8/4/2019 Theme 1 Week 1 Yr 2

1/80

Theme 1 week 1NURSING CARE OF DISORDERS OF THE

SKIN/INTEGUMENTARY/EYE, EAR,

NOSE AND THROATSYSTEM

Presenter

Mrs. S Ayub1/8/11

8/4/2019 Theme 1 Week 1 Yr 2

2/80

Objectives

At the end of the session thestudent should be able to :

Define key terms

Demonstrate the knowledge and skills in theassessment of medical / surgical conditions

affecting the Skin, EENT .

8/4/2019 Theme 1 Week 1 Yr 2

3/80

Objectives Cont

Demonstrate nursing knowledge and skills to care

for the patient with Skin and EENT problems

using the Nursing process model as a framework.

Prepare and assist patients undergoing

diagnostic, therapeutic, corrective surgery andrehabilitative procedures.

8/4/2019 Theme 1 Week 1 Yr 2

4/80

Assessment of the skin

Equipment needed: good lighting

Small centimeter ruler

Penlight Gloves

8/4/2019 Theme 1 Week 1 Yr 2

5/80

Skin

Examination is correlated with information

obtained in the history

Inspection : observe for color

Skin color, pigmentation, lesions, jaundice,

cyanosis, scars, moisture, edema, color of the

mucous membrane, hair distribution, nails.

8/4/2019 Theme 1 Week 1 Yr 2

6/80

Palpation Examine the skin for:

Temperature, texture, elasticity, turgor.

Skin findings:

Normally warm, slightly moist Smooth and returns quickly to original shape

when picked up by two fingers when released.

Characteristic hair distribution over body,

Nails present, smooth and care for.

8/4/2019 Theme 1 Week 1 Yr 2

7/80

Physical examination

Focus on skin, hair and nails,

Ask patient skin are of concern

Examine the skin surface under good light Compare right and left side of the body

Note the distribution and configuration of

skin lesions Note shape, boarder, texture and surface of

lesion.

8/4/2019 Theme 1 Week 1 Yr 2

8/80

Palpate lesions for texture, warmth andtenderness

Use metric ruler to determine size of lesion-

serve as a baseline for comparison withsequent measurements

Examine scalp, nails and oral mucous for dark

skinned individuals Look for black, purple or grey lesions palpate

carefully- determine if rashes are present.

8/4/2019 Theme 1 Week 1 Yr 2

9/80

Skin disorders

Skin disorders are the major cause of disability,

disfiguration and discomfort.

Skin is integral to self image. As the largest and

most visible organ of the body, skin is involved inrelating to others.

Facial expressions and temporary changes in skin

color reflect emotion and contribute to nonverbalcommunication. One's image is altered by

changes in and styling of hair and nails.

8/4/2019 Theme 1 Week 1 Yr 2

10/80

Tinea

8/4/2019 Theme 1 Week 1 Yr 2

11/80

Tinea (dhani)

8/4/2019 Theme 1 Week 1 Yr 2

12/80

Psoriasis

8/4/2019 Theme 1 Week 1 Yr 2

13/80

8/4/2019 Theme 1 Week 1 Yr 2

14/80

Skin also provides a sensitive form of

communication touch. Appearance is often

important

Undesirable skin changes may not only create

visual abnormalities but also may make a

person feel less perfect.

Skin comprises of 15 % of body weight.

Three layers: epidermal, dermal, and

subcutaneous.

8/4/2019 Theme 1 Week 1 Yr 2

15/80

Diagnostic procedures.

Explain any procedure to the patient and

significant others.

Allow them to ask questions and express

concerns

Teach them appropriate wound care and

indications of possible side effects and

complications that should be reported.

8/4/2019 Theme 1 Week 1 Yr 2

16/80

Skin biopsy

Removes a skin tissue specimen for

histological assessment.

Three types: shave, dermal punch and surgical

excision.

8/4/2019 Theme 1 Week 1 Yr 2

17/80

Shave biopsy

Obtain tissue for analysis from possibly

malignant epidermal growths.

Dermal punch biopsy: a circular instrument

with a sharp cutting edge to remove a

specimen of skin that includes the epidermal,

dermal and the subcutaneous layer.

