2ObjectivesExplain dermatitis and psoriasisDiscuss the education plan for a client with inflammatory disordersList drugs used for treatment of inflammatory disordersIdentify foods causing allergiesIdentify topical drugs used for the client with disorders of the skinDiscuss components of a client education plan for the self-use of topical medications
3DERMATITISContact dermatitis from tape.Poison ivy dermatitis.
4CONTACT DERMATITIS PATHOPHYSIOLOGY: -direct contact with agents in the environmentthat a person is hypersensitive to-epidermis becomes inflamed and damagedby the repeated contact-soaps, industrial chemicals, plants ,etc.
6SIGNS AND SYMPTOMS-lesions at the point of contact. -burning, pain, itching, and swelling. -red with papules -small, raised , solid skin lesions less than 1 cm. in diameter
7ASSESSMENT SUBJECTIVE DATA -history of the pt.’s activities -ask for a log of the past 48 hours before thes/s developed.
8ASSESSMENT SUBJECTIVE DATA -tried a new soap. -traveling and using different personal items.-working with plants or flowers.-severe itching.-difficulty moving the affected area.
9ASSESSMENT OBJECTIVE DATA: -erythema. -papules /vesicles that generally ooze andweep a clear fluid.-scratch marks.-edema of the area.
10DIAGNOSTIC TESTS-health history to identify the agent. -intra-dermal skin testing. -elimination diets are used to identify food allergies. -elevated serum IgE levels and eosinopilia.
11NURSING DIAGNOSES Impaired skin integrity, related to scratching Pain, related to pruritis
12TREATMENT MEDICAL MANAGEMENT -identify the cause of the hypersensitive reaction.-treat symptomatically-swelling, itching, discomfort.-oral antihistamines-corticosteroids topically.-prophylactic treatment for asthma
13NURSING INTERVENTIONS -protect the inflamed area from further harm. -rest the affected area. -wet dressings (Burrow’s solution) -use medical aseptic technique when applying the corticosteroids to the open lesions. -provide a cool environment with humidity. -cold compresses -deceases the circulation and cause vasoconstriction -this relieves the pruritis
14NURSING INTERVENTIONS, CONT. -daily baths with an application of oil.-cut the fingertips-decreases excoriation from scratching- wear mittens or gloves).-clothing should be lightweight and loose.
15TEACHING-keep a history of possible predisposing offensive agents. -avoid the causative agent once it has been identified. -avoid any rubbing of the area -any excessive heat -any soaps -these can all cause itching which could easily re-open the wound
16PROGNOSIS -removal of the offensive agent results in full recovery -if there is a recurrence, then the pt. may needto be desensitized.
17DERMATITIS VENENATA, EXFOLIATIVE DERMATITIS, AND DERMATITIS MEDICAMENTOSA
18Inflammatory Disorders of the Skin Dermatitis venenata, exfoliative dermatitis, and dermatitis medicamentosaEtiology/pathophysiologyDermatitis venenata:-Contact with certain plantsExfoliative dermatitis:-Ingestation of heavy metals, antibiotics, aspirin,codeine, gold, or iodineDermatitis medicamentosa:-Hypersensitivity to a medication
19DERMATITIS VENENATA-Contact with certain plants - poison oak /poison ivy. -Mild-severe erythema with pruritis -Body undergoes a sensitizing antigen formation on first exposure -Lymphocytes to release irritating chemicals - inflammation - edema - vesiculation
20EXFOLIATIVE DERMATITIS -Ingestation of heavy metals, or by antibiotics, aspirin, codeine, arsenic, mercury gold oriodine.-Skin sloughs off-swollen/reddened-severe pruritis-fever-Patients are hospitalized-Treatment is individualized.
21EXFOLIATIVE DERMATITIS -Cause should be removed and treated -Prevent secondary infections -Avoid further irritation. -Maintain fluid balance.
22DERMATITIS MEDICAMENTOSA -Medication causes a hypersensitive reaction -Any drug can cause a reaction -penicillin, codeine, and iron.
