of fingers, in the pad of skin above the first joint
                 Usually the thumb or index finger (fingernail bed)
                 Staph aureus
                 Causes: bacterial or viral infection that enters skin by wound
              Treatment: MD examine/ if abscessed- incision and drainage/soak fingers 3-5 times a day,
              antibiotics, 1-2 weeks to heal
              Common, contagious, superficial skin infection
              Highly contagious in children
              Streptococcus and staph aureus
              Starts on face and around mouth. Lesions have pus and form curst. Easily spread to other parts
              of body by pus
              May itch, not typically painful
              Treatment: topical antibiotic ointment, isolation
              Associated with kidney failure/problems

                       F UNGAL I NFECTIONS

      Fungus causes a characteristic lesion with clear center and a rough, scaly, circular border
      Causes: contagious/spread through infected pets or through direct contact with infected individual
      Treatment: antifungal meds (topical 1 ), unsuccessful then PO
      Treat the source (infected pet)
      Capitis is common in children, can cause scaling and bald patches. No sharing hats, combs, brushes.


      Tinea Pedis
      Fungus can be found on floors, socks, and clothing
      Thrives on moist, warm skin (feet)
      When the skin is injured by the fungus, bacteria can invade and cause cellulitis
      Symptoms: itching, burning feet, skin may peel, crack and bleed
      Treatment: need to make the area less suitable for growth and antifungal meds

                       I NFLAMMATORY S KIN I NFECTIONS

      Nonspecific irritation of the skin
      Cause: bacteria, fungus, parasite, or foreign substances such as detergents, perfumes, certain materials
      Contact dermatitis- allergic reaction to substance that comes in contact with skin (soap)
      Atopic Dermatitis- “eczema” chronic, itching inflammation
      Stasis Dermatitis- “eczema” of legs” caused by poor circulation
      Chronic dermatitis can cause thickening, change in pigmentation, and scaling
      Acute dermatitis presents as red, itching area of blisters and oozing
      Treatment: removal of offending substance and corticosteroid ointments


      Chronic and non-infectious
      Patches of raised, reddish skin covered by silvery-white scale. Skin usually looks very thick with different
      Elbow, knees, back and scalp, but can be anywhere on the body
      May itch, scratch, and bleed
      No cure- have flare up and remission
      May develop “psoriatic arthritis”- causing inflammation of joints
      Treatments: topical-mild, phototherapy- mild to mod, systemic (orally or inject) mod-severe
      Incidence: 4.5 million adults in the US
      150,000 new cases each year
      20% have moderate to severe cases
      Equally distributed in males and females
      Ethnic link: Caucasian
      Usually starts between ages of 15-35 years old.
      Predisposing factors: stress, skin injury, strep infections, and weather will all trigger psoriasis


      General term encompassing various inflamed skin conditions, “atopic dermatitis”
      Chronic, relapsing, itchy rash
      Non contagious
      No cure
      10-20% of the world population is affected by eczema.
      Usually appears during childhood- may clear or disappear with age
      Dry, red, extremely itchy patches on skin
      Chronic scratching leads to leathery skin
      What makes them itch? Triggers include rough or coarse material, soaps, detergents, dander, stress…)
      No known cause but associated with allergies
      Have increased risk of allergic rhinitis and asthma


      Moisturize frequently
      Avoid sudden temperature and/or humidity changes
      Decrease stress
      Avoid scratchy materials
      Avoid harsh soaps and detergents
      Avoid environmental triggers
      Prevention: does not need to bathe everyday or use too hot water
      If has eczema need to look to respiratory systems due to link with asthma and allergies


      Chronic inflammation caused by autoimmune disease (pg. 1065)`
      Body produces abnormal antibodies in their blood that target tissues within their own body rather than
      foreign infectious agents.
      Internal organs are involved
      Can affect skin, heart, lungs, kidneys, joints, and nervous system
      More women than men (worse prior to menstrual period) female hormone link
      Usually 20-45 years old when diagnosed
      Ethnic link: more African American and Asians
      Causes: genetic link, viruses, drugs that stimulate immune system, UV light exposure)
      Complain of fatigue, aches and pains, arthritis, may have low grade fever, Reynaud’s phenomenon
      (change in the coloration of the fingers, will be cold and numb with stress, and become pink, purple, or
      Have low blood clotting factors so they have a high risk of excessive bleeding
      Butterfly rash on the face
      Fingers become white due to lack of blood flow, then blue as vessels dilate to keep blood in tissues, finally red as
      blood flow returns (Reynaud’s syndrome)
      Treatment: no permanent cure the goal is to relieve symptoms and protect organs by decreasing
      inflammation and/or the level of autoimmune activity in the body
      Mild- Intermittent anti-inflammatory meds
      Severe- corticosteroids
      Increase rest during active disease
      May use NSAIDS for pain (ibuprofen, Motrin) anti-inflammatory

