Basic Structures Of The Integumentary System 4433w
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Basic Structures of the Integumentary System
Epidermis
Stratum basale Stratus spinosum Stratum granulosum Stratum lucidum Stratum corneum
Dermis
Papillary layer: contains capillaries and receptor sites for touch and pain Reticular layer: contains receptors for deep touch as well as sweat and sebaceous glands
Subcutaneous tissue Appendages
Hair Nails Glands Apocrine: sweat glands located in the axilla, anus, and genital area Eccrine: sweat glands located on the forehead, hands, and soles of the feet Sebaceous: glands located throughout the body that secrete sebum and that are highly influenced by increased hormones, especially adrogens
Basic Functions of the Integumentary System
Epidermis
Dermis
Subcutaneous tissue
Appendages
Disorders of the Integumentary System
Problems caused by vascularity
Spider angioma:
a flat, bright red spot with radiating blood vessels at the edges commonly found on the upper body varies in size from a tiny dot up to 1.5 to 2 cm spider angiomas are caused by vascular dilation of the vessels commonly seen with high estrogen levels, pregnancy, liver disease, and/or vitamin B deficiency
Petechiae:
flat red spots approximately 1 to 2 mm in diameter that do not change in color when blanched; these are caused by tiny capillaries that have broken, possibly caused by thinning of the blood (anticoagulant effect), liver disease, vitamin K deficiency, or septicemia
Purpura:
purple/blue-appearing patch varies in size and shape caused by a bleeding disorder or broken blood vessels and may appear throughout the body
Primary skin lesions
Macule:
nonpalpable, flat lesion that has color and measures<1 cm examples: freckles, chloasma
Papule:
elevated palpable mass, measuring less than 0.5 cm examples include warts and moles
Nodule: an elevated firm lesion with a circumscribed border that measures approximately 1 to 2 cm
Vesicle: fluid-filled,
elevated mass that measures less than 0.5 cm if the fluid mass measures greater than 0.5 cm, the mass is termed a bulla examples of vesicles include chickenpox, small burns, and herpes virus lesion
BULLA
Plaque:
elevated group of papules that have convalesced into one lesion measuring greater than 0.5 cm examples are actinic keratosis and psoriasis
Pustule:
elevated, serous (pus)-filled vesicle that can measure any size examples include acne and boils
Wheal:
variable-sized, elevated erythemic lesion with an irregular border that contains fluid in the tissue of the skin examples include insect bites and hives
Secondary skin lesion
Atrophy:
dry, thin, taut skin that appears wasted from loss of collagen an example is aged skin hydration with fluids and keeping skin wellmoisturized with emollients such as Eucerin TM cream are helpful for this condition
Crusts:
dried pus or blood on the skin surface resulting from a vesicle that has ruptured examples of crusts include the final stages of chickenpox lesions or impetigo lesions
Erosion:
superficial indentation of the skin that results from a previous lesion an example of erosion is a scratch mark that has not healed over time
Fissure:
linear break in the skin with sharp edges, extending into the dermis examples include athlete`s foot or cracks in the corner of the mouth from chapped lips
Scales:
Scar:
dry, dead skin that sloughs off the skin surface and that may be dry or greasy examples include dandruff or psoriasis the flat connective tissue resulting from healing over the site of previous injury, which may vary in size, color, and shape examples include healed surgery incisions or acne scars
Ulcers:
deep excavations in the skin; they may vary in size and shape and extend into the dermis or subcutaneous tissue examples include chancres and pressure ulcers
Chronic Dermatologic Problems
Eczema
Eczema
Description:
inflammatory response in which the skin appears erythmic, scaly, dry and thickened may appear in various stages, depending on the type (e.g., infantile eczema vs. adult eczema) etiology is unknown eczema is characterized by lymphohistiocytic infiltration of the vessels of the skin Common form of chronic dermatitis
Clinical manifestations:
are generally secondary to scratching of the skin dry, pruritic skin that appears thickened and discolored may even cause a break in the skin in which bleeding or oozing occurs lesions may appear as papules or pustules that can lead to excoriation
Therapeutic management
Bath: advise the client not to use harsh soaps; avoid frequent bathing Wet dressings of Burow`s solution may be used in severe cases Emollients: frequent use of emollients (EucerinTM, AquaphorTM) is recommended Allergens: remove all triggers and/or allergens; avoid skin with all wool products and lanolin preparations
Priority nursing diagnoses:
Impaired skin integrity Altered comfort
Medication therapy:
Antihistamines such as diphenhydramine hydrochloride (BenadrylTM) severe cases may require topical or oral steroids for brief periods antipruritic
TYPES
OF ECZEMA 1. Infantile eczema - lesions begin in the cheek and progress to the extremities and trunk - lesions starts as vesicles, which can result in oozing and crusting of excoriated areas 2. Adult atopic eczema - markedly dry skin that extremely itchy - excoriation,lichenification and even scarring can lead to leathery areas in the antecubital and popliteal areas
3. Nummular eczema - Lesions developed as coined shaped papulovesicular patches on the arms and legs - excoriation and subsequent bacterial infections can lead to lichenification
Psoriasis
Psoriasis
Description:
chronic, inflammatory skin disorder lesions appear as whitish, scaly plaques on the scalp, knees, and/or elbows no known etiology thought to be a multifactorial disease in which a T-lymphocyte mediated dermal immune response occurs most client with psoriasis have a family history of the disease
Clinical manifestations:
dry, scaly rash that may appear a silvery scales or plaques usually found on the scalp, knees, or elbows
Priority nursing diagnoses:
Impaired skin integrity Altered comfort
Therapeutic management:
direct sun exposure to the skin site may be beneficial for some clients emollients: frequent use of emollients and keratolytic agents are beneficial for scalp psoriasis topical steroids antihistamines may be used for pruritus
Seborrheic Dermatitis
Seborrheic Dermatitis Description: common
chronic skin condition occurring in areas of active sebaceous glands, such as the face, scalp, body folds, sternal area, and axilla appears as an erythematous scaling lesion that may appear dry or greasy etiology is unknown but possible causes are believed to be hormonal influence, nutritional deficiency, neurogenic influence, dysfunction of the sebaceous glands, and/or fungal infection
Clinical manifestations:
erythmic, scaly lesions that appear in varying degrees (oily or flaky dry skin), pruritic, and may cause secondary bacterial infections common sites include scalp, eyebrows, nose, ears, sternal area, and axilla seen more frequently in colder weather periods, and it is thought to be caused by decreased humidification and decreased exposure to sunlight
Therapeutic management:
scalp treatment: selenium sulfide 2.5 percent suspension or coal tar shampoos and topical steroid creams
Priority nursing diagnoses:
Impaired skin integrity Altered comfort Risk for infection
Malignant Neoplasms
Actinic Keratosis
Actinic Keratosis
Description:
pre-malignant macules found on the skin surface of fair skinned individuals who are 50 years of age or older, but can be seen in high-risk individuals at any age development occurs because of chronic sun exposure to the skin light-skin complexion are at the highest risk considered pre-malignant lesions approximately 1 percent will progress to squamous cell carcinoma
Clinical manifestations:
erythematous, rough, and shiny-textured macules may appear as a single macule or in groups; commonly seen on the face, ears, scalp, lips, neck, and hands
Therapeutic management
Prophylactic treatment is recommended to prevent development these lesions Protection from ultraviolet rays of the sun with the use of clothing and sunscreens are recommended when exposed to sunlight Biopsy and removal of the lesion is recommended if changes in the lesion occur; these changes include the color, border, size, and shape of the lesions
Basal Cell Carcinoma
Basal Cell Carcinoma
Description:
abnormal cell growth of the basal layer of the epidermal skin most common contributor to this growth is ultraviolet rays from sunlight exposure; basal cells do not mature appropriately into keratinocytes, which results in neoplastic growth of the cells the surrounding tissue is also destroyed least aggressive type of skin cancer and rarely metastasizes to other organs
Clinical manifestations:
characteristics of the five types of basal cell carcinoma: Nodular basal cell carcinoma: small, firm papule, which appears as pearly, white, pink, or flesh-colored, and is commonly seen on the face, neck, and/or head
Nodular Basal Cell Carcinoma
Superficial
this papule or plaque is the second most common lesion and is commonly seen on the trunk and extremities
Pigmented
basal cell carcinoma:
basal cell carcinoma:
this tumor is less common and usually found on the head, neck, or face; it has the ability to concentrate melanin, which causes deeper pigmentation of the center of the tumor
Superficial Basal Cell Carcinoma
Pigmented Basal Cell Carcinoma
Morpheaform
basal cell carcinoma:
least common form this tumor is found on the head and neck, appearing like a tumor with finger-like projections (usually ivory-or flesh-colored) and typically resembles a scar it has the ability to invade and destroy adjacent tissue and structures
Morpheaform Basal Cell Carcinoma
Keratotic found
basal cell carcinoma:
on the preauricular or postauricular
area contains both basal cells and squamous cells that keratinize if removed, this tumor is likely to recur high risk of metastasizing to other structures
Therapeutic management
Monitor progress of growth of all lesions lesions > 2 cm have a high reoccurrence rate suspicious lesions are excised and sent for pathological examination
Educate
clients regarding importance of monitoring lesions and early identification of new lesions suggest monthly assessment of the skin by the client and periodic screening based on symptoms by healthcare provider Encourage protection from ultraviolet light exposure by using sunscreen with SPF > 15 and wearing clothing such as hats and clothing to protect the skin
Priority nursing diagnoses:
Impaired skin integrity Risk for disturbed body image Fear or anxiety
Medication therapy: none
Kaposi`s Sarcoma
Kaposi`s Sarcoma
Description:
skin cancer of the endothelial lining of the small blood vessels, seen most commonly on the face, nose, and ears etiology is unknown a cancer speculated to be related to an infective agent such as a retrovirus, such as the virus that causes acquired immunodeficiency syndrome (AIDS)
Clinical manifestations
Vascular lesions (macules, papules, nodules) that can affect the skin and viscera Over time the lesions enlarge and become confluent, forming large masses as these masses enlarge, the tissue below the mass becomes involved and the tumor then invades the lymphatic tissue, which may then result in varying degrees of lymphoedema, primarily affecting the genitalia and lower extremities
As the disease progresses, this tumor may interfere with internal organ function may cause bleeding to the point of hemorrhage (commonly seen as a late sign) Initially Kaposi`s sarcoma may be symptom-free pain maybe experienced in the later stage
Therapeutic management:
Priority nursing diagnose:
isolated lesions may be removed by excision cryotherapy, and/or local radiation for comfort and/or cosmetic treatment Impaired skin integrity Fear or anxiety Risk for disturbed body image
Medication therapy:
chemotherapy treatment can be used as a single agent or a combination treatment
Nonmelanoma: Squamous Cell Carcinoma
Nonmelanoma: Squamous Cell Carcinoma
Description
The most common type of skin cancer fair-skinned males tend to have a higher incidence majority occurring from 30 to 60 years of age occurs on areas of the skin that are frequently exposed to ultraviolet light, such as the face, ears, nose, lips, and hands; grows quicker , more aggressive, and is more likely to metastasize than basal cell carcinoma