23DERMATITIS MEDICAMENTOSA Signs and symptoms-mild to severe erythema-pruritus.-vesicles/eruptions-respiratory distress-especially with medicamentosa
29NURSING DIAGNOSESImpaired skin integrity, related to crusted, open lesionsRisk for infection, related to break in skinDeficient knowledge, related to the cause and spread of the disease
30TREATMENT -Therapeutic baths -Administration of corticosteroids. -Treatment is directed at the cause.
31NURSING INTERVENTIONS: Dermatitis venenata--Wash the affected area immediately aftercontact with the offending allergen-Cool, open, wet dressings to the lesions-Calamine lotion
32NURSING INTERVENTIONS -Therapeutic baths with colloid solution, lotions, and ointments - alleviates the itching -Emotional support - the physical appearance is difficult for both the patient/family to accept.
33NURSING INTERVENTIONS Dermatitis medicamentosa -center around the causative drug and discontinuation -if the drug cannot be identified -no drugs should be given -lesions will disappear after the medication has been stopped -PCP must be notified for further orders
34TEACHING-Wear a medical alert bracelet/necklace showing the name of the allergen -Inspect the lesions daily -exudate, size, and body part. -Fever -have the pt. check his temperature -Medical asepsis/aseptic hand washing technique
35TEACHING-Appropriate application of topical meds -Keep the involved areas dry when giving care -Own personal items that are not to be shared – -linens, towels, comb, etc. -Family must be involved with the teaching
36PROGNOSISFull recovery-when the offending agent is gone
37Inflammatory Disorders of the Skin Urticaria (Wheals/Hives)Etiology/pathophysiologyAllergic reaction-release of histamine in an antigen-antibody reaction-drugs-food-insect bites-inhalants-emotional stress-exposure to heat or cold
38Inflammatory Disorders of the Skin Clinical manifestations/assessmentPruritusBurning painWheals/ hives- release of histamine- capillaries to dilate- increased permeability
44TREATMENT Medical management/nursing interventions -Identify and alleviate cause.-Antihistamine (Benadryl).-Therapeutic bath.-Epinephrine.-Teach patient possible causes.-Teach preventive measures.
45TEACHING . Signs and symptoms of a anaphylactic reaction. -shortness of breath-wheezing-cyanosis
46PROGNOSIS Full recovery when the obnoxious agent is removed/avoided. Patient must comply with the treatment regimen.
47Inflammatory Disorders of the Skin AngioedemaEtiology/pathophysiology-form of urticaria-subcutaneous tissue-same offenders as urticaria-eyelids, hands, feet, tongue, larynx, GI, genitalia,or lips-angioedema is a local edema of an entire areararely occurs in more than a single area at onetime
48Inflammatory Disorders of the Skin AngioedemaClinical manifestations/assessment-burning /pruritus-lesions that are normal on the outer skin-edema-acute pain -in the GI tract-respiratory distress -in the larynx-edema of an entire area -eyelid, feet, lips, etc.
55Inflammatory Disorders of the Skin Eczema (atopic dermatitis)Etiology/pathophysiology-Allergen causes histamine to be released-antigen-antibody reaction-Primarily occurs in infants.-chocolate, orange juice, eggs, wheat.
57ASSESSMENT-Papules/vesicles -edged with redness -ruptures -discharges a yellow, thick exudate -dries, becomes crusted -infected -skin becomes shiny, de-pigmented -dry scales.
58ASSESSMENT SUBJECTIVE: -pruritis -scratching -children are more fussy/irritable-anorexic.-skin is tender to the touch.-family history of allergies-asthma is often associated with children whohave eczema.
59ASSESSMENT-Papules and vesicles -scalp, forehead, cheeks, neck, and extremities. -Erythematic/dryness of area. -Pruritis.
