chapter 27 care of patients with skin problems. xerosis (dryness) a common problem among older...
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Chapter 27
Care of Patients with Skin Problems
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Xerosis (Dryness)
• A common problem among older patients• Fine flaking of the stratum corneum• Generalized pruritus• Scratching may result in secondary skin
lesions, excoriations, lichenification, and infection
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Collaborative Management
• Nursing interventions aim to rehydrate the skin and relieve itching.
• Bathing with moisturizing soaps, oils, and lotions may reduce dryness.
• Water softens the outer skin layers; creams and lotions seal in the moisture provided by water.
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Pruritus (Itching)
• Pruritus is caused by stimulation of itch-specific nerve fibers at the dermal-epidermal junction.
• Itching is a subjective symptom similar to pain.• “Itch-scratch-itch” cycle.• Cool sleeping environment is helpful.• Fingernails should be trimmed short.• Antihistamines.• Topical steroids.
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Sunburn
• First-degree, superficial burn• Cool baths• Soothing lotions• Antibiotic ointments for blistering and
infected skin• Topical corticosteroids for pain
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Urticaria (Hives)
• Urticaria—presence of white or red edematous papules or plaques of varying sizes
• Removal of triggering substances• Antihistamines helpful• Avoidance of overexertion, alcohol
consumption, and warm environments, which can worsen symptoms
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Trauma
• Phases of wound healing:– Inflammatory phase– Fibroblastic or connected tissue repair phase– Maturation or remodeling phase
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Process of Wound Healing
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Process of Wound Healing (Cont’d)
• First intention resulting in a thin scar• Second intention (granulation) and
contraction—a deeper tissue injury or wound• Third intention (delayed closure)—high risk
for infection with a resultant scar
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Partial-Thickness Wounds
• Involve damage to the epidermis and upper layers of the dermis
• Heal by re-epithelialization within 5 to 7 days • Skin injury immediately followed by local
inflammation
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Re-epithelialization
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Full-Thickness Wounds
• Damage extends into the lower layers of the dermis and underlying subcutaneous tissue.
• Removal of the damaged tissue results in a defect that must be filled with granulation tissue to heal.
• Contraction develops in healing process.
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Pressure Ulcer
• Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period.
• Mechanical forces that create ulcers: – Pressure– Friction– Shear
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Shearing Force
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Identification of High-Risk Patients
• Mental status changes• Independent mobility• Nutritional status• Incontinence
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Pressure-Relieving Techniques
• Adequate pressure relief key to prevention of pressure ulcers
• Capillary closing pressure• Pressure-relief products and devices• Positioning
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Wound Assessment
• Pressure ulcers and their features are classified and assessed in four stages:– Stage I– Stage II– Stage III– Stage IV
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Four Stages of Pressure Ulceration
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Wound Assessment
• Location• Size• Color• Extent of tissue involvement• Cell types in the wound base and margins• Exudate• Condition of surrounding tissue• Presence of foreign bodies
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Wound Contamination/Wound Infection
• A wound that is exposed is always contaminated but not always infected. Contamination is the presence of organisms without any manifestations of infection.
• Wound infection is contamination with pathogenic organisms to the degree that growth and spread cannot be controlled by the body’s immune defenses.
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Nonsurgical Management
• Dressings:– Mechanical débridement– Natural chemical débridement– Hydrophobic material– Hydrophilic material
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Nonsurgical Therapy
• Physical therapy• Drug therapy• Nutrition therapy• New technologies:– Electrical stimulation– Vacuum-assisted wound closure (VAC) – Hyperbaric oxygen (HBO) – Topical growth factors– Skin substitutes
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Hyperbaric Oxygen Therapy
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Surgical Management
• Surgical débridement• Skin grafting
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Community-Based Care
• Home care management• Health teaching• Health care resources
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Bacterial Infections
• Folliculitis—superficial infection involving only the upper portion of the follicle
• Furuncle (boil)—much deeper infection in the follicle
• Cellulitis—generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue
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Furuncle
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Cellulitis
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Herpes Simplex Virus
• Type 1 herpes simplex virus (HSV-1)—classic recurring cold sore
• Type 2 herpes simplex virus (HSV-2)—genital herpes
• Herpes zoster (shingles)
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Herpes Simplex Virus (Cont’d)
• Herpetic whitlow—a form of herpes simplex infection occurring on the fingertips of medical personnel who have come in contact with viral secretions
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Herpes Zoster/Shingles
• Caused by reactivation of the dormant varicella-zoster virus in patients who have previously had chickenpox.