Etiology and pathophysiology
The etiology multifactoral Environmental causes include ultraviolet radiation, chemicals, physical trauma, and pollution With exposure of ultraviolet light to the skin, the rays penetrate the tissue and alter normal DNA and suppress the body`s T-cell and B-cell immunity, producing tumors of the squamous epithelial or mucous membranes
As the tumor grows, the cells increase in size and an irregular shape is formed Tumors may proliferate and invade the dermal layer of the skin may also present from preexisting skin lesions, such as old scars these tumors may proliferate into the dermal structure and can cause metastasis by the lymphatic tissue
Clinical manifestations
Squamous cell carcinoma mat present as a small fleshy colored papule that is firm to touch As the tumor grows, the color may change and appear erythemic, sore, and/or even bleed if touched
Therapeutic management
Recommended management is removal of the tumors by: cryotherapy surgical excision electrodesiccation radiotherapy The cure rate is approximately 90 percent recommended to remove these tumors as soon as identified to prevent the person`s risk of metastasis
Nursing management
teaching methods to prevent further tumors from arising minimizing sun exposure wear protective clothing wear sunscreen with a SPF of 15 or greater avoid tanning booths
Priority nursing diagnoses:
Impaired skin integrity Ineffective health maintenance Fear or anxiety Risk for disturbed body image
Medication therapy: none
Bacterial infection
Bacterial Infections (Pyodermas) It
includes a variety of acquired skin lesions characterized by erythema and pustules
Most
common causative organisms are gram-positive staphylococci and betahemolytic streptococci
Impetigo
Impetigo
Description:
A superficial skin infection that initially appears as an erythemic vesicle and later changes to a honey-colored crusted lesion most commonly seen in children but occasionally affects adults An alteration in skin integrity occurs, and bacteria invade the epidermis and cause an infection most common organisms are Staphylococcus aureas and group-A beta-hemolytic streptococcus
Clinical manifestation
lesions are commonly found on the face, arms, legs, and buttocks appear as thin erythemic vesicles, which then becomes honey-colored crusts or erosions may occur as a single lesion or several lesions that have convalesced and appear as a group of lesions
Therapeutic management:
encourage good hand washing with hot soapy water to prevent spreading the bacteria to others
for recurrent lesions, a culture of the site is obtained to isolate the pathogens
Priority
nursing diagnosis:
Ineffective
Medication topical
health maintenance
therapy:
antibiotics For severe cases, systemic antibiotics are recommended
Cellulitis
Cellulitis
Description
A bacterial infection of the dermal and subcutaneous tissues with lesions appearing in various stages, ranging from vesicles, bullae, abscesses, and plaques
most
commonly seen in adults group-A beta-hemolytic Streptococcus pyogenes and Staphylococcus aureus being the most frequent organisms involved occurs because of a break in the integrity of the skin (abrasion, laceration, etc.) may also occur secondary to a skin lesion
Clinical manifestations:
cellulites is characterized by an erythemic, swollen, tender-to-touch area of the skin at the site of entry of the bacteria; associated symptoms include fever, chills, malaise, and anorexia with associated regional lymphadenopathy
Therapeutic management:
rest, elevation of the extremity, moist heat to the site for comfort consider culture and sensitivity of tissue site for severe cases for necrotic tissue, surgical excision and debridement are recommended along with antibiotic therapy
Priority
nursing diagnosis:
Impaired
skin integrity
Medication antibiotic
therapy:
therapy
Folliculitis Staphylococcal
infection in one or more hair
follicles Appears
in pustule formation; inflammation occurs resulting in erythema
It
is commonly seen in the beard area of men who shave and on women’s leg
Furuncle (boils) It
is an acute inflammation arising deep in one or more hair follicles and spreading into the surrounding dermis
Manifest
a deep, coin sized erythematous pustule, lesions are painful and usually develops a cellulitis with a white center on the skin surface
Carbuncle It
refers to the group of infected hair follicles
A
subcutaneous infection develops into red, painful mass which can spread and cause septicemia
It
occurs most commonly at the back and upper neck
Stye/ Hordeolum It
manifest as a pink, swollen area in the eyelid
Nursing Management ister
medications Prevent infection and infection transmission - Instruct the client not to squeeze a boil or pimple Instruct the client to bathe at least daily with bactericidal soap Isolate drainage in severe cases of folliculitis, furuncles or carbuncles Promote comfort measures - ive treatments - apply warm, moist compresses Provide client and family teaching
Viral infection
Herpes simplex virus (Type 1, Type 2)
Herpes simplex virus (Type 1, Type 2)
Description
manifested by vesicles on the oral mucosamouth or lips, which is HSV Type 1, or in the genital mucosa (HSV Type II) Herpes simplex virus (HSV) can occur at any age The virus is spread by direct of contaminated body fluids incubation period range of 2 to 14 days
The
virus occurs in three stages
Primary – blisters occur on the mucosa or lips; malaise and fever are also common symptoms Recurrent infections – outbreaks may occur at any time and are commonly precipitated by stress and illness; symptoms are usually milder than the primary; commonly present with a prodrome of tingling, itching, or a burning sensation at the site prior to the outbreak of lesions Latency period – the virus remains dormant in the body
Clinical manifestations
The primary symptoms include: malaise, fever, and vesicles appearing on the mucosa Secondary symptoms include: prodrome of tingling, burning sensation prior to the outbreak of vesicles on the mucosa latency period is asymptomatic
Therapeutic management:
advise rest encourage good handwashing technique to prevent spreading the virus comfort measures such as petroleum jelly or lip balm may be used for oral lesions
to
prevent spreading the virus, avoid close with others while lesions are present to prevent HSV Type 2, advise the use of latex condoms to prevent spreading genital lesions Priority
nursing diagnosis:
Impaired
tissue integrity Altered comfort
Medication therapy:
acetaminophen (Tylenol) or camphophenique may be used for comfort as needed antiviral medications such as acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex) may be used to check further replication of the virus and diminish symptoms if started within 24 to 48 hours after initial onset of lesions
Herpes Zoster
Herpes Zoster
Description
A viral infection manifested by vesicles on the skin commonly seen in older adults and the elderly it is estimated to occur in approximately 20 percent of the U.S. population Herpes zoster is a reactivation of the varicella virus, which has been dormant for many years, in the dorsal root ganglia
Clinical manifestations:
vesicular rash on the skin that usually follows one dermatome clusters of vesicles are common along with symptoms of tingling, itching, burning, and even pain at the site of the lesions the client may experience fatigue, malaise, fever, and headache in addition to the local discomfort of the rash
Therapeutic management:
comfort measures include wet dressings or soaks (Burow`s solution) at the lesion sites two to three times a day oatmeal baths (Aveeno TM) are soothing and help to dry up lesions rest is recommended the virus may be transmitted to others; therefore care should be taken to avoid persons at risk lesions should be monitored for secondary bacterial infections
Priority nursing diagnoses:
Impaired skin integrity Altered comfort
Medication therapy:
antiviral medications may be used if therapy is started within 24 to 48 hours after the outbreak of vesicles current medications include acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) acetaminophen (Tylenol) and ibuprofen (Motrin) may be used for discomfort
Fungal infections
Candidiasis
Candidiasis
Description
Infection caused by candida albicans, a yeast-like fungus that most often causes superficial cutaneous infections Symptomatic infections occur on moist cutaneous sites and mucosal surfaces if local immunity is disturbed
can affect all ages diaper rash in infants summertime inframammary rash in women vaginitis in premenopausal women oral candidiasis in immunocompromised clients buttocks and perineal rash in incontinent clients Risk factors moist, warm, or altered skin integrity systemic antibiotics pregnancy, birth control use poor nutrition diabetes, or chronic illnesses immunosuppression
Clinical manifestations:
lesions are bright red, smooth macules with a macerated appearance and a scaling elevated border characteristic “satellite” lesions are small, similar-appearing macules outside the main lesion
Oral candidiasis - known as thrush and is characterized by white, milky removable plaques on the oral mucosa associated symptoms may include a burning sensation or decreased taste Vulovaginitis - found on the vaginal mucosa and can spread to the pertineum and groin; satellite lesions are usually present other signs and symptoms include excessive itching and a thick, white, curdlike vaginal discharge
Perineal/diaper and skin-fold rash - occurs on the perigenital and perianal areas and can extend to the inner thighs and buttocks other areas affected include axilla, umbilical area, and under the breasts erythema, papules, pustules, and a scaling border are characteristic Balanitis - inflammation of the glans and the prepuce of the penis that typically present as flattened pustules with edema, scaling, erosion, burning, and tenderness
Paronychial infection - erythema, edema, and tenderness of the nail folds a creamy, purulent discharge may be expressed with pressure on the nail the nails usually become discolored and have ridging
Candida organisms may also be a causative agent in otitis externa and scalp disorders
Therapeutic management:
diagnosis is made by culture of scrapings or by microscopic examination of scaling with potassium hydrochloride (KOH) preparation Avoid sharing linens or personal items Use clean towel and washcloth daily Dry all skin folds, avoid frequent immersion of hands in water Wear clean cotton underwear daily
For vaginal candida, avoid tight clothing and pantyhose, bathe more frequently and dry genital area thoroughly may need to treat sexual partner at the same time to avoid reinfection or have the partner use condoms until resolved avoid douching and change perineal pads frequently
For vaginal candida, avoid tight clothing and pantyhose, bathe more frequently and dry genital area thoroughly may need to treat sexual partner at the same time to avoid reinfection or have the partner use condoms until resolved avoid douching and change perineal pads frequently
Priority nursing diagnosis:
Impaired tissue integrity Acute pain
Medication therapy
Oral candidiasis: nystatin, clotrimazole, and in recurrent cases, ketoconazole, fluconazole, or itraconazole; liver function tests must be monitored because of risk of hepatotoxicity Perineal: topical treatment with nystatin ointments BID Balantitis: topical treatment with imidazole cream or nystatin powder BID
Paronychial : topical imidazole cream or application of
2 percent gentian violet; for nonresponsive cases, systemic ketoconazole or fluconazole; systemic medications require monitoring of liver function tests because of risk of hepatotoxicity Hair/scalp: antifungal shampoo Vulvovaginitis: vaginal creams/suppositories or treatment with DiflucanTM
Infestations
Pediculosis
Pediculosis
Description
An infestation of the skin or hair by the species of blood- sucking lice capable of living as external parasites on the human host Pediculosis capitis is the head louse, the size of a sesame seed, clear in color when hatched but becomes grayish-white to red/brown after maturing
Head lice infestation is very common among school age children of all socioeconomic backgrounds and spread by sharing combs, hats, and scarves Pediculosis pubis, also known as “crabs”, infests the genital area and is one of the most common sexually transmitted diseases
Pubic