60Inflammatory Disorders of the Skin Eczema (atopic dermatitis)Diagnostic testsHealth history (heredity is a primary factor).Diet elimination.Skin testing and IgE serum tests.Medical management/nursing interventionsReduce exposure to allergenHydration of skinTopical steroidsLotions—Eucerin, Alpha-Keri, Lubriderm, or Curel 3-4 times/day
67Inflammatory Disorders of the Skin Acne vulgarisEtiology/pathophysiology-Occluded oil glands (the sebaceous glands)-The cause is unknown-Androgens increase the size of the oil gland-It primarily occurs in adolescents-Influencing factors-Diet-Stress-Heredity-Overactive hormones
68Inflammatory Disorders of the Skin Acne vulgarisClinical manifestations/assessment-Tenderness and edema-Oily, shiny skin-Pustules-Comedones-blackheads- the effect of oxygen on sebum, not dirt-Scarring from traumatized lesions
78NURSING INTERVENTIONS -Adolescents may not comply with long-term treatment regimens. -Evaluate the pt.’s understanding/reaction to his acne disorder. -What does acne mean to the pt.? -Focus on: -skin care -compliance -emotional support
79NURSING INTERVENTIONS -Prevention -identification of factors that directly increase acne -Cleanliness decreases infection/promotes healing. -The skin should be washed 2-3 times/ day with a medicated soap -Improvement is slow so compliance is hard.
81NURSING INTERVENTIONS -Often it takes 3 weeks of treatment -Family support -Primary cause for low self-esteem -Not comparing oneself with others -Give positive reinforcement -Focus on his strengths
82TEACHING-Both the physical and emotional needs of the pt. -Diet, hygiene, stress reduction, makeup, and medications. -Coping skills. -Adolescent should talk about his feelings -decreases any long-term effects that acne may have on his personality.
83PROGNOSIS Prognosis is good. Lasting psychological effects can occur from the scarring that may result.In rare cases, eczema may develop from taking med: for acne, such as isotretinoin.
85Psoriasis Etiology/pathophysiology Noninfectious. Skin cells divide more rapidly than normal-normal– skin replaced every 28 days-psoriasis-skin replaced every 7 days.-occur at any age.-hereditary.-at the epidermis.-no known predisposing factors.-severe scaling is the result of the rapid cell division.
86ASSESSMENT SUBJECTIVE: -pruritis. -feelings of depression, frustration, loneliness.-people may stare at them.
87ASSESSMENT Clinical manifestations/assessment -raised, erythematous, circumscribed, silvery, scaling plaques-scalp, elbows, knees, chin, and trunk-primary lesion is papular.
88DIAGNOSTIC TESTS -no special tests. -observation of the patient/symptoms.
89TREATMENTGoal-slow the proliferation of the epithelial layers of the skin.Topical steroidsKeratolytic agents-occlusive wet dressings to decrease inflammationTar preparationsSalicylic acidReduces shedding of the outer layer of skinPhotochemotherapyPUVAOral psoralenUltraviolet light
90NURSING DIAGNOSESImpaired skin integrity, related to proliferation of epithelial cellsSituational low self-esteem, related to appearanceSocial isolation, related to decreased self-esteem
91NURSING INTERVENTIONS -Administration of the treatment modality.-Rest-Promote psychological well-being-counseling, exercise, etc.-Focus on positive attributes.-Medical asepsis.-Conceal obvious lesions.
92TEACHING -Nature of the disease -Treatments -Compliance with medical care.-Disease is not CURABLE-Patient needs to understand this.
93PROGNOSIS -Chronic disease. -Clinical course is variable -less than 50% will have a prolonged remission.-Severity:-cosmetic problem to a life-threateningemergency
94Systemic Lupus Erythematosus (SLE) Etiology/pathophysiologyAutoimmune disorder- antibodies against its own cellsInflammation of almost any body part.Skin, joints, kidneys, and serous membranesAffects women more than men-9 times more women than menContributing factorsImmunological, hormonal, genetic, and viral.Origin still remains a mystery.
95SLE -Disease of exacerbations and remissions -triggered by contributing factors.-Inflammatory lesions-affect several organ systems-skin, joints, kidneys, and serous membranes.-T-suppressor cells decrease
96SLE Clinical manifestations/assessment Erythema butterfly rash over nose and cheeksAlopeciaButterfly rash- occurs in 10-50% of patientsPhotosensitivityOrganic brain syndrome
97SLE Polyarthralgias and polyarthritis -90-95% of patients Pleuritic painPleural effusionPericarditisVasculitisOral ulcersAnemia-most common.