• Multiple lesions occur in a segmental distribution on the skin area innervated by the infected nerve.
• Eruption lasts several weeks.• Postherpetic neuralgia occurs after lesions
have resolved.
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Fungal Infections (Dermatophyte)
• Tinea pedis• Tinea manus• Tinea cruris• Tinea capitis• Tinea corporis• Candida albicans
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Assessment
• History • Laboratory assessment:– Tzanck smear– Swab culture– Potassium hydroxide (KOH) test
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Interventions
• Skin care with proper cleansing• Isolation Precautions• Drug therapy
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Skin Care
• Bathe daily with an antibacterial soap.• Remove any pustules or crusts gently.• Apply warm compress twice a day to furuncles
or areas of cellulitis.• Apply Burow's solution to viral lesions.• Avoid excessive moisture.• Ensure optimal patient positioning.
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Drug Therapy for Skin Disorders
• Antibacterial drugs• Antifungal drugs• Anti-inflammatory drugs
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Cutaneous Anthrax
• Infection caused by the spores of the bacterium Bacillus anthracis
• Diagnosis based on appearance of the lesions and culture or anthrax antibodies in the blood
• Oral antibiotics for 60 days—ciprofloxacin or doxycycline
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Cutaneous Anthrax
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Pediculosis
• Pediculosis—infestation by human lice:– Head lice—pediculosis capitis– Body lice—pediculosis corporis– Pubic or crab lice—pediculosis pubis
• Pruritus most common symptom• Drugs• Laundering of clothing and bed linen
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Scabies
• Scabies is a contagious skin disease caused by mite infestations.
• Scabies is transmitted by close and prolonged contact or infested bedding.
• Examine skin between fingers and on the palms.
• Infestation is confirmed by an examination of a scraping of a lesion under a microscope.
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Common Inflammations
• Contact dermatitis, atopic dermatitis• Interventions include:– Steroids– Avoidance of oil-based products– Antihistamines– Compresses and baths
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Psoriasis
• Lifelong disorder with exacerbations and remissions
• Scaling disorder with underlying dermal inflammation; possibly an autoimmune reaction
• Psoriasis vulgaris most often seen• Exfoliative psoriasis—an explosively eruptive
and inflammatory form of the disease
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Psoriasis Vulgaris
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Treatment of Psoriasis
• Corticosteroids • Tar preparations• Other topical therapies • Ultraviolet light therapy• Systemic therapy:– Biologic agents– Cytotoxic agents– Immunosuppressants
• Emotional support
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Benign Tumors
• Cysts• Seborrheic keratoses • Keloids• Nevi (moles)
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Skin Cancer
• Actinic keratoses• Squamous cell carcinomas• Basal cell carcinomas• Melanomas—highly metastatic; survival
depends on early diagnosis and treatment
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Skin Cancer (Cont’d)
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Surgical Management of Skin Cancer
Surgical management:– Cryosurgery – Curettage and electrodesiccation– Excision– Mohs’ surgery– Wide excision
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Nonsurgical Management of Skin Cancer
• Drug therapy• Radiation therapy
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Plastic Surgery
• Rhytidectomy (face-lift)• Rhinoplasty (reconstruction of the nose)
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Acne
• Red pustular eruption affecting the sebaceous glands of the skin
• Progressive disorder that manifests as noninflammatory comedones, inflammatory papules, pustules, and cysts
• Topical agents• Systemic antibiotics and possibly isotretinoin
(Accutane) helpful
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Other Skin Disorders
• Lichen planus with itchy papules• Pemphigus vulgaris with chronic blistering• Toxic epidermal necrolysis—a rare, acute drug
reaction• Stevens-Johnson syndrome• Leprosy