lice can spread by sexual Nits/eggs attach to the hair shaft by a cement-like/cocoon-like structure and are difficult to remove Lice live up to 30 days and a female can lay up to 100 eggs
Clinical manifestations
Intensive pruritis is the most common symptom that may result in excoriations Head lice may resemble dandruff flakes; however, they are not easily brushed off Papular urticaria may be found at the neck or pubic area
Therapeutic management
Nits must be mechanically removed 50/50 white vinegar-water solution may loosen the nits olive oil may also be used nit comb is used to remove nits from the hair shafts
lice
may also be removed by fingers or tweezers; nits remove more easily by back-combing the hair To treat eyelashes apply petrolatum to lashes b.i.d. for 10 days; lice will either suffocate or slide off
Educate children and parents about mode of transmission (person to person) and preventative measures, such as not sharing combs, brushes, hats, scarves, helmets, headphones, bedding, or sleeping bags Coats and hats should be hang separately and not touching each other
Sleeping
material should be labeled and kept separately in plastic bags All family need to be examined and treated at the same time Soak personal hair items in 2 percent Lysol or pediculocide for 1 hour Shaving hair is not found to be helpful Machine-wash all washable clothing used in the last 48 hours and dry in the dryer for at least 20 minutes
Place unwashable items in airtight plastic bags for a period of 1 week to kill lice Upholstered furniture or pillows may be ironed with a hot iron Clean any item in with hair with 2 percent Lysol or pediculocide Vacuum mattresses, rugs, upholstered furniture, and stuffed animals regularly
Medication therapy
For pediculosis capitis: permethrin (Nix), pyrethrin shampoo (Rid), or lindane (Kwell) shampoo left on 5 to 10 minutes and then washed off; lindane can be repeated in 1 week; due to neurotoxicity of lindane, it should not be used by children, nursing or pregnant women, individuals with known seizure disorders, or on open skin
For pediculosis pubis: treatment includes lindane, pyrethrin (Rid) or permethrin (Nix) as a shampoo left on for 10 minutes or as a lotion left on for several hour Co-trimoxazole (Bactrim DS): b.i.d. for 3 days has been shown to be effective; a second therapy 10 days later may be necessary to kill emerging nits before they reproduce
Scabies
Scabies
Description
A contagious disease caused by infestation of the skin by the mite Sarcoptes scabiei var hominis; the impregnated mite burrows into the skin and remains there for life (approximately 30 days), laying 2 to 3 eggs per day; the eggs hatch in 3 to 4 days and reach maturity in 4 days, migrate to the skin surface, mate, and repeat the cycle
more common in people who don`t have bathing facilities or access to clotheswashing facilities mite can live in clothing fibers and can be transmitted by of infected clothing or bed linens Pathological findings by skin biopsy of a nodule will reveal portions of the mitealthough rarely performed diagnosis is usually made by clinical presentation of burrows, vesicles, and nodules
Clinical manifestations
Presents as a generalized pruritic rash particularly of the hands, wrists, elbows, axillary areas, breasts, abdomen, or genitals Itching may become intense increased warmth of the skin and nocturnal itching is a classic symptom, since mites tend to have increased movement at night
Lesions may be erythematous, crusted papules, or purplish nodules, which may be accompanied by flesh-colored, raised burrows (threadlike linear ridges a few millimeters in length with a minute black dot at one end) clients develop itch approximately 10 to 14 days after exposure exposure to hot water or steam also can increase pruritis
Therapeutic management
Close family and personal s must be treated as well, even if there are no apparent signs or symptoms All bed clothing, linens, unwashed worn clothing, and stuff animals should be washed and dried in a hot dryer because the dryer kills the mite
Mites
and eggs may be killed by placing items in airtight plastic bags for 7 days since the mite cannot live off the host more than 3 days; mites can live 24 to 36 hours in room conditions and longer in humid environments Relief from itching may not occur for 3 to 6 weeks after treatment because of hypersensitivity of the skin to debris left in the burrow
Lotions/creams should be applied from the neck down, using a toothbrush to get under fingernails and toenails; the lotion is showered off 8 to 12 hours later
Priority nursing diagnoses:
Impaired skin integrity Altered comfort
Medication therapy Permethrin 5% cream (Elimite) is the treatment of choice; a second application in 48 hours is sometimes recommended Crotamiton 10% (Eurax) is less toxic but is also slightly less effective therefore application for 2 nights is advised
Lindane 1% cream or lotion (Kwell) is the least expensive but has the potential for neurotoxicity and should not be used by children, nursing or pregnant women, people with a known seizure disorder, or any widespread excoriations/open skin; treatment after 1 week Systemic antipruritics May require emollients and midpotency corticosteroids after using scabicide to suppress hyperreactivity caused by the mites
Allergic reactions
Dermatitis
Dermatitis Description An
eruption of the skin related to with an irritating substance or allergen primary irritant dermatitis affects individuals exposed to specific irritants and produces discomfort immediately
Common irritants include chemicals, dyes, metals, and latex gloves allergic dermatitis affects only individuals previously sensitized to the ant it represents a delayed hypersensitivity reaction most common are poison ivy, sumac, and oak
dermatitis an inflammation caused by an external irritant or allergic reaction mediated by IgE the epidermal reaction is caused by Tlymphocytes the location of the rash helps provide clues to the offending antigen there is no specific age or sex affected, but black skin is less susceptible
Clinical
manifestations
Acute: papules, vesicles, bullae with surrounding erythema; crusting, oozing, and pruritis may be present Chronic: erythematous base, thickening with lichenification, scaling, and fissuring Drainage of large vesicles may be necessary without removing tops
Aveeno (oatmeal) baths are helpful to decrease itching Antihistamines of choice may be used to decrease itching and edema Use calamine lotion to aid drying
Priority
nursing diagnoses:
Impaired skin integrity Altered comfort
Apply wet dressings to oozing, pruritic lesions to aid in drying and debridement; cool tap water, Burrow`s solution 1 to 40, saline 1 tsp/pint water and silver intrate solution can be used Suppress inflammation with antibacterial solution May use topical steroid creams but do not use on the face
Medication
therapy
Midpotency topical corticosteroids High- potency topical corticosteroids such as amcinonide (Cyclocort) 0.1% or dexamethasone (Decaderm) 0.25% Systemic medications including prednisone, antibiotics, and antihistamines
Urticaria
Urticaria
Description
An itchy rash, single or multiple superficial raised pale macules with red halo; subsides rapidly, no scars or change in pigmentation may be recurrent Acute urticaria is a response to many stimuli
IgE-mediated histamine release from mast cells is sometimes seen in response to drug exposure and subsides over several hours Chronic urticaria persists over 6 weeks; it is not mediated by IgE; it is also associated with fever, chills, arthralgia, myalgia, and headache
Urticaria is a response to massive release from mast cells in the superficial dermis; this can be caused by multiple agents such as drug reaction, food or food additive allergy, inhalant, or ingestion allergy, transfusion reaction, insect bite or sting, bacterial, viral, fungal or helminthic infection, collagen vascular disease, lupus, heat, cold, sunlight, or emotional stress
True urticarial lesions do not remain in the same area of the skin longer than 24 hours lesions that are present 72 hours or longer suggest cutaneous vasculitis as a possible cause
Clinical manifestations
Single or multiple raised, blanched, central wheals surrounded by red flare that is intensely pruritic May occur anywhere on the body Variable size of 1 to 2 mm to 15 to20 cm or larger Resolves spontaneously in less than 48 hours
Therapeutic management
Cool moist compresses help to control itching Avoidance of etiology is known Antihistamine if accidentally reexposed Instruct client that there is risk of lifethreatening reaction on reexposure
Priority nursing diagnoses:
Impaired skin integrity Risk for injury Altered comfort
Medication therapy
Subcutaneous istration of epinephrine 1:1000 for intense itching Antihistamines Histamine (H2) receptor antagonists may enhance effectiveness of conventional antihistamines Cyprohepadine (Periactin) 4 mg every 6 hours for cold urticaria Corticosteroids for pressure urticaria Topical sunscreens and hydroxyzine (Vistaril) for solar urticaria
Benign Conditions
Lentigo
Lentigo
Description
A brown macule resembling a freckle except that the border is usually irregular Benign lentigo resembles a freckle lentigo maligna (pre-melanoma) is a brown or black mottled, irregularly outlined, slowly enlarging lesion in which there are an increased number of scattered atypical melanocytes; it usually occurs on the face; one-third progress to melanoma but transition may take 10 to 15 years Senile lentigo (liver spots) occurs on exposed skin of older white individuals
Clinical manifestations
Benign lentigo: freckle, pigmented, flat, or slightly elevated macule Lentigo maligna: brown/black uneven macule with irregular border which slowly extends Senile lentigo: pigmented flat areas usually on sun-exposed areas
Therapeutic management
Instruct on ABCD of skin lesions: asymmetry, border, color, and diameter Teach to inspect skin routinely and seek professional advice for any noted changes Instruct clients to use sunscreens, hats, or caps when out in the sun to avoid overexposure
Priority nursing diagnoses:
Risk for ineffective health maintenance
Medication therapy
No medication needed for lentigo Lentigo maligna: follow-up by a dermatologist is recommended
Seborrheic Keratosis
Seborrheic Keratosis
Description Benign plaques, beige to brown or even black in color, ranging in size from 3 to 20 mm in diameter with a velvety or warty surface The pathophysiology of this condition involves the proliferation of immature keratinocytes and melanocytes totally within the dermis it affects mainly males 30 years and older
Clinical manifestations
“Stuck-on” brown spots over the trunk which may bleed when irritated by clothing or picked Size varies from 1 to 3 cm May be skin-colored, tan, brown, or black and are usually oval-shaped with a warty, greasy feel Usually present on the face, neck, scalp, back, and upper chest
Therapeutic management
Sunscreens, decrease sun exposure, and avoid tanning Wear hats when outdoors Teach the ABCD of skin lesions that indicate need for evaluation by a healthcare provider
Medication therapy
No medications indicated for seborrheic keratosis May be removed by electrocautery or frozen with liquid nitrogen the area may be hypopigmented after removal
Vitiligo
Vitiligo
Description
Are totally white macules with an absence of melanocytes An acquired, slowly progressive depigmentation in small or large areas of the skin caused by a decrease in active melanocytes Type A: nondermatomal and widespread involved in 75 percent of cases Type B: dermatomal and segmental; 50 percent of cases begins between ages 10 to 30
Clinical manifestations
Loss of pigment with increased sunburning of areas more often occurs around the eyes, mouth, and anus May be pruritic and associated with premature graying
Therapeutic Avoid
management
sun exposure, which may increase differentiation between normal and abnormal skin Skin dyes/cosmetics for blending purposes
Priority nursing diagnoses:
Risk for disturbed body image
Medication therapy
Localized with midpotency steroids Oral systemic steroids are effective in arresting disease progression Depigmenting of normal skin with hydroquinone cream (Melanex)
Pressure Ulcers
Pressure Ulcers
Description
Ischemic lesions of the skin and underlying tissue caused by external pressure that impairs the flow of blood and lymph also known as bedsores and decubitus ulcers
Pressure