102DIAGNOSTIC TESTS Rapid plasma reagin Skin and renal biopsy C-reactive protein (CRP)Coomb’s testLE cell prep (lupus erythematosus)UrinalysisChest x-ray
103NURSING DIAGNOSESImpaired skin integrity, related to skin rash, hair loss, skin atrophy, discoid lesions involving other parts of the body.
104NURSING DIAGNOSESDisturbed body image, related to baldness, skin pattern pathologies
105TREATMENTGOALS: -Relief /managaement of symptoms. -Inducement of remission. -Prevention of complications. -Suppression of inflammation.
106SLE Medical management/nursing interventions No cure -treat symptoms, induce remission, alleviateexacerbation.MedicationsNonsteroidal ant-inflammatory agents.anti-malarial drugs (hydroxychloroquine).corticosteroids ( prednisone)-Peak amounts of steroids help to achieve remissionAnti-neoplastic agents ( Imuran, Cytoxan).Topical corticosteroid creams are used for the rash.
107MEDICATIONS Anti-infective drugs -treat/prevent infections -specific agent depends on the infection site-Cipro for a UTI.Dialysis for pts. with renal involvement.Lab Tests-assess renal function (BUN/serum creatinine)Analgesics-painDiuretics-fluid retention
108TREATMENT Balance rest and exercise Balanced diet Avoid direct sunlight
109NURSING INTERVENTIONS -Thorough assessment -multi-systemic disease. -Skin care -avoiding direct sunlight -protective clothing -sunscreen. -Balance rest and activity. -Recognize s/s of exacerbation -fever, rash, cough
110NURSING INTERVENTIONS -Recognize the s/s of infection. -Reduce stress. -Balanced diet -Reduction of sodium intake.
111NURSING INTERVENTIONS -emotional, psychosocial, and spiritual support. -activity level -prevention of infection -potential complications -information on living a normal life.
112Pharmacology for the treatment of inflammatory skin disorders CorticosteroidsEmollientsAntipsoriatics
113Corticosteroids -local inflammatory disorders -Topical administration -avoids systemic adverse effects-the inflammatory site must be localized andaccessible-effective and relatively safe form of therapy-prescription and non-prescription products
114NURSING INTERVENTIONS -Monitor site for healing--increased use of topical steroids decreasesvasoconstriction-decreases the absorption of the steroid-requires a higher amount/more frequent usage-Monitor for increased facial redness when decreasing theamount of topical steroid secondary to tolerance.-Skin atrophy, striae (stretch marks), steroid allergies or skininfections-Fungal infections will not resolve with the use of topical steroids
115Emollients-Dry skin -infections, excessive bathing or strong soaps/detergents -pruritus, cracking, and predisposition to skin disorders -prevent the loss of additional skin moisture be forming a occlusive barrier on the skin surface -waxes, fats and/or oils -urea-enhances the skin’s ability to hold moisture -Oils, creams, lotions, bath oils -daily after showering of bathing -do not apply to skin lesions that are moist/exudative
116Antipsoriatics Alefacept- -first antibiological therapy for moderate to severe chronic plague psoriasis-provides longer remissions the other treatments-adverse effects- serious infectionEfalizumab--immunosuppressive recombinant monoclonal antibody-stimulates the bodies immune system’s ability to fightdisease-adverse effects- thrombocytopenia, hypersensitivity,, headache,fever, chills, nausea and myalgia
117Food Allergies Definition: -Ingestion of food that the person’s immune systemincorrectly identifies as harmful- 4% of adults have food allergies-6-8% of children age 4 years of younger
118-Immune system creates food specific antibodies. -Antigens which are foreign substances (food)-produces the immune response-antibodies start destroying the antigens-immune system discharges large amountsof histamine and chemicals-cause the allergic reaction
120Allergic Reaction Respiratory -Tongue swelling, dyspnea Gastrointestinal-Nausea, abdominal pain, diarrheaSkin-Hives, rashCardiovascular-Tachycardia, hypotensionNeurological-Anxiety, loss of consciousness
121Anaphylaxis -Severe reaction to allergen -Swelling of the lips, tongue, throat-blocks the upper airway resulting insuffocation-Emergency situation
122Common allergy foods:-Eggs, peanuts, tree nuts, fish, shellfish, wheat,soy-Peanuts and tree nuts- severe reactions!-0.6% of Americans are allergic to peanuts-young children-allergic to eggs, milk, peanuts, tree nuts and soy.-outgrow their allergies-usually be allergic to peanuts and tree nuts for therest of their life.
