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INTEGUMENTARY OBJECTIVES 1-11 Integumentary system is made up of: Integumentary system is made up of: Skin, accessory structures, and subcutaneous tissues.

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Presentation on theme: "INTEGUMENTARY OBJECTIVES 1-11 Integumentary system is made up of: Integumentary system is made up of: Skin, accessory structures, and subcutaneous tissues."— Presentation transcript:

1 INTEGUMENTARY OBJECTIVES 1-11 Integumentary system is made up of: Integumentary system is made up of: Skin, accessory structures, and subcutaneous tissues Skin, accessory structures, and subcutaneous tissues Body covering separating internal environment from external environment Body covering separating internal environment from external environment Barrier against pathogens, most chemical, and injury to inner structures. Barrier against pathogens, most chemical, and injury to inner structures. Is an organ, the largest Is an organ, the largest 2 layers; epidermis and the dermis 2 layers; epidermis and the dermis

2 EPIDERMIS Stratified,squamous epithelial tissue Stratified,squamous epithelial tissue AVASCULAR; nourishment from DERMIS AVASCULAR; nourishment from DERMIS Thickest on palms of hands, soles of feet Thickest on palms of hands, soles of feet Innermost layer is STRATUM GERMANITIVUM Innermost layer is STRATUM GERMANITIVUM Mitosis occurs to produce NEW epidermal cells. Usually occurs at constant rate, but increased pressure produces increased production to form calluses. Mitosis occurs to produce NEW epidermal cells. Usually occurs at constant rate, but increased pressure produces increased production to form calluses.

3 New cells in the EPIDERMIS produce KERATIN New cells in the EPIDERMIS produce KERATIN Keratin is a waterproofing protein, prevents loss of water as well as prevents entry of excess H2O. When die and slough off, also removes pathogens Keratin is a waterproofing protein, prevents loss of water as well as prevents entry of excess H2O. When die and slough off, also removes pathogens As new cells get pushed to surface of epidermis, they die, become the STRATUM CORNEUM, OUTERMOST LAYER As new cells get pushed to surface of epidermis, they die, become the STRATUM CORNEUM, OUTERMOST LAYER Loss of large portions of this layer greatly increase risks for infection and dehydration Loss of large portions of this layer greatly increase risks for infection and dehydration

4 MELANOCYTES,cells in the lower EPIDERMIS, produce the protein MELANIN. Amounts produced are genetically determined. Melanin is what gives color to skin and hair. MELANOCYTES,cells in the lower EPIDERMIS, produce the protein MELANIN. Amounts produced are genetically determined. Melanin is what gives color to skin and hair. Exposing melanin to UV rays causes an increase in production. Melanin is incorporated in to the epidermal cells, making them darker before they die. Tanning is a direct result of this process. Exposing melanin to UV rays causes an increase in production. Melanin is incorporated in to the epidermal cells, making them darker before they die. Tanning is a direct result of this process. Melanin is important in that it acts as a pigment barrier to exposure from UV rays and thereby, protects the str. germanitivum from mutational changes that can lead to extensive skin damage and cancerous lesions. Melanin is important in that it acts as a pigment barrier to exposure from UV rays and thereby, protects the str. germanitivum from mutational changes that can lead to extensive skin damage and cancerous lesions.

5 Langerhans cells, a type of MACROPHAGE, are located in BOTH the epidermis and the dermis. They act to present ANTIGENS to the HELPER T CELLS; a first line barrier to invasion through the skin by pathogens Langerhans cells, a type of MACROPHAGE, are located in BOTH the epidermis and the dermis. They act to present ANTIGENS to the HELPER T CELLS; a first line barrier to invasion through the skin by pathogens

6 DERMIS Made up of fibrous connective tissue Made up of fibrous connective tissue Cells are called FIBROBLASTS Cells are called FIBROBLASTS They produce THE PROTEIN FIBERS OF COLLAGEN and ELASTIN,which support the skin and allow for some skin stretching and recoil They produce THE PROTEIN FIBERS OF COLLAGEN and ELASTIN,which support the skin and allow for some skin stretching and recoil THE DERMIS ALSO CONTAINS the hair and nail follicles, GLANDS, NERVE ENDINGS AND BLOOD SUPPLY. THE blood CAPILLARIES are found in the PAPILLARY layer of the dermis THE DERMIS ALSO CONTAINS the