ulcers are a common and serious complication affecting the frail, disabled, acutely ill, or immobile client, usually in longterm care and rehabilitation settings Most common sites are over bony prominences, such as elbows, hips, heels, outer ankles, and base of spine over 95 percent of ulcers develop on the lower part of the body
Causes include an uneven application of pressure over a bony hard site high pressure applied for 2 hours (produces irreversible tissue ischemia and necrosis), shearing forces that develop when a seated person slides toward the floor or foot of the bed if supine, frictional forces that develop when pulling a client across a bed sheet, and moisture from incontinence or perspiration
Clinical manifestations:
pressure ulcers are staged according to their characteristics Assessment: risk factors: immobility, malnutrition, and low body weight, hypoalbuminemia, fecal and/or urinary incontinence, bone fracture, vitaminC deficiency, low diastolic blood pressure, age-related skin changes such as diminished pain perception, thinning of epidermis,
loss
of epidermal vessels, altered barrier properties, reduced immunity and slowed wound healing, anemia, infections, peripheral vascular insufficiency, dementia, malignancies, diabetes, CVA, dry skin, and edema
Diagnostic and laboratory test findings:
culture of the wound WBC with differential and sedimentation rate to determine presence of primary or secondary infection if no progression of ulcer, albumin levels may be obtained to determine dietary needs
Therapeutic management
Evaluate risk factors Improve overall nutritional status – adequate protein intake Clean wound each time dressing is changed to remove dead tissue, excess fluid and debris Main body temperature and acidic pH Never use antiseptics and harsh skin cleaners that may harm tissue
Employ pressure reduction via specialized beds Reposition client every 2 hours Use devices such as padding (gel pads), floatation pads, mattress overlays and specialize (such as air-fluidized, oscillating, or kinetic) beds Avoid agents that delay wound healing such as topical corticosteroids, hydrogen peroxide, iodine, and hypochlorite Control fecal and urine incontinence
Avoid massage over bony prominences Use moisture barrier Assess site every 8 to 12 hours; carefully document healing, e.g., state there is a “healing Stage III ulcer, rather than “Stage II ulcer” if ulcer was Stage III and exhibits healing Use absorption dressing if wound has large amounts of exudates and change frequently
Priority nursing diagnoses:
Impaired skin integrity Disturbed body image Risk for infection Pain Risk for imbalanced nutrition: less than body requirements Risk for ineffective thermoregulation Impaired tissue perfusion Risk for impaired physical mobility Anxiety
Planning and implementation
Provide relief of pressure on wound perform ive range of motion and encourage active range of motion exercises Encourage oral high-calorie and high-protein supplements Encourage oral zinc, vitamins A and C, and iron to aid in tissue healing Conduct systemic skin inspection at least once daily Monitor weight and nutrition intake
Clean skin at time of soiling and routine intervals Keep skin well-hydrated and lubricated Avoid exposure to cold, dry environments Document all risk factors and implement strategies Ensure that proper positioning schedules are followed every 2 hours Use pressure reduction aids
Medication therapy
Clindamycin (Cleocin) or gentamycin (Garamycin) may be ordered for complications such as cellulites, osteomyelitis, or sepsis Vitamin C 500 mg b.i.d. and zinc sulfate supplements aid healing Antibiotic prophylaxis will eradicate bacterial component
A 2-week trial of topical antimicrobials should be used only for a clean superficial ulcer that is either not healing or producing a moderate amount of exudates – cultures are necessary to determine whether antifungal or specific antibacterial agents are indicated
Enzymatic debriding agents such as collagenase (Santyl, Granulex), fibinolysin-desoxyribonuclease (Elase), papin (Panafil), or sutilains (Travase) are used with a moisture barrier to protect surrounding tissue Recommended dressings include polyurethane films (Op-SiteTM, TegadermTM), absorbent hydrocolloid dressings (DuodermTM)
Client education
Need for frequent evaluation of all clients with a history of pressure sores, especially if they have limited mobility Nutritional requirements and meal planning Early identification of skin redness to prevent breakdowns Skin cleansing routine Underpads to absorb moisture Repositioning techniques and frequency Need to evaluate and ensure continence and facilities Use of mattress overlays, seat cushions or special mattresses Ways to avoid injuries
Burn Injury
Description: an alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity, or radiation There are several types of burn injury: thermal chemical electrical radiation
Thermal:
results from dry heat (flames) or moist heat (steam or hot liquids) most common type causes cellular destruction that results in vascular, bony, muscle, or nerve complications can also lead to inhalation injury if the head and neck area is affected
Chemical burns
are caused by direct with either acidic or alkaline agents they alter tissue perfusion leading to necrosis
Electric
burns:
severity
depends on type and duration of current and amount of voltage it follows the path of least resistance (muscles, bone, blood vessels, and nerves) sources of electrical injury include direct current, alternating current, and lightning
Radiation burns:
are usually associated with sunburn or radiation treatment for cancer usually superficial extensive exposure to radiation may lead to tissue damage and multisystem injury
Emergent phase of burn management:
the emergent/resuscitative stage lasts from the onset of injury through successful fluid resuscitation during this stage, it is determined whether the client is to be transported to a burn center for complex intervention depending on onset of injury, identification of burn source, and complicating factors
Classification of burn depth:
done according to the depth of damaged tissue
Superficial
thickness (formerly first-degree):
involves the epidermis only and is recognized by characteristics of erythema, absence of blisters for 24 hours, local pain; healing occurs spontaneously in 3 to 5 days with no scar formation
Superficial thickness (formerly first-degree)
Superficial partial thickness (formerly second-degree):
involves the epidermis and dermis, characterized by moist areas that are red to ivory whit in color, blisters form immediately; area is painful because touch and pain receptors are intact; area heals with greater or lesser amounts of scarring within 21 to 28 days
Deep partial thickness (formerly seconddegree):
involves possibly the entire layer of the dermis, and is more severe than a superficial partial thickness burn skin appendages are left intact area has a dry waxy whitish appearance and may be difficult to differentiate initially from full-thickness burns may heal spontaneously in about 1 month although skin grafting is often done to close the wound, accelerate healing, reduce scarring, and reduce risk of infection
Superficial partial thickness (formerly second-degree)
Full thickness (formerly third-degree):
involves destruction of all skin elements with coagulation of subdermal plexus muscle and tendons may be involved
Full thickness (formerly third-degree)
An
estimate of the burn size is calculated using the “Rule of Nines” or the Lund and Browder method each chart s for 100 percent of the total body surface area (TBSA) although the Lund and Browder method takes into the client`s age when estimating body surface area
Severity of burn is classified using the American Burn, and major burn; these categories help determine treatment Nursing assessment: history of injury, estimate burn extent and depth, obtain past medical history and medication history including date of last tetanus prophylaxis assess for other concurrent injuries
Diagnostic and lab test findings:
may have elevated hematocrit and decreased hemoglobin caused by fluid shift decreased sodium and increased potassium caused by damage to capillary and cell membranes
elevated
BUN and creatinine caused by dehydration myoglobin in urinalysis possible deterioration of arterial blood gases oxygen saturation readings depending on respiratory status
Priority nursing diagnoses:
Risk for deficient fluid volume Risk for infection Impaired physical mobility Imbalanced nutrition; less than body requirements
Ineffective
breathing pattern Impaired tissue perfusion Risk for impaired gas exchange Anxiety Risk for ineffective thermoregulation Pain Impaired skin integrity
Therapeutic management First aid: douse flames with water or smother them with a blanket, coat, or other similar object cool a scald burn with use of cool water flush chemical burns copiously with water or other appropriate irrigant after dusting away any dry powder if present remove client from with an electrical source only after current has been shut off
Priority care is on ABCs:
airway, breathing, and circulation; assess for smoke inhalation injury (singed nares, eyebrows or lashes; burns on the face or neck; stridor, increasing dyspnea) give oxygen (up to 100 percent as prescribed), being prepared for possible intubation and mechanical ventilation if severe inhalation injury or carbon monoxide inhalation has occurred assess for signs of shock caused by fluid shifts (increase pulse, falling BP and urine output, pallor, cool clammy skin, deteriorating level of consciousness)
Fluid resuscitation:
Brooke formula uses 2 ml/kg/% TBSA burned (3/4 crystalloid plus ¼ colloid) plus maintenance fluid of 2,000 mL D5W per 24 hours Parkland (Baxter) formula uses 4 mL/kg/% TBSA burned per 24 hours (crystalloid only – lactated Ringer`s) both formulas give half of 24 hour total in the first 8 hours, and the second half over the next 16 hours
Other considerations:
remove all rings and jewelry to avoid tourniquet effect caused by swelling/edema of burn site provide cardiac monitoring for the first 24 hours after an electrical burn
Medication therapy:
pain therapy, tetanus prophylaxis, topical antimicrobial as well as systemic antibiotics
Client education:
focuses in this phase on brief explanations about the injury, treatments, and ongoing nursing care
Acute phase of burn management: this phase begins with the start of diuresis (usually 48 to 72 hours post-burn) and ends with closure of the burn wound
Clinical manifestations:
vary depending on cause, depth and TBSA of burn associated symptoms arising from other organ systems may include nausea and vomiting, pain, skin redness, chills, respiratory distress, and hypovolemia
Therapeutic management:
wound care management (debridement, dressing changes, hydrotherapy, possible escharotomy, wound grafting) nutritional therapies (high-calorie, highprotein diet with vitamins and minerals) infection control pain management psychosocial physical therapy maintain fluid/hydration status maintain heated environment
Medication therapy:
topical and/or systemic antibiotic therapy pain control with opioid analgesics is usually required
Rehabilitative phase of burn management: this phase begins with wound closure and ends when the client returns to the highest level of health restoration
Clinical manifestations:
depend on cause, body surface area affected and depth may have immobility or restriction of mobility of affected area scarring is possible
Therapeutic management:
obtain psychosocial evaluation provide and management arrange counseling if necessary prevent immobility contractures with exercises or ongoing physical therapy assist in returning to work, family and social life use preventative measures for scar formation (such as burn garments) assess home environment for needs and accessibility assess pain management needs
Medication therapy:
ongoing pain management antibiotic therapy as necessary
Client education
Environmental safety use low temperature setting for hot water heater ensure access to and adequate number of electrical cords/outlets, isolate household chemicals avoid smoking in bed Use of household smoke detectors with emphasis on maintenance
Proper storage and use of flammable substances Evacuation plan for family Care of burn at home Signs and symptoms of infection How to identify risk of skin changes Use of sunscreen to protect healing tissue and other protective skin care measures