123-are hereditary -a child having allergies increases when both parents have allergies -allergic to the common foods eaten in their countries -rice allergies are common in Japan
124Diagnosis -family history of allergies -food diary -scratch test -RAST (radioallergosorbant test)-measures the presence f food-specific IgEin the blood-elimination of food from the diet-food challenge-capsules of different foods and a placebo-ingested and then followed to see if an allergicreaction occurs (rarely done)
125Treatment--avoid foods that cause allergiesPrognosis-not curable but manageable-multiple medications being researched
126Nursing Considerations -Carefully reading food labels-Inquire of the food ingredients when eating out.-Counseling by a dietician on the foods that theirchildren need to avoid-Medical alert bracelet with the name of foodallergy
127Epinephrine injection -carried at all times- person, parents of children- severe/ anaphylactic reaction to foods or medicationsEpi-pen auto injection-pre-measured epinephrine injection- costs $50Along with a Epi-pen the person should carry:-food allergies-3 emergency contacts-Physicians name and telephone number-description of how to treat the reaction
128Pharmacology of skin disorders Topical antiseptics/germicidesTopical Anti-InfectivesTopical Cortico-steroidsTopical Local AnestheticsTopical EnzymesKeratolytics
129Topical Antiseptics and Germicides Long history of usage-spices, vegetable oils and extracts of trees/plants-1800’s Pastuer, Koch-substances that slowed or destroyed pathogenicorganismsDefinition:-an agent that kills or inhibits the growth ofmicroorganisms that is applied to living tissue
134Nursing Considerations -hypersensitivity-systemic absorption if applying to aextensively damaged skin-Neomycin -observe for changes in renalfunction:-decreased urine output-elevated Creatine and BUN- changes in hearing.
135Topical Local Anesthetics Inhibits the conduction of nerve impulses from sensory nerves- reduces pain/pruritis-insect bites, burns and plant allergies-patches, ointments, creams, sprays, liquids of jellyform-Types- “caine”-Lidocaine-Benzocaine-Tetracaine-Cocaine
136Nursing Considerations -absorbed systemically through damaged ordiseased skin-local or systemic adverse effects-if the medication is applied to a large area ofskin-systemic hypersensitivity-CNS stimulant-hypotension-slow heart rate-possible cardiac arrest-avoid in clients-hypersensitivity to “caine” medications-severely traumatized skin
137Topical Enzymes Remove dead tissue -enhances the formation of new tissue- promotes wound healingSelectively digest dead tissueSpecifically digest protein of dead tissueDestroys components of the necrotic tissue mass.
138Types-Collagenase (Santyl)-digests collagen that 75% of skin tissueFibrinolysin/Desoxyribonuclease (Elase)-dissolves the fibrin structure of blood clots/DNA strands- make up necrotic tissue.
139Nursing considerations Santyl-The wound must be free of antiseptic/antibacterial medicationsCompatible with triple antibiotic medicationApply Burrows solution to stop the enzymaticactionElase-Observe for hypersenitivity/allergic reaction
140Keratolytics Remove excess keratin layer of skin -acne, warts, psoriasis, corns calluses andfungal infectionsBreaks down the protein structure of the keratinlayer-easier removal of the compacted cellularmaterialTypes-Salicylic Acid, Lactic acid
141Nursing Considerations -Apply after bathing-Soaked in water for several minutes-Occlude with a dressing/plastic wrap afterapplying medication-Apply overnight and remove in the morning-Repeated applications will probably control thehyperkeratinic skin growth-occasional reapplications may be needed forreoccurrence