      “common acne”
      Inflammatory condition of sebaceous glands of skin.
      Results from excessive stimulus of the skin by androgens (hormones).
      Red, elevated areas on the skin that may develop into pustules and even further into cysts that can cause
      Common in teenagers because of the hormonal factor


      Dietary: no support for chocolate or iodine in diet in clinical research
      Topical: (mild cases) astringent lotions, oil-removing pads, acne soaps, clean skin often to decrease the
      bacterial count
      Oral: (severe) oral antibiotics
      Accutane: form of Vitamin A that decreases the amount of sebum (oil) released by the sebaceous glands.
      Avoid Accutane if pregnant or could become pregnant for 1 month after taking because it can cause
      severe birth defects. They need to avoid sunlight.

                        V IRAL S KIN I NFECTIONS

      “Fever Blister” or “Cold Sore”
      Caused by 2 types of Herpes viruses: HSV1 and HSV2
      Transmission is by direct contact with lesions
      Lives in nerve ganglia, triggered by sunlight, menstruation, injury or stress
      S/S: burning, tingling, erythema, vesicle formation, pain
      Healing time is 10-14 days for the exterior portion and then grows dormant
      May cause systemic reactions such as fever and sore throat


      Caused by varicella zoster (same herpes virus that causes chicken pox)
      Decreased immune system makes you more susceptible to Herpes Zoster
      After infected with chicken pox, the varicella virus remains dormant in the sensory dorsal ganglia. Years
      after the initial chicken pox infections, the virus become inactivated.
        Childhood chicken pox- dormant to sensory dorsal ganglia along sensory nerve fibers, reactivated and
        travels from ganglia via sensory nerves to corresponding skin dermatone area.
        Begins as papules and then develops into vesicles with erythematous base unilaterally on face, trunk,
        and/or thorax. Stay for 3-5 days and then erupt, crust, and dry.
        Recovery takes 2-3 weeks
        Pain is associated with lesion eruption and it may stay after the lesion is gone because nerve ganglia had
        been exposed
        Treatment: Acyclovir or Famvir (antiviral agents) topical, oral, Parenteral. Pain=over-the-counter anti-
        inflammatory or prescription pain meds.
        Infectious until lesions dry and decreased risk if never had varicella

                          N ON -M ALIGNANT S KIN D ISORDERS

        Benign (not cancerous) overgrowth of skin pigment forming cells called melanocytes on the skins surface
        Present at birth (congenital) or appearing early in life (acquired)
        Check any changes in the skin. Use the ABCD rule.


   A.   Asymmetry; one-half of the nevus does not match the other half
   B.   Border Irregularity (edges are ragged, blurred, or notched)
   C.   Color variation or dark black color
   D.   Diameter greater than 5 mm ( size of a pencil eraser)


        Assess ABCD
        Look for any parallel growth around surgical incision
        Vertical growth- determine metastasis and treat accordingly


        Caused by the human papilloma virus (HPV)
        Can affect the skin or the mucous membranes
        Most warts in the non-genital area are benign, but most genital warts are precancerous
      Transmitted by skin contact
      3 most common types
          I.  Common wart: skin/mucous membranes and grows above skin surface
         II.  Plantar wart: on feet- extend deep into skin- painful
        III.  Condylomata Acuminata: (venereal wart) moist areas, cauliflower-like appearance- pink purple


                  salicylic acid “Compound W”
                  Liquid nitrogen- freezes the wart off
                  Burning the wart off
                  Liquid nitrogen
                  Chemical treatment
                  Laser surgery
                  Interferon injections to the site

                       M ALIGNANT T UMORS OF THE S KIN

  1) Basal Cell Carcinomas:
              most common form,
              any area that has constant sun exposure,
              does require treatment,
              stay out of the sun,
              slow-growing and rarely metastasize
  2) Squamous cell carcinomas:
              Develop in the middle layer of epidermis
              Can spread
              Life threatening if not treated
  3) Malignant Melanoma:
              Abnormal growth of melanocytes
              Most aggressive cancer with faster growth rate
              Much greater potential for metastasis if untreated
              Fair skin at most risk
                          S KIN I NFESTATIONS