Epidermis
Stratum basale Stratus spinosum Stratum granulosum Stratum lucidum Stratum corneum
Dermis
Papillary layer: contains capillaries and receptor sites for touch and pain Reticular layer: contains receptors for deep touch as well as sweat and sebaceous glands
Subcutaneous tissue Appendages
Hair Nails Glands Apocrine: sweat glands located in the axilla, anus, and genital area Eccrine: sweat glands located on the forehead, hands, and soles of the feet Sebaceous: glands located throughout the body that secrete sebum and that are highly influenced by increased hormones, especially adrogens
Basic Functions of the Integumentary System
Epidermis
Dermis
Subcutaneous tissue
Appendages
Disorders of the Integumentary System
Problems caused by vascularity
Spider angioma:
a flat, bright red spot with radiating blood vessels at the edges commonly found on the upper body varies in size from a tiny dot up to 1.5 to 2 cm spider angiomas are caused by vascular dilation of the vessels commonly seen with high estrogen levels, pregnancy, liver disease, and/or vitamin B deficiency
Petechiae:
flat red spots approximately 1 to 2 mm in diameter that do not change in color when blanched; these are caused by tiny capillaries that have broken, possibly caused by thinning of the blood (anticoagulant effect), liver disease, vitamin K deficiency, or septicemia
Purpura:
purple/blue-appearing patch varies in size and shape caused by a bleeding disorder or broken blood vessels and may appear throughout the body
Primary skin lesions
Macule:
nonpalpable, flat lesion that has color and measures<1 cm examples: freckles, chloasma
Papule:
elevated palpable mass, measuring less than 0.5 cm examples include warts and moles
Nodule: an elevated firm lesion with a circumscribed border that measures approximately 1 to 2 cm
Vesicle: fluid-filled,
elevated mass that measures less than 0.5 cm if the fluid mass measures greater than 0.5 cm, the mass is termed a bulla examples of vesicles include chickenpox, small burns, and herpes virus lesion
BULLA
Plaque:
elevated group of papules that have convalesced into one lesion measuring greater than 0.5 cm examples are actinic keratosis and psoriasis
Pustule:
elevated, serous (pus)-filled vesicle that can measure any size examples include acne and boils
Wheal:
variable-sized, elevated erythemic lesion with an irregular border that contains fluid in the tissue of the skin examples include insect bites and hives
Secondary skin lesion
Atrophy:
dry, thin, taut skin that appears wasted from loss of collagen an example is aged skin hydration with fluids and keeping skin wellmoisturized with emollients such as Eucerin TM cream are helpful for this condition
Crusts:
dried pus or blood on the skin surface resulting from a vesicle that has ruptured examples of crusts include the final stages of chickenpox lesions or impetigo lesions
Erosion:
superficial indentation of the skin that results from a previous lesion an example of erosion is a scratch mark that has not healed over time
Fissure:
linear break in the skin with sharp edges, extending into the dermis examples include athlete`s foot or cracks in the corner of the mouth from chapped lips
Scales:
Scar:
dry, dead skin that sloughs off the skin surface and that may be dry or greasy examples include dandruff or psoriasis the flat connective tissue resulting from healing over the site of previous injury, which may vary in size, color, and shape examples include healed surgery incisions or acne scars
Ulcers:
deep excavations in the skin; they may vary in size and shape and extend into the dermis or subcutaneous tissue examples include chancres and pressure ulcers
Chronic Dermatologic Problems
Eczema
Eczema
Description:
inflammatory response in which the skin appears erythmic, scaly, dry and thickened may appear in various stages, depending on the type (e.g., infantile eczema vs. adult eczema) etiology is unknown eczema is characterized by lymphohistiocytic infiltration of the vessels of the skin Common form of chronic dermatitis
Clinical manifestations:
are generally secondary to scratching of the skin dry, pruritic skin that appears thickened and discolored may even cause a break in the skin in which bleeding or oozing occurs lesions may appear as papules or pustules that can lead to excoriation
Therapeutic management
Bath: advise the client not to use harsh soaps; avoid frequent bathing Wet dressings of Burow`s solution may be used in severe cases Emollients: frequent use of emollients (EucerinTM, AquaphorTM) is recommended Allergens: remove all triggers and/or allergens; avoid skin with all wool products and lanolin preparations
Priority nursing diagnoses:
Impaired skin integrity Altered comfort
Medication therapy:
Antihistamines such as diphenhydramine hydrochloride (BenadrylTM) severe cases may require topical or oral steroids for brief periods antipruritic
TYPES
OF ECZEMA 1. Infantile eczema - lesions begin in the cheek and progress to the extremities and trunk - lesions starts as vesicles, which can result in oozing and crusting of excoriated areas 2. Adult atopic eczema - markedly dry skin that extremely itchy - excoriation,lichenification and even scarring can lead to leathery areas in the antecubital and popliteal areas
3. Nummular eczema - Lesions developed as coined shaped papulovesicular patches on the arms and legs - excoriation and subsequent bacterial infections can lead to lichenification
Psoriasis
Psoriasis
Description:
chronic, inflammatory skin disorder lesions appear as whitish, scaly plaques on the scalp, knees, and/or elbows no known etiology thought to be a multifactorial disease in which a T-lymphocyte mediated dermal immune response occurs most client with psoriasis have a family history of the disease
Clinical manifestations:
dry, scaly rash that may appear a silvery scales or plaques usually found on the scalp, knees, or elbows
Priority nursing diagnoses:
Impaired skin integrity Altered comfort
Therapeutic management:
direct sun exposure to the skin site may be beneficial for some clients emollients: frequent use of emollients and keratolytic agents are beneficial for scalp psoriasis topical steroids antihistamines may be used for pruritus
Seborrheic Dermatitis
Seborrheic Dermatitis Description: common
chronic skin condition occurring in areas of active sebaceous glands, such as the face, scalp, body folds, sternal area, and axilla appears as an erythematous scaling lesion that may appear dry or greasy etiology is unknown but possible causes are believed to be hormonal influence, nutritional deficiency, neurogenic influence, dysfunction of the sebaceous glands, and/or fungal infection
Clinical manifestations:
erythmic, scaly lesions that appear in varying degrees (oily or flaky dry skin), pruritic, and may cause secondary bacterial infections common sites include scalp, eyebrows, nose, ears, sternal area, and axilla seen more frequently in colder weather periods, and it is thought to be caused by decreased humidification and decreased exposure to sunlight
Therapeutic management:
scalp treatment: selenium sulfide 2.5 percent suspension or coal tar shampoos and topical steroid creams
Priority nursing diagnoses:
Impaired skin integrity Altered comfort Risk for infection
Malignant Neoplasms
Actinic Keratosis
Actinic Keratosis
Description:
pre-malignant macules found on the skin surface of fair skinned individuals who are 50 years of age or older, but can be seen in high-risk individuals at any age development occurs because of chronic sun exposure to the skin light-skin complexion are at the highest risk considered pre-malignant lesions approximately 1 percent will progress to squamous cell carcinoma
Clinical manifestations:
erythematous, rough, and shiny-textured macules may appear as a single macule or in groups; commonly seen on the face, ears, scalp, lips, neck, and hands
Therapeutic management
Prophylactic treatment is recommended to prevent development these lesions Protection from ultraviolet rays of the sun with the use of clothing and sunscreens are recommended when exposed to sunlight Biopsy and removal of the lesion is recommended if changes in the lesion occur; these changes include the color, border, size, and shape of the lesions
Basal Cell Carcinoma
Basal Cell Carcinoma
Description:
abnormal cell growth of the basal layer of the epidermal skin most common contributor to this growth is ultraviolet rays from sunlight exposure; basal cells do not mature appropriately into keratinocytes, which results in neoplastic growth of the cells the surrounding tissue is also destroyed least aggressive type of skin cancer and rarely metastasizes to other organs
Clinical manifestations:
characteristics of the five types of basal cell carcinoma: Nodular basal cell carcinoma: small, firm papule, which appears as pearly, white, pink, or flesh-colored, and is commonly seen on the face, neck, and/or head
Nodular Basal Cell Carcinoma
Superficial
this papule or plaque is the second most common lesion and is commonly seen on the trunk and extremities
Pigmented
basal cell carcinoma:
basal cell carcinoma:
this tumor is less common and usually found on the head, neck, or face; it has the ability to concentrate melanin, which causes deeper pigmentation of the center of the tumor
Superficial Basal Cell Carcinoma
Pigmented Basal Cell Carcinoma
Morpheaform
basal cell carcinoma:
least common form this tumor is found on the head and neck, appearing like a tumor with finger-like projections (usually ivory-or flesh-colored) and typically resembles a scar it has the ability to invade and destroy adjacent tissue and structures
Morpheaform Basal Cell Carcinoma
Keratotic found
basal cell carcinoma:
on the preauricular or postauricular
area contains both basal cells and squamous cells that keratinize if removed, this tumor is likely to recur high risk of metastasizing to other structures
Therapeutic management
Monitor progress of growth of all lesions lesions > 2 cm have a high reoccurrence rate suspicious lesions are excised and sent for pathological examination
Educate
clients regarding importance of monitoring lesions and early identification of new lesions suggest monthly assessment of the skin by the client and periodic screening based on symptoms by healthcare provider Encourage protection from ultraviolet light exposure by using sunscreen with SPF > 15 and wearing clothing such as hats and clothing to protect the skin
Priority nursing diagnoses:
Impaired skin integrity Risk for disturbed body image Fear or anxiety
Medication therapy: none
Kaposi`s Sarcoma
Kaposi`s Sarcoma
Description:
skin cancer of the endothelial lining of the small blood vessels, seen most commonly on the face, nose, and ears etiology is unknown a cancer speculated to be related to an infective agent such as a retrovirus, such as the virus that causes acquired immunodeficiency syndrome (AIDS)
Clinical manifestations
Vascular lesions (macules, papules, nodules) that can affect the skin and viscera Over time the lesions enlarge and become confluent, forming large masses as these masses enlarge, the tissue below the mass becomes involved and the tumor then invades the lymphatic tissue, which may then result in varying degrees of lymphoedema, primarily affecting the genitalia and lower extremities
As the disease progresses, this tumor may interfere with internal organ function may cause bleeding to the point of hemorrhage (commonly seen as a late sign) Initially Kaposi`s sarcoma may be symptom-free pain maybe experienced in the later stage
Therapeutic management:
Priority nursing diagnose:
isolated lesions may be removed by excision cryotherapy, and/or local radiation for comfort and/or cosmetic treatment Impaired skin integrity Fear or anxiety Risk for disturbed body image
Medication therapy:
chemotherapy treatment can be used as a single agent or a combination treatment
Nonmelanoma: Squamous Cell Carcinoma
Nonmelanoma: Squamous Cell Carcinoma
Description
The most common type of skin cancer fair-skinned males tend to have a higher incidence majority occurring from 30 to 60 years of age occurs on areas of the skin that are frequently exposed to ultraviolet light, such as the face, ears, nose, lips, and hands; grows quicker , more aggressive, and is more likely to metastasize than basal cell carcinoma
Etiology and pathophysiology