Surgical Excision Biopsy: used when necessary

to totally incise a lesion

8/4/2019 Theme 1 Week 1 Yr 2

18/80

Inflammatory skin conditions

Atopic dermatitis(atopic and flexural Eczema)

eczematous dermatoses (eczema, nummular,

dyshydrotic, and hand eczema,

neurodermitisis)

8/4/2019 Theme 1 Week 1 Yr 2

19/80

Atopic dermatitis/atopic eczema :

Medical intervention

Control of pruritis, symptom relieve, and

prevention of secondary infection are most

important.

Protect the skin from scratching

Avoid excessive washing or bathing because

soap and water may aggravate the problem.

Clean the skin with bath oils.

8/4/2019 Theme 1 Week 1 Yr 2

20/80

Atopic dermatitis/atopic eczema :

Nursing diagnosis:

Impaired skin integrity due to inflammation:

Nursing intervention: use prescribedtreatment baths to rehydrate skin and relieve

pruritis. Apply emollients frequently

Reapply when the skin feels dry.

Hold medication and notify the physician ifburning, discomfort, or increased pruritisoccurs.

8/4/2019 Theme 1 Week 1 Yr 2

21/80

Comfort, alteration in, due to

inflammation

Nursing intervention: during the acute phase

try to remove the patient from the

environment or home to prevent from more

itching or environmental and other triggeringfactors that induce itching.

Provide a well ventilated, cool room and light,

loose clothing, avoid irritating fibres such aswools or polyester.

8/4/2019 Theme 1 Week 1 Yr 2

22/80

Protect skin from self injury. ( cut nails short,

use cotton gloves and socks)

Assess possible triggering factors such as

allergens, or irritants, bacterial and viral, or

fungal infection, environmental changes, such

as temperature and humidity changes, or

emotional or physical stress.

Protect from exposure to herpes simplex virus.

8/4/2019 Theme 1 Week 1 Yr 2

23/80

Potential alteration in self concept due

to body image change

Some skin conditions evoke feelings of anxiety,embarrassment, disgust, or repulsion in anaffected patient and others

Nursing intervention: recognize thepsychosocial impact of the skin disorder onthe person and significant others and evaluateyour feelings about the person, the persons

skin condition ways you communicate yourfeelings and the persons perception of them.

8/4/2019 Theme 1 Week 1 Yr 2

24/80

Be aware of your non- verbal communicatione.g. negative body language and expressionsof rejection.

Assess the persons and significant others fornegative reactions to the skin disorder.

Develop rapport

Acknowledge concerns and facilitate theexpression of feelings.

Beware of individuals feelings

8/4/2019 Theme 1 Week 1 Yr 2

25/80

Assess the persons perception of self, the skin

disorder, and its impact.

Use helpful verbal and non- verbal therapeutic

communication skills.

Use physical touch appropriately.

Observe the persons interactions with others

and assess interpersonal relationship.

8/4/2019 Theme 1 Week 1 Yr 2

26/80

Anticipate social isolation, depression andwithdrawal during the acute phase orexacerbation of chronic skin conditions.

Foster self esteem by giving sincerecomplements on the persons activities and

appearances.

Discuss ways of covering the skin disorder ifthe patient wishes e.g. cosmetics to concealscars.

8/4/2019 Theme 1 Week 1 Yr 2

27/80

Recognize that as an individuals condition

improves, the persons perception of self and

others will improve.

8/4/2019 Theme 1 Week 1 Yr 2

28/80

Eczema

In acute phase topical corticosteroids may beprescribed. Apply emollients frequently.

During the acute phase use only lotion bases.

For chronic phases rehydrate the skin withemollient socks and treatment baths.

reapply when skin is dry,

If eczema worsens suspect intolerance to newtopical medication and report this to thephysician

8/4/2019 Theme 1 Week 1 Yr 2

29/80

Eczema in arms

8/4/2019 Theme 1 Week 1 Yr 2

30/80

Alteration in comfort due to pruritis

and pain.

Observe indications of secondary infections

(bacterial, viral, or fungal)

Depending of location of dermatitis assess for

and avoid environmental irritants

8/4/2019 Theme 1 Week 1 Yr 2

31/80

Xerotic eczema/ dry skin

Skin is dehydrated, erythemotous, scaling andfinely cracked. Occurs in patches and mayinvolve any skin surface.