          Parasite that live on blood of animal or human host
          “louse” living parasite
          “nit” is the un-hatched egg laid by female louse on hair shaft. Pearl-gray or brown color.
          Not sharing clothes, hats, coats, hair accessories, especially with children


        “itch mite”
        Between fingers, inner surface of wrist, elbows, and belt line
        Small red-brown burrows- 2mm in length
        Puritis- always present especially at night
        Highly contagious- wear gloves with care to clients


  i.    Pediculosis Corporis: body lice
        *live on clothing and bed linens
        *bites cause macule and itching
  ii.   Pediculosis Capitis: Head lice
        *Common behind ears, nape of the neck
        *transmitted by contact (hat, comb, coat)
 iii.   Pediculosis Pubis: pubic Lice
        *spread through sexual activity or contact with infested clothing or linens
        *skin irritation and itching


        RID: Over-the-counter
                 Pesticide in the form of a shampoo/gel/home spray
        Lindane: prescription
                 Potentially neurotoxic
                 Not recommended for 1 line treatment
                         B URNS

        2.5 million per year
        35% are children (newborn-4 years old kitchen/bathroom)(5-7 years old outdoors/kitchen)
                  Heat (most common)
                  Chemicals (caustic Chemicals)
                  Radiation (radioactive energy)


   1.   First Degree: damage to outer layer of skin. Pain, redness, swelling (superficial)
   2.   Second Degree: “partial thickness: 1 layer (epidermis) burned all the way through and some level of
        burning to dermis. Bright red skin, blistered, swollen, and moist- very painful!
                  Superficial partial thickness burn- involves the entire epidermis
                  Deep partial thickness burn- involves the entire dermis plus hair follicles, dermis is damaged
                       o *pink skin with blisters*
                  Extremely painful. May leave permanent scars
                            Do not break the blisters.
                            Don’t try to remove stuck clothing
                            Use cool running water for 5-10 minutes (no ice)
                            Elevate above the heart level
                            Keep clean to prevent infection (may cover with a clean sheet)
                            Depth and tissue damage- may need burn center care or wound management
   3.   Third Degree: “full thickness”- extends into hypodermis, causing destruction of the full thickness of skin
        with its nerve supply (numbness). Leaves scars and may cause loss of function and/or sensation.
                  Will need hospital management
                  Will need to monitor for I&O, infection, pain, and respiratory problems
                  May not be painful- nerve endings are destroyed
                  Skin will be white, brown, black , or red with no blanching
                  Look at color of urine, may be dark red or ruby colored, this is caused by muscle breakdown. The
                  myoglobin is excreted through the urine.
                  Life threatening depending on % of body surface injured
                  `Will have to look at possible skin grafting. The skin will not regenerate when damaged down to
                  the hypodermis area. Monitor for signs and symptoms of rejection.
                            Graft site- burned area covered with skin graft
                  Will need dressing for 2-5 days
                            Donor site- unburned area that was removed to cover burned site, “skinned knee”
                  Dressing for 1-2 weeks

         Autograft: transplant of the client’s own tissue. This is the most successful. These are considered
         “permanent grafts:. Immobilize area after grafted.
         Xenograft- skin transplants from animal species to a human. Not very successful. Pig skin commonly used
         for temporary coverage for a massive burn.
         Homograft: fresh skin from a human cadaver- may be a precursor to an autograft.


         Infection control begins at admission and continues until grafting is complete
         Use reverse isolation
         Septicemia can occur at any time during hospitalization


         Age: less than 4 or greater than 60 years, higher chance of complications and death from severe burns.
         Infants: poor antibody response and fluid requirements can be very tricky
         Older patients: may have underlying complications- cause exacerbations and complicate situation


% of body surface burned

         Each leg=18%
         Each arm=9%
         Front torso=18%
         Back torsos=18%
         Genital area=1%

*Not used in infants (larger head to body ratio)

*Not good with short, obese, or very thin individuals

*Don’t need to remember actual percentages

      Head, neck and chest: risk of respiratory problems
      Neck: prone to contractures
      Perineum: very susceptible to infection


      All burns result in complications
      Common complications
               Renal failure
               Heart failure/disease


      Immediate effect is destruction of protective skin area. This leads to disruption of homeostasis, diffusion
      of vascular components into extra-vascular tissue, electrolyte imbalance, and diminished blood volume.
      Can lead to multisystem trauma.
      1 24 hours: protect airway- airway edema leads stridor, hoarseness, wheezing (usually on inspiration),
      and mental status change. Position for airway intubation and correct fluid loss.