The etiology multifactoral Environmental causes include ultraviolet radiation, chemicals, physical trauma, and pollution With exposure of ultraviolet light to the skin, the rays penetrate the tissue and alter normal DNA and suppress the body`s T-cell and B-cell immunity, producing tumors of the squamous epithelial or mucous membranes
As the tumor grows, the cells increase in size and an irregular shape is formed Tumors may proliferate and invade the dermal layer of the skin may also present from preexisting skin lesions, such as old scars these tumors may proliferate into the dermal structure and can cause metastasis by the lymphatic tissue
Clinical manifestations
Squamous cell carcinoma mat present as a small fleshy colored papule that is firm to touch As the tumor grows, the color may change and appear erythemic, sore, and/or even bleed if touched
Therapeutic management
Recommended management is removal of the tumors by: cryotherapy surgical excision electrodesiccation radiotherapy The cure rate is approximately 90 percent recommended to remove these tumors as soon as identified to prevent the person`s risk of metastasis
Nursing management
teaching methods to prevent further tumors from arising minimizing sun exposure wear protective clothing wear sunscreen with a SPF of 15 or greater avoid tanning booths
Priority nursing diagnoses:
Impaired skin integrity Ineffective health maintenance Fear or anxiety Risk for disturbed body image
Medication therapy: none
Bacterial infection
Bacterial Infections (Pyodermas) It
includes a variety of acquired skin lesions characterized by erythema and pustules
Most
common causative organisms are gram-positive staphylococci and betahemolytic streptococci
Impetigo
Impetigo
Description:
A superficial skin infection that initially appears as an erythemic vesicle and later changes to a honey-colored crusted lesion most commonly seen in children but occasionally affects adults An alteration in skin integrity occurs, and bacteria invade the epidermis and cause an infection most common organisms are Staphylococcus aureas and group-A beta-hemolytic streptococcus
Clinical manifestation
lesions are commonly found on the face, arms, legs, and buttocks appear as thin erythemic vesicles, which then becomes honey-colored crusts or erosions may occur as a single lesion or several lesions that have convalesced and appear as a group of lesions
Therapeutic management:
encourage good hand washing with hot soapy water to prevent spreading the bacteria to others
for recurrent lesions, a culture of the site is obtained to isolate the pathogens
Priority
nursing diagnosis:
Ineffective
Medication topical
health maintenance
therapy:
antibiotics For severe cases, systemic antibiotics are recommended
Cellulitis
Cellulitis
Description
A bacterial infection of the dermal and subcutaneous tissues with lesions appearing in various stages, ranging from vesicles, bullae, abscesses, and plaques
most
commonly seen in adults group-A beta-hemolytic Streptococcus pyogenes and Staphylococcus aureus being the most frequent organisms involved occurs because of a break in the integrity of the skin (abrasion, laceration, etc.) may also occur secondary to a skin lesion
Clinical manifestations:
cellulites is characterized by an erythemic, swollen, tender-to-touch area of the skin at the site of entry of the bacteria; associated symptoms include fever, chills, malaise, and anorexia with associated regional lymphadenopathy
Therapeutic management:
rest, elevation of the extremity, moist heat to the site for comfort consider culture and sensitivity of tissue site for severe cases for necrotic tissue, surgical excision and debridement are recommended along with antibiotic therapy
Priority
nursing diagnosis:
Impaired
skin integrity
Medication antibiotic
therapy:
therapy
Folliculitis Staphylococcal
infection in one or more hair
follicles Appears
in pustule formation; inflammation occurs resulting in erythema
It
is commonly seen in the beard area of men who shave and on women’s leg
Furuncle (boils) It
is an acute inflammation arising deep in one or more hair follicles and spreading into the surrounding dermis
Manifest
a deep, coin sized erythematous pustule, lesions are painful and usually develops a cellulitis with a white center on the skin surface
Carbuncle It
refers to the group of infected hair follicles
A
subcutaneous infection develops into red, painful mass which can spread and cause septicemia
It
occurs most commonly at the back and upper neck
Stye/ Hordeolum It
manifest as a pink, swollen area in the eyelid
Nursing Management ister
medications Prevent infection and infection transmission - Instruct the client not to squeeze a boil or pimple Instruct the client to bathe at least daily with bactericidal soap Isolate drainage in severe cases of folliculitis, furuncles or carbuncles Promote comfort measures - ive treatments - apply warm, moist compresses Provide client and family teaching
Viral infection
Herpes simplex virus (Type 1, Type 2)
Herpes simplex virus (Type 1, Type 2)
Description
manifested by vesicles on the oral mucosamouth or lips, which is HSV Type 1, or in the genital mucosa (HSV Type II) Herpes simplex virus (HSV) can occur at any age The virus is spread by direct of contaminated body fluids incubation period range of 2 to 14 days
The
virus occurs in three stages
Primary – blisters occur on the mucosa or lips; malaise and fever are also common symptoms Recurrent infections – outbreaks may occur at any time and are commonly precipitated by stress and illness; symptoms are usually milder than the primary; commonly present with a prodrome of tingling, itching, or a burning sensation at the site prior to the outbreak of lesions Latency period – the virus remains dormant in the body
Clinical manifestations
The primary symptoms include: malaise, fever, and vesicles appearing on the mucosa Secondary symptoms include: prodrome of tingling, burning sensation prior to the outbreak of vesicles on the mucosa latency period is asymptomatic
Therapeutic management:
advise rest encourage good handwashing technique to prevent spreading the virus comfort measures such as petroleum jelly or lip balm may be used for oral lesions
to
prevent spreading the virus, avoid close with others while lesions are present to prevent HSV Type 2, advise the use of latex condoms to prevent spreading genital lesions Priority
nursing diagnosis:
Impaired
tissue integrity Altered comfort
Medication therapy:
acetaminophen (Tylenol) or camphophenique may be used for comfort as needed antiviral medications such as acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex) may be used to check further replication of the virus and diminish symptoms if started within 24 to 48 hours after initial onset of lesions
Herpes Zoster
Herpes Zoster
Description
A viral infection manifested by vesicles on the skin commonly seen in older adults and the elderly it is estimated to occur in approximately 20 percent of the U.S. population Herpes zoster is a reactivation of the varicella virus, which has been dormant for many years, in the dorsal root ganglia
Clinical manifestations:
vesicular rash on the skin that usually follows one dermatome clusters of vesicles are common along with symptoms of tingling, itching, burning, and even pain at the site of the lesions the client may experience fatigue, malaise, fever, and headache in addition to the local discomfort of the rash
Therapeutic management:
comfort measures include wet dressings or soaks (Burow`s solution) at the lesion sites two to three times a day oatmeal baths (Aveeno TM) are soothing and help to dry up lesions rest is recommended the virus may be transmitted to others; therefore care should be taken to avoid persons at risk lesions should be monitored for secondary bacterial infections
Priority nursing diagnoses:
Impaired skin integrity Altered comfort
Medication therapy:
antiviral medications may be used if therapy is started within 24 to 48 hours after the outbreak of vesicles current medications include acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) acetaminophen (Tylenol) and ibuprofen (Motrin) may be used for discomfort
Fungal infections
Candidiasis
Candidiasis
Description
Infection caused by candida albicans, a yeast-like fungus that most often causes superficial cutaneous infections Symptomatic infections occur on moist cutaneous sites and mucosal surfaces if local immunity is disturbed
can affect all ages diaper rash in infants summertime inframammary rash in women vaginitis in premenopausal women oral candidiasis in immunocompromised clients buttocks and perineal rash in incontinent clients Risk factors moist, warm, or altered skin integrity systemic antibiotics pregnancy, birth control use poor nutrition diabetes, or chronic illnesses immunosuppression
Clinical manifestations:
lesions are bright red, smooth macules with a macerated appearance and a scaling elevated border characteristic “satellite” lesions are small, similar-appearing macules outside the main lesion
Oral candidiasis - known as thrush and is characterized by white, milky removable plaques on the oral mucosa associated symptoms may include a burning sensation or decreased taste Vulovaginitis - found on the vaginal mucosa and can spread to the pertineum and groin; satellite lesions are usually present other signs and symptoms include excessive itching and a thick, white, curdlike vaginal discharge
Perineal/diaper and skin-fold rash - occurs on the perigenital and perianal areas and can extend to the inner thighs and buttocks other areas affected include axilla, umbilical area, and under the breasts erythema, papules, pustules, and a scaling border are characteristic Balanitis - inflammation of the glans and the prepuce of the penis that typically present as flattened pustules with edema, scaling, erosion, burning, and tenderness
Paronychial infection - erythema, edema, and tenderness of the nail folds a creamy, purulent discharge may be expressed with pressure on the nail the nails usually become discolored and have ridging
Candida organisms may also be a causative agent in otitis externa and scalp disorders
Therapeutic management:
diagnosis is made by culture of scrapings or by microscopic examination of scaling with potassium hydrochloride (KOH) preparation Avoid sharing linens or personal items Use clean towel and washcloth daily Dry all skin folds, avoid frequent immersion of hands in water Wear clean cotton underwear daily
For vaginal candida, avoid tight clothing and pantyhose, bathe more frequently and dry genital area thoroughly may need to treat sexual partner at the same time to avoid reinfection or have the partner use condoms until resolved avoid douching and change perineal pads frequently
For vaginal candida, avoid tight clothing and pantyhose, bathe more frequently and dry genital area thoroughly may need to treat sexual partner at the same time to avoid reinfection or have the partner use condoms until resolved avoid douching and change perineal pads frequently
Priority nursing diagnosis:
Impaired tissue integrity Acute pain
Medication therapy
Oral candidiasis: nystatin, clotrimazole, and in recurrent cases, ketoconazole, fluconazole, or itraconazole; liver function tests must be monitored because of risk of hepatotoxicity Perineal: topical treatment with nystatin ointments BID Balantitis: topical treatment with imidazole cream or nystatin powder BID
Paronychial : topical imidazole cream or application of
2 percent gentian violet; for nonresponsive cases, systemic ketoconazole or fluconazole; systemic medications require monitoring of liver function tests because of risk of hepatotoxicity Hair/scalp: antifungal shampoo Vulvovaginitis: vaginal creams/suppositories or treatment with DiflucanTM
Infestations
Pediculosis
Pediculosis
Description
An infestation of the skin or hair by the species of blood- sucking lice capable of living as external parasites on the human host Pediculosis capitis is the head louse, the size of a sesame seed, clear in color when hatched but becomes grayish-white to red/brown after maturing
Head lice infestation is very common among school age children of all socioeconomic backgrounds and spread by sharing combs, hats, and scarves Pediculosis pubis, also known as “crabs”, infests the genital area and is one of the most common sexually transmitted diseases
Pubic
lice can spread by sexual Nits/eggs attach to the hair shaft by a cement-like/cocoon-like structure and are difficult to remove Lice live up to 30 days and a female can lay up to 100 eggs