Common in elderly people If severe, skin is tight, it itches and is painful.

In low humidity, excessive water is lost from

the stratum corneum. Water loss causesXerotic chapping, especially in artificiallyheated rooms

8/4/2019 Theme 1 Week 1 Yr 2

32/80

Medical intervention

Preventing dryness and relieving symptoms

Rehydrate the skin by tepid soaks

Emollients impede the fate of water

evaporation from the skin by their residual oil

film.

Avoiding bathing with soap and using a cold-

air humidifier is recommended.

8/4/2019 Theme 1 Week 1 Yr 2

33/80

Xerotic eczema/ dry skin : impaired

skin integrity due to dehydration of

stratum corneum

Correct skin cleaning, use superfatted soap or

bath oil, limit use of soap except in

intertriginous areas, avoid soap during shower

or bath, avoid hot water baths.

Practice proper dry skin care daily, pat rather

than rub, dry.

8/4/2019 Theme 1 Week 1 Yr 2

34/80

Stasis dermatitis

Provide dry skin care

Assess for self- induced injury and a history of

trauma.

Assess for evidence of skin thinning and the

presence of ulceration

Teach person and significant others way of

reducing and relieving pruritis and explain

prescribed medication

8/4/2019 Theme 1 Week 1 Yr 2

35/80

Teach ways to reduce edema (elevating the

legs 30 degrees, wearing professionally fitted

support hose, avoiding standing, crossing the

legs and ankles and wearing shoes andclothing that are constricting).

8/4/2019 Theme 1 Week 1 Yr 2

36/80

Contact dermatitis

Take a thorough health history, including

information about recent exposure to

soap/ detergents, lotions, powders, toilet

items, medications, ( oral, topical, OTC),

solvents, chemicals, plants, new clothing,

cosmetics, and fragrances.

8/4/2019 Theme 1 Week 1 Yr 2

37/80

Until patch testing is completed,

reduce exposure to suspected

environmental allergens/ irritants.Patch testing may worsen the

condition if performed during the

acute stage of the dermatitis.

8/4/2019 Theme 1 Week 1 Yr 2

38/80

Knowledge deficit

Review identified allergens/irritants ,possible

sources of allergen/ irritant contact,

recognition of irritants/ allergens, ways to

avoid and limit contact, and ways to relievepruritis.

8/4/2019 Theme 1 Week 1 Yr 2

39/80

Sunburn

Reduce skin temperature and inflammation

by applying cool tap water soaks or by cool tap

water baths.

Warn the person that it is too dangerous to

become too cool ( hypothermia) is skin intact,

apply an oil- in water moisturizing lotion.

8/4/2019 Theme 1 Week 1 Yr 2

40/80

Assess skin for blistering. Apply cold sterile,

normal saline soaks continuously to blisters.

Apply nonadhering sterile dressing.

Observe for bacterial infections. Soak and cool baths promote comfort.

Provide teaching/ learning opportunities to

view photo protection methods Advise person to avoid sun exposure until

desquamation is resolved.

8/4/2019 Theme 1 Week 1 Yr 2

41/80

Furuncles and carbuncles

Hasten lesion maturation and relieve

discomfort by applying warm compressions

t.i.d.

Prepare for incision when infection becomes

localized and fluctuates when palpated.

Obtain bacterial culture and sensitivity test.

Provide teaching/learning opportunities.

8/4/2019 Theme 1 Week 1 Yr 2

42/80

Knowledge deficit regarding

communicability of bacterial infection.

Teach the patient to change the dressings on

an open draining furuncle/ carbuncle

frequently, to dispose off dressing carefully

and to wash hands

Bath in antibacterial skin cleanser to use

disposable razor and discard after each use.

The persons linen should be washedthoroughly and separately from other linen.

8/4/2019 Theme 1 Week 1 Yr 2

43/80

Nail disorders

Onycholysis: nursing diagnosis: impaired skin

integrity due to inflammation

Intervention: take an appropriate culture of

the nail to detect bacterial, viral or myocotic

infection. Instruct the person about the

prescribed treatment. Assess the persons

history for trauma and / or chemical irritants.