      With exposure to heat, capillaries are damaged and become permeable to fluid. They let fluid leak out of
      the capillaries and into the interstitial spaces resulting in edema and blister formation.
      The resulting fluid shifts are directly proportional to the depth and extent of the burn.
      Treatment- fluid therapy is going to be directly related to the severity of the burn.
      Really watch intake and output
      They will lose a lot of plasma through burn surface. Urine output is going to decrease drastically.


      Severity is based on:
               Size of the burn (expressed in % of total body area using Rule of Nine’s)
               Depth of the burn
               Past medical history
               Part of the body that is burned

      Parkland Formula- 4mL X wt/kg X % burned
      Use rule of nines for percent burned with no decimals
      Physician will determine and nurse will check behind
      If possible, give half the calculated amount over the first eight hours from the time of injury and the
      remaining half over the next 16 hours.


      Dehydrate more rapidly than adults (increase ratio of body surface area to weight, increased metabolism,
      and thinner skin)
      Need more fluids than adults
      Use formal and add 1,500 mL of LR per square meter of surface area, and adjust this based on urine
      output monitored hourly
      Keep child’s minimum hourly output at 1 mL/kg/hr


      Edema, dyspnea, neck vein distension, ascites, weight gain
      Must continually assess for these signs and symptoms
      They may be weighed twice a day


      Monitor for shock (<BP, >HR, pale, clammy skin, blue lips,…), monitor electrolyte and protein loss (caused
      by volume shifts from intravascular to extra vascular compartment secondary to > in capillary
      Any partial thickness burn over 9% can cause shock. Immediate < in BP treat for shock.
      Prevent shock with LR and Albumin
      48-72 hours: eschar (scabbing over the burned area) forms- initially is sterile, in absence of topical
      antimicrobial, bacteria will colonize. Primary source of bacterial infections secondary to burns is the
      intestinal tract, whether from vomitus, diarrhea, etc.
      Should not have anything PO for first 48 hours due to N/V. After 48 hours and free from respiratory
      problems and shock, then can give small amounts of fluids (1-2 ounces an hour). If unable to tolerate, will
      switch back to NPO.

      Goal is to reduce bacterial count, not to sterilize
      Sulfamylon Acetate- broad bacteriostatic action against many gram negative and gram positive organisms
      (pseudomonas). Easy to apply, but tends to be painful with application b/c it burns. Must pre-medicate
      with use.
                May cause acid-base imbalances and should not be used on large areas of the body- use on ears
                and nose
      Silver Nitrate- Liquid, used to kill antibiotic resistant strains of bacteria. Not used much anymore. Cover
      with moist dressing. If allowed to dry out, further burns site! Turns everything brown.
      Silvadene- (topical crème) antibacterial/antifungal- wear sterile gloves and use sterile technique- easy to
      use and painless. Do not use if allergic to septra.
      Betadine: broad spectrum antiseptic- used for > 30 years. To prevent and treat wound infections. Active
      agent providone iodine (prevents infection and does not harm wound).
      Neosporin and Bacitracin- used commonly on 1 degree facial wounds. Antimicrobial effects.


      Exposure- “open method” – mainly used with 1 degree burns. Not used much for advanced burns- dries
      out surface, and impeded delivery of nutrients to skin cells.
      Use an occlusive dressing: works by excluding atmospheric oxygen while promoting growth of new blood
                Advantages: Decreased dressing changes and decreased cost
                Disadvantages: adhere to skin- pain, and can’t control wound discharge and odor
      Wet Dressing: prevents scab formation, and debrides wound. Needs to be sterile
      Hydrotherapy- dilates blood vessels, removes wastes from body tissues. May do mechanical debridement
      during hydrotherapy. Do not use for more than 30 minutes to prevent metabolic stress and to keep the
      client from getting cold.


      Pain Management: NSAIDS- minor burns. Morphine for more advanced burns. IV preferred (SQ, IM not
      well absorbed) Pre-medicate before dressing changes. May be on a morphine drip or PCA. (Make sure
      that respirations are at least 12 before administering morphine)
      Nutrition: high calorie (metabolic rate triples), high protein (wound-healing) not including high fat.
      Vitamin C assists in collagen formation.
      Environment: temperature should be greater than 84 degrees, air currents will cause tremendous pain.
      Positioning: prevent contractures- change position frequently, don’t bend at joints for extended time,
      encourage ROM, Supine- flat
      Don’t use Fowler’s position which promotes contractures. Do not use knee gatch or pillows
      Follow order with splints and exercise programs initiated by physical therapy.

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