Clinical manifestations
Intensive pruritis is the most common symptom that may result in excoriations Head lice may resemble dandruff flakes; however, they are not easily brushed off Papular urticaria may be found at the neck or pubic area
Therapeutic management
Nits must be mechanically removed 50/50 white vinegar-water solution may loosen the nits olive oil may also be used nit comb is used to remove nits from the hair shafts
lice
may also be removed by fingers or tweezers; nits remove more easily by back-combing the hair To treat eyelashes apply petrolatum to lashes b.i.d. for 10 days; lice will either suffocate or slide off
Educate children and parents about mode of transmission (person to person) and preventative measures, such as not sharing combs, brushes, hats, scarves, helmets, headphones, bedding, or sleeping bags Coats and hats should be hang separately and not touching each other
Sleeping
material should be labeled and kept separately in plastic bags All family need to be examined and treated at the same time Soak personal hair items in 2 percent Lysol or pediculocide for 1 hour Shaving hair is not found to be helpful Machine-wash all washable clothing used in the last 48 hours and dry in the dryer for at least 20 minutes
Place unwashable items in airtight plastic bags for a period of 1 week to kill lice Upholstered furniture or pillows may be ironed with a hot iron Clean any item in with hair with 2 percent Lysol or pediculocide Vacuum mattresses, rugs, upholstered furniture, and stuffed animals regularly
Medication therapy
For pediculosis capitis: permethrin (Nix), pyrethrin shampoo (Rid), or lindane (Kwell) shampoo left on 5 to 10 minutes and then washed off; lindane can be repeated in 1 week; due to neurotoxicity of lindane, it should not be used by children, nursing or pregnant women, individuals with known seizure disorders, or on open skin
For pediculosis pubis: treatment includes lindane, pyrethrin (Rid) or permethrin (Nix) as a shampoo left on for 10 minutes or as a lotion left on for several hour Co-trimoxazole (Bactrim DS): b.i.d. for 3 days has been shown to be effective; a second therapy 10 days later may be necessary to kill emerging nits before they reproduce
Scabies
Scabies
Description
A contagious disease caused by infestation of the skin by the mite Sarcoptes scabiei var hominis; the impregnated mite burrows into the skin and remains there for life (approximately 30 days), laying 2 to 3 eggs per day; the eggs hatch in 3 to 4 days and reach maturity in 4 days, migrate to the skin surface, mate, and repeat the cycle
more common in people who don`t have bathing facilities or access to clotheswashing facilities mite can live in clothing fibers and can be transmitted by of infected clothing or bed linens Pathological findings by skin biopsy of a nodule will reveal portions of the mitealthough rarely performed diagnosis is usually made by clinical presentation of burrows, vesicles, and nodules
Clinical manifestations
Presents as a generalized pruritic rash particularly of the hands, wrists, elbows, axillary areas, breasts, abdomen, or genitals Itching may become intense increased warmth of the skin and nocturnal itching is a classic symptom, since mites tend to have increased movement at night
Lesions may be erythematous, crusted papules, or purplish nodules, which may be accompanied by flesh-colored, raised burrows (threadlike linear ridges a few millimeters in length with a minute black dot at one end) clients develop itch approximately 10 to 14 days after exposure exposure to hot water or steam also can increase pruritis
Therapeutic management
Close family and personal s must be treated as well, even if there are no apparent signs or symptoms All bed clothing, linens, unwashed worn clothing, and stuff animals should be washed and dried in a hot dryer because the dryer kills the mite
Mites
and eggs may be killed by placing items in airtight plastic bags for 7 days since the mite cannot live off the host more than 3 days; mites can live 24 to 36 hours in room conditions and longer in humid environments Relief from itching may not occur for 3 to 6 weeks after treatment because of hypersensitivity of the skin to debris left in the burrow
Lotions/creams should be applied from the neck down, using a toothbrush to get under fingernails and toenails; the lotion is showered off 8 to 12 hours later
Priority nursing diagnoses:
Impaired skin integrity Altered comfort
Medication therapy Permethrin 5% cream (Elimite) is the treatment of choice; a second application in 48 hours is sometimes recommended Crotamiton 10% (Eurax) is less toxic but is also slightly less effective therefore application for 2 nights is advised
Lindane 1% cream or lotion (Kwell) is the least expensive but has the potential for neurotoxicity and should not be used by children, nursing or pregnant women, people with a known seizure disorder, or any widespread excoriations/open skin; treatment after 1 week Systemic antipruritics May require emollients and midpotency corticosteroids after using scabicide to suppress hyperreactivity caused by the mites
Allergic reactions
Dermatitis
Dermatitis Description An
eruption of the skin related to with an irritating substance or allergen primary irritant dermatitis affects individuals exposed to specific irritants and produces discomfort immediately
Common irritants include chemicals, dyes, metals, and latex gloves allergic dermatitis affects only individuals previously sensitized to the ant it represents a delayed hypersensitivity reaction most common are poison ivy, sumac, and oak
dermatitis an inflammation caused by an external irritant or allergic reaction mediated by IgE the epidermal reaction is caused by Tlymphocytes the location of the rash helps provide clues to the offending antigen there is no specific age or sex affected, but black skin is less susceptible
Clinical
manifestations
Acute: papules, vesicles, bullae with surrounding erythema; crusting, oozing, and pruritis may be present Chronic: erythematous base, thickening with lichenification, scaling, and fissuring Drainage of large vesicles may be necessary without removing tops
Aveeno (oatmeal) baths are helpful to decrease itching Antihistamines of choice may be used to decrease itching and edema Use calamine lotion to aid drying
Priority
nursing diagnoses:
Impaired skin integrity Altered comfort
Apply wet dressings to oozing, pruritic lesions to aid in drying and debridement; cool tap water, Burrow`s solution 1 to 40, saline 1 tsp/pint water and silver intrate solution can be used Suppress inflammation with antibacterial solution May use topical steroid creams but do not use on the face
Medication
therapy
Midpotency topical corticosteroids High- potency topical corticosteroids such as amcinonide (Cyclocort) 0.1% or dexamethasone (Decaderm) 0.25% Systemic medications including prednisone, antibiotics, and antihistamines
Urticaria
Urticaria
Description
An itchy rash, single or multiple superficial raised pale macules with red halo; subsides rapidly, no scars or change in pigmentation may be recurrent Acute urticaria is a response to many stimuli
IgE-mediated histamine release from mast cells is sometimes seen in response to drug exposure and subsides over several hours Chronic urticaria persists over 6 weeks; it is not mediated by IgE; it is also associated with fever, chills, arthralgia, myalgia, and headache
Urticaria is a response to massive release from mast cells in the superficial dermis; this can be caused by multiple agents such as drug reaction, food or food additive allergy, inhalant, or ingestion allergy, transfusion reaction, insect bite or sting, bacterial, viral, fungal or helminthic infection, collagen vascular disease, lupus, heat, cold, sunlight, or emotional stress
True urticarial lesions do not remain in the same area of the skin longer than 24 hours lesions that are present 72 hours or longer suggest cutaneous vasculitis as a possible cause
Clinical manifestations
Single or multiple raised, blanched, central wheals surrounded by red flare that is intensely pruritic May occur anywhere on the body Variable size of 1 to 2 mm to 15 to20 cm or larger Resolves spontaneously in less than 48 hours
Therapeutic management
Cool moist compresses help to control itching Avoidance of etiology is known Antihistamine if accidentally reexposed Instruct client that there is risk of lifethreatening reaction on reexposure
Priority nursing diagnoses:
Impaired skin integrity Risk for injury Altered comfort
Medication therapy
Subcutaneous istration of epinephrine 1:1000 for intense itching Antihistamines Histamine (H2) receptor antagonists may enhance effectiveness of conventional antihistamines Cyprohepadine (Periactin) 4 mg every 6 hours for cold urticaria Corticosteroids for pressure urticaria Topical sunscreens and hydroxyzine (Vistaril) for solar urticaria
Benign Conditions
Lentigo
Lentigo
Description
A brown macule resembling a freckle except that the border is usually irregular Benign lentigo resembles a freckle lentigo maligna (pre-melanoma) is a brown or black mottled, irregularly outlined, slowly enlarging lesion in which there are an increased number of scattered atypical melanocytes; it usually occurs on the face; one-third progress to melanoma but transition may take 10 to 15 years Senile lentigo (liver spots) occurs on exposed skin of older white individuals
Clinical manifestations
Benign lentigo: freckle, pigmented, flat, or slightly elevated macule Lentigo maligna: brown/black uneven macule with irregular border which slowly extends Senile lentigo: pigmented flat areas usually on sun-exposed areas
Therapeutic management
Instruct on ABCD of skin lesions: asymmetry, border, color, and diameter Teach to inspect skin routinely and seek professional advice for any noted changes Instruct clients to use sunscreens, hats, or caps when out in the sun to avoid overexposure
Priority nursing diagnoses:
Risk for ineffective health maintenance
Medication therapy
No medication needed for lentigo Lentigo maligna: follow-up by a dermatologist is recommended
Seborrheic Keratosis
Seborrheic Keratosis
Description Benign plaques, beige to brown or even black in color, ranging in size from 3 to 20 mm in diameter with a velvety or warty surface The pathophysiology of this condition involves the proliferation of immature keratinocytes and melanocytes totally within the dermis it affects mainly males 30 years and older
Clinical manifestations
“Stuck-on” brown spots over the trunk which may bleed when irritated by clothing or picked Size varies from 1 to 3 cm May be skin-colored, tan, brown, or black and are usually oval-shaped with a warty, greasy feel Usually present on the face, neck, scalp, back, and upper chest
Therapeutic management
Sunscreens, decrease sun exposure, and avoid tanning Wear hats when outdoors Teach the ABCD of skin lesions that indicate need for evaluation by a healthcare provider
Medication therapy
No medications indicated for seborrheic keratosis May be removed by electrocautery or frozen with liquid nitrogen the area may be hypopigmented after removal
Vitiligo
Vitiligo
Description
Are totally white macules with an absence of melanocytes An acquired, slowly progressive depigmentation in small or large areas of the skin caused by a decrease in active melanocytes Type A: nondermatomal and widespread involved in 75 percent of cases Type B: dermatomal and segmental; 50 percent of cases begins between ages 10 to 30
Clinical manifestations
Loss of pigment with increased sunburning of areas more often occurs around the eyes, mouth, and anus May be pruritic and associated with premature graying
Therapeutic Avoid
management
sun exposure, which may increase differentiation between normal and abnormal skin Skin dyes/cosmetics for blending purposes
Priority nursing diagnoses:
Risk for disturbed body image
Medication therapy
Localized with midpotency steroids Oral systemic steroids are effective in arresting disease progression Depigmenting of normal skin with hydroquinone cream (Melanex)
Pressure Ulcers
Pressure Ulcers
Description
Ischemic lesions of the skin and underlying tissue caused by external pressure that impairs the flow of blood and lymph also known as bedsores and decubitus ulcers
Pressure