8/4/2019 Theme 1 Week 1 Yr 2

44/80

Knowledge deficit regarding condition

and its management.

Intervention.: provide teaching/ learning

opportunities including(a) method of reducing

trauma, e.g. clipping nails to reduce further

separation (b) avoiding manicuring or selfinduced trauma. (c) limiting chemical irritants

such as soap, cleansers, nail products. (d)

keeping the nail dry, and if rubber gloves areused reduce maceration by lining them with

thin cotton gloves.

8/4/2019 Theme 1 Week 1 Yr 2

45/80

Paronychia

Impaired skin integrity due to inflammationand bacterial and fungal infection.

Intervention: apply warm soaks three times a

day to reduce pressure and pain. Assist inincision and drainage of inflamed sites. Obtainappropriate cultures of purulent material.Teach the person about prescribe topical /or

systemic antibiotic therapy, emphasizing needfor compliance during treatment.

8/4/2019 Theme 1 Week 1 Yr 2

46/80

Unguis Incarnatus

( ingrown toe nails)

Impaired skin integrity due to local

trauma and inflammation

Intervention: warm soaks 20 severaltimes a day. Assess for secondary

bacterial infection.

8/4/2019 Theme 1 Week 1 Yr 2

47/80

Explain postsurgical wound care. if

nail potion is removed or clipped,

keep a white petroleum impregnatedcotton wick under the remaining nail

edge. Teach the person to change

wick daily.

P li d li ki

8/4/2019 Theme 1 Week 1 Yr 2

48/80

Premalignant and malignant skin

conditions

Basal cell epithelioma: impaired skin integrity

due to cutaneous malignancy.

Intervention: encourage prompt treatment to

minimize local tissue destruction. Teach

postoperative wound care.

P i l l i i i d

8/4/2019 Theme 1 Week 1 Yr 2

49/80

Potential alteration in copying due to

fear and malignancy

Intervention: explain that metastases seldom

occur with this condition.

Knowledge deficit regarding condition and its

management

Intervention: assess the history of sun exposure

and evaluate the signs of skin damage. Review

photo protection methods with the personand significant others.

8/4/2019 Theme 1 Week 1 Yr 2

50/80

Actinic Keratosis ( Solar Keratosis)

Potential skin integrity impairment due to

chronic repetitious actinic damage.

Intervention: assess all sun- exposed skin sites

for actinic damage. A shave biopsy may be

used to rule out malignancy in a suspicious

lesion . Explain the treatment plan to the

person and significant others.

K l d d fi it di diti

8/4/2019 Theme 1 Week 1 Yr 2

51/80

Knowledge deficit regarding condition

and its management.

Intervention; discuss the necessity for

reassessment to detect early signs of skin

damage. (b) need to avoid sun exposure, and

(c ) methods of photo protection

S ll i P i kl ll

8/4/2019 Theme 1 Week 1 Yr 2

52/80

Squamous cell carcinoma, Prickle cell

carcinoma

Potential alteration in coping due to fear of

malignancy and disfigurement.

Intervention: discuss the impact of chronicity

or malignancy, exacerbations, social isolation,

depression, and coping mechanisms with the

person and significant others. Feelings of

anger and frustrations may be experiencedand expressed to health professionals

8/4/2019 Theme 1 Week 1 Yr 2

53/80

Help the individual and significant others to

identify and expect realist treatment

outcomes and to set realistic goals.

Provide appropriate realistic goals.

Recognize the complexity of the condition.

Acknowledge expressed fears of reoccurrence

or progressive worsening of the condition.

8/4/2019 Theme 1 Week 1 Yr 2

54/80

Malignant melanoma

Knowledge deficit regarding condition and its

management : intervention: review the

planned surgical procedure, discuss

postoperative wound care, recognize that theextent of surgical intervention depends on the

stage of the lesion.

Additional treatment may includechemotherapy or immunotherapy

8/4/2019 Theme 1 Week 1 Yr 2

55/80

Discuss the need for medical supervision anddemographic assessment every three to sixmonths.

Prevention guidelines include (a) monthly selfassessments scalp, trunk and intertriginous

and genital areas to identify pigmentedlesions, (b) seek medical follow up for any nevichanges, ( c) encourage blood relatedrelatives to obtain demographic assessment

(d) limit sun exposure and (e) perform photoprotection measures.

8/4/2019 Theme 1 Week 1 Yr 2

56/80

The eye structure

8/4/2019 Theme 1 Week 1 Yr 2

57/80

Equipment

Ophthalmoscope, Snellens chart.

Inspection:

Sclera and iris: check for color

Pupils: check for size, shape, symmetry,

reactions to light and accommodation

Eye movement; extra ocular movements. Eye

naturally moves in conjugate fashion.

8/4/2019 Theme 1 Week 1 Yr 2

58/80

Cross visual fields

Confrontation: normally is full medially and

laterally, superiorly and inferiorly in both eyes.

Visual acuity: check with Snellens chart

normal vision: 6/6

Myopia -- near sightedness and

Hyperopia far sightedness.

Common disorders of eye and related

8/4/2019 Theme 1 Week 1 Yr 2

59/80

Common disorders of eye and related

structures.

Normal eyelid function is to(1) protect the

eyes from foreign bodies, external injury,

undue exposure, and excessive light,

and (2) lubricate the eyeballs by distributing

secretions over them, washing away dust and

keeping the corneas moist and transparent.

8/4/2019 Theme 1 Week 1 Yr 2

60/80

Blepharitis (granulated eyelids)

Inflammation of the eyelid margin.

Assessment reveals eyelid irritation, burning

and itching. The eyelid margins appear red-

rimmed and have scales or granulations on

them.

Sometimes the eyelids margins are ulcerated

and the eyelashes fall out.

8/4/2019 Theme 1 Week 1 Yr 2

61/80

Intervention

Removing scales from the eyelids daily with a

damp cotton applicator followed by applying

warm compression

Cleaning the scalp, eyebrows and lid margins,

Applying antibiotic or sulfonamide eye

ointment daily to the lid margins to prevent

buildup of the scales (preferably at night sinceointment blurs vision).

8/4/2019 Theme 1 Week 1 Yr 2

62/80

Hordeolum (Stye)

Is the postular infection of the eyelash follicle or

sebaceous gland on an eyelid margin (typically

staphylococcal in origin).

Assessment reveals a very painful red swelling onthe eyelid margin. The intensity of pain relates to

the amount of swelling. Common in all age

groups.

Begins with local irritation, redness and swelling

and progresses to an acute tender abscess.

8/4/2019 Theme 1 Week 1 Yr 2

63/80

Intervention

Teaching the person not to squeeze at the

lesion since this spreads the infection.

Apply warm, moist compresses to hasten

suppuration

Compresses usually cause a stye to open and

drain without surgery.

8/4/2019 Theme 1 Week 1 Yr 2

64/80

Virus infection

Herpes Zoster involving the eye typically has

an unilateral trigeminal distribution. Skin

lesion are deeper than those of herpes

simplex. They are painful, can become secondarily

infected, and often leave permanent scars.

8/4/2019 Theme 1 Week 1 Yr 2

65/80

Intervention

Ocular treatment is vigorous with mydriatic,

antibiotic, and corticosteroid ointment. Keep

skin lesions clean of infections and crusts by

cleaning and applying antibiotic ointment andhot soaks.

Disorders of the Conjunctiva Sclera

8/4/2019 Theme 1 Week 1 Yr 2

66/80

Disorders of the Conjunctiva, Sclera,

and Cornea

Conjunctivitis is the inflammation of the

conjunctiva.

Generally exogenous and results from

bacterial or viral infection

May result from endogenous inflammation,

allergy, chemical irritations, and fungal or

parasitic infections

8/4/2019 Theme 1 Week 1 Yr 2

67/80

Assessment

Redness, swelling and lacrimation

Pain occurs if cornea is involved.

If conjunctivitis is associated with allergy,

itching occurs

Eye discharge varies in amount and nature

depending on the causative organism.

Ask if eyelids stick together when waking.

8/4/2019 Theme 1 Week 1 Yr 2

68/80

Intervention

With corneal involvement, photophobia may

occur and dark glasses are required.