ulcers are a common and serious complication affecting the frail, disabled, acutely ill, or immobile client, usually in longterm care and rehabilitation settings Most common sites are over bony prominences, such as elbows, hips, heels, outer ankles, and base of spine over 95 percent of ulcers develop on the lower part of the body
Causes include an uneven application of pressure over a bony hard site high pressure applied for 2 hours (produces irreversible tissue ischemia and necrosis), shearing forces that develop when a seated person slides toward the floor or foot of the bed if supine, frictional forces that develop when pulling a client across a bed sheet, and moisture from incontinence or perspiration
Clinical manifestations:
pressure ulcers are staged according to their characteristics Assessment: risk factors: immobility, malnutrition, and low body weight, hypoalbuminemia, fecal and/or urinary incontinence, bone fracture, vitaminC deficiency, low diastolic blood pressure, age-related skin changes such as diminished pain perception, thinning of epidermis,
loss
of epidermal vessels, altered barrier properties, reduced immunity and slowed wound healing, anemia, infections, peripheral vascular insufficiency, dementia, malignancies, diabetes, CVA, dry skin, and edema
Diagnostic and laboratory test findings:
culture of the wound WBC with differential and sedimentation rate to determine presence of primary or secondary infection if no progression of ulcer, albumin levels may be obtained to determine dietary needs
Therapeutic management
Evaluate risk factors Improve overall nutritional status – adequate protein intake Clean wound each time dressing is changed to remove dead tissue, excess fluid and debris Main body temperature and acidic pH Never use antiseptics and harsh skin cleaners that may harm tissue
Employ pressure reduction via specialized beds Reposition client every 2 hours Use devices such as padding (gel pads), floatation pads, mattress overlays and specialize (such as air-fluidized, oscillating, or kinetic) beds Avoid agents that delay wound healing such as topical corticosteroids, hydrogen peroxide, iodine, and hypochlorite Control fecal and urine incontinence
Avoid massage over bony prominences Use moisture barrier Assess site every 8 to 12 hours; carefully document healing, e.g., state there is a “healing Stage III ulcer, rather than “Stage II ulcer” if ulcer was Stage III and exhibits healing Use absorption dressing if wound has large amounts of exudates and change frequently
Priority nursing diagnoses:
Impaired skin integrity Disturbed body image Risk for infection Pain Risk for imbalanced nutrition: less than body requirements Risk for ineffective thermoregulation Impaired tissue perfusion Risk for impaired physical mobility Anxiety
Planning and implementation
Provide relief of pressure on wound perform ive range of motion and encourage active range of motion exercises Encourage oral high-calorie and high-protein supplements Encourage oral zinc, vitamins A and C, and iron to aid in tissue healing Conduct systemic skin inspection at least once daily Monitor weight and nutrition intake
Clean skin at time of soiling and routine intervals Keep skin well-hydrated and lubricated Avoid exposure to cold, dry environments Document all risk factors and implement strategies Ensure that proper positioning schedules are followed every 2 hours Use pressure reduction aids
Medication therapy
Clindamycin (Cleocin) or gentamycin (Garamycin) may be ordered for complications such as cellulites, osteomyelitis, or sepsis Vitamin C 500 mg b.i.d. and zinc sulfate supplements aid healing Antibiotic prophylaxis will eradicate bacterial component
A 2-week trial of topical antimicrobials should be used only for a clean superficial ulcer that is either not healing or producing a moderate amount of exudates – cultures are necessary to determine whether antifungal or specific antibacterial agents are indicated
Enzymatic debriding agents such as collagenase (Santyl, Granulex), fibinolysin-desoxyribonuclease (Elase), papin (Panafil), or sutilains (Travase) are used with a moisture barrier to protect surrounding tissue Recommended dressings include polyurethane films (Op-SiteTM, TegadermTM), absorbent hydrocolloid dressings (DuodermTM)
Client education
Need for frequent evaluation of all clients with a history of pressure sores, especially if they have limited mobility Nutritional requirements and meal planning Early identification of skin redness to prevent breakdowns Skin cleansing routine Underpads to absorb moisture Repositioning techniques and frequency Need to evaluate and ensure continence and facilities Use of mattress overlays, seat cushions or special mattresses Ways to avoid injuries
Burn Injury
Description: an alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity, or radiation There are several types of burn injury: thermal chemical electrical radiation
Thermal:
results from dry heat (flames) or moist heat (steam or hot liquids) most common type causes cellular destruction that results in vascular, bony, muscle, or nerve complications can also lead to inhalation injury if the head and neck area is affected
Chemical burns
are caused by direct with either acidic or alkaline agents they alter tissue perfusion leading to necrosis
Electric
burns:
severity
depends on type and duration of current and amount of voltage it follows the path of least resistance (muscles, bone, blood vessels, and nerves) sources of electrical injury include direct current, alternating current, and lightning
Radiation burns:
are usually associated with sunburn or radiation treatment for cancer usually superficial extensive exposure to radiation may lead to tissue damage and multisystem injury
Emergent phase of burn management:
the emergent/resuscitative stage lasts from the onset of injury through successful fluid resuscitation during this stage, it is determined whether the client is to be transported to a burn center for complex intervention depending on onset of injury, identification of burn source, and complicating factors
Classification of burn depth:
done according to the depth of damaged tissue
Superficial
thickness (formerly first-degree):
involves the epidermis only and is recognized by characteristics of erythema, absence of blisters for 24 hours, local pain; healing occurs spontaneously in 3 to 5 days with no scar formation
Superficial thickness (formerly first-degree)
Superficial partial thickness (formerly second-degree):
involves the epidermis and dermis, characterized by moist areas that are red to ivory whit in color, blisters form immediately; area is painful because touch and pain receptors are intact; area heals with greater or lesser amounts of scarring within 21 to 28 days
Deep partial thickness (formerly seconddegree):
involves possibly the entire layer of the dermis, and is more severe than a superficial partial thickness burn skin appendages are left intact area has a dry waxy whitish appearance and may be difficult to differentiate initially from full-thickness burns may heal spontaneously in about 1 month although skin grafting is often done to close the wound, accelerate healing, reduce scarring, and reduce risk of infection
Superficial partial thickness (formerly second-degree)
Full thickness (formerly third-degree):
involves destruction of all skin elements with coagulation of subdermal plexus muscle and tendons may be involved
Full thickness (formerly third-degree)
An
estimate of the burn size is calculated using the “Rule of Nines” or the Lund and Browder method each chart s for 100 percent of the total body surface area (TBSA) although the Lund and Browder method takes into the client`s age when estimating body surface area
Severity of burn is classified using the American Burn, and major burn; these categories help determine treatment Nursing assessment: history of injury, estimate burn extent and depth, obtain past medical history and medication history including date of last tetanus prophylaxis assess for other concurrent injuries
Diagnostic and lab test findings:
may have elevated hematocrit and decreased hemoglobin caused by fluid shift decreased sodium and increased potassium caused by damage to capillary and cell membranes
elevated
BUN and creatinine caused by dehydration myoglobin in urinalysis possible deterioration of arterial blood gases oxygen saturation readings depending on respiratory status
Priority nursing diagnoses:
Risk for deficient fluid volume Risk for infection Impaired physical mobility Imbalanced nutrition; less than body requirements
Ineffective
breathing pattern Impaired tissue perfusion Risk for impaired gas exchange Anxiety Risk for ineffective thermoregulation Pain Impaired skin integrity
Therapeutic management First aid: douse flames with water or smother them with a blanket, coat, or other similar object cool a scald burn with use of cool water flush chemical burns copiously with water or other appropriate irrigant after dusting away any dry powder if present remove client from with an electrical source only after current has been shut off
Priority care is on ABCs:
airway, breathing, and circulation; assess for smoke inhalation injury (singed nares, eyebrows or lashes; burns on the face or neck; stridor, increasing dyspnea) give oxygen (up to 100 percent as prescribed), being prepared for possible intubation and mechanical ventilation if severe inhalation injury or carbon monoxide inhalation has occurred assess for signs of shock caused by fluid shifts (increase pulse, falling BP and urine output, pallor, cool clammy skin, deteriorating level of consciousness)
Fluid resuscitation:
Brooke formula uses 2 ml/kg/% TBSA burned (3/4 crystalloid plus ¼ colloid) plus maintenance fluid of 2,000 mL D5W per 24 hours Parkland (Baxter) formula uses 4 mL/kg/% TBSA burned per 24 hours (crystalloid only – lactated Ringer`s) both formulas give half of 24 hour total in the first 8 hours, and the second half over the next 16 hours
Other considerations:
remove all rings and jewelry to avoid tourniquet effect caused by swelling/edema of burn site provide cardiac monitoring for the first 24 hours after an electrical burn
Medication therapy:
pain therapy, tetanus prophylaxis, topical antimicrobial as well as systemic antibiotics
Client education:
focuses in this phase on brief explanations about the injury, treatments, and ongoing nursing care
Acute phase of burn management: this phase begins with the start of diuresis (usually 48 to 72 hours post-burn) and ends with closure of the burn wound
Clinical manifestations:
vary depending on cause, depth and TBSA of burn associated symptoms arising from other organ systems may include nausea and vomiting, pain, skin redness, chills, respiratory distress, and hypovolemia
Therapeutic management:
wound care management (debridement, dressing changes, hydrotherapy, possible escharotomy, wound grafting) nutritional therapies (high-calorie, highprotein diet with vitamins and minerals) infection control pain management psychosocial physical therapy maintain fluid/hydration status maintain heated environment
Medication therapy:
topical and/or systemic antibiotic therapy pain control with opioid analgesics is usually required
Rehabilitative phase of burn management: this phase begins with wound closure and ends when the client returns to the highest level of health restoration
Clinical manifestations:
depend on cause, body surface area affected and depth may have immobility or restriction of mobility of affected area scarring is possible
Therapeutic management:
obtain psychosocial evaluation provide and management arrange counseling if necessary prevent immobility contractures with exercises or ongoing physical therapy assist in returning to work, family and social life use preventative measures for scar formation (such as burn garments) assess home environment for needs and accessibility assess pain management needs
Medication therapy:
ongoing pain management antibiotic therapy as necessary
Client education
Environmental safety use low temperature setting for hot water heater ensure access to and adequate number of electrical cords/outlets, isolate household chemicals avoid smoking in bed Use of household smoke detectors with emphasis on maintenance
Proper storage and use of flammable substances Evacuation plan for family Care of burn at home Signs and symptoms of infection How to identify risk of skin changes Use of sunscreen to protect healing tissue and other protective skin care measures
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