Specific antibacterial medications (local and

systemic)

Eye irrigations

Hot moist compressions

Eye drops or ointments

8/4/2019 Theme 1 Week 1 Yr 2

69/80

Corticosteroids are contraindicated ininfectious conjunctivitis since they reduce theocular resistance to bacteria.

Eye patches are also contraindicated sincecovering an eye that has surface bacterialinfection promotes bacterial growth.

Allergic conjunctivitis can be treated withtopical decongestants, steroids or non-steroidal agent such as 4 % cromolyn sodium

Trachoma

8/4/2019 Theme 1 Week 1 Yr 2

70/80

Trachoma

a chronic infectious disease of the conjunctiva

and cornea caused by Chlamydia trachomatis.

Is caused by direct contact and is very

communicable

If untreated leads to blindness

Trachoma responds well to local and systemic

sulfonamides or local antibiotics (tetracycline

or erythromycin). Personal cleaniness isessential

Increased intraocular pressure:

8/4/2019 Theme 1 Week 1 Yr 2

71/80

Increased intraocular pressure:

Glaucoma

Assessment reveals red eye, steamy cornea,

shallow interior chamber, turbid aqueous,

greatly elevated IOP and moderately dilated

nonreactive pupil. The person typically experiences blurred

vision, halos around lights, or a rapid loss of

vision.

8/4/2019 Theme 1 Week 1 Yr 2

72/80

Intervention

To control nausea and relieve the intense pain.

The pain tends to subside once the IOP is

reduced.

A peripheral iridectomy is the surgicalprocedure of choice when the acute episode is

relieved.

8/4/2019 Theme 1 Week 1 Yr 2

73/80

Postoperative intervention

Dilation of pupils with cycloplegic drugs to

prevent posterior synechiae and steroid drugs

to decrease inflammation. Immediate

ambulation is usual. Eye patch is not required , though a shield is

used to protect the eye.

8/4/2019 Theme 1 Week 1 Yr 2

74/80

Lens Opacity (cataract)

Cataract surgery is the only available

treatment. The cloudy lens is removed

Disorders of the nose

8/4/2019 Theme 1 Week 1 Yr 2

75/80

Disorders of the nose Epistaxis: assessment: bleeding usually

apparent however person often swallowsblood making assessment of degree of blood

difficult

Nausea secondary to swallowing blood. Hypotension or frank shock if bleeding

prolonged or severe.

Site of bleeding may be anterior or posteriorlocalization of bleeding site may be difficult.

8/4/2019 Theme 1 Week 1 Yr 2

76/80

Intervention

Position patient sitting up unless hypotensive

pinch nostrils together to apply pressure

Obtain postural vital signs

Order hemotocrit or hemoglobin if bleeding issignificant

Locally applied vasoconstrictors e.g. cocaineor epinephrine are often used to control

bleeding , silver nitrate is used occasionally,xylocaine nasal spray

8/4/2019 Theme 1 Week 1 Yr 2

77/80

Cont

Nasal packing with non adherent gauze

Provide mouth care

Provide reassurance

Learning / teaching: techniques for homeostasis

Follow up care

Humidification and application of water soluble

lubricant

Indication of airway obstruction

f

8/4/2019 Theme 1 Week 1 Yr 2

78/80

Disorders of the ear Group A: External ear disorders: deformities,

foreign bodies, impacted cerumen (ear wax) ,external otitis, furunculosis, malignant

tumors, ear drum perforation,

Group b:

Internal ear disorders: otitis media,

otosclerosis,

Aural surgical procedures:

Rehabilitation for hearing impaired people

l d d d

8/4/2019 Theme 1 Week 1 Yr 2

79/80

Nasal and sinus disorders Group c : rhinitis, (common cold), allergic rhinitis,

nasal polyps, epistaxis Group D: sinusitis, assessment and intervention

Group e: swallowing disorders (Dysphagia),

esophageal disorders Group F : achalasia, esophagitis,

Group G: hiatus hernia and esophageal cancer

Group H: tonsillitis, thyroid and parathyroiddisorders

Prepare assessment, nursing diagnosis andintervention for you group work

8/4/2019 Theme 1 Week 1 Yr 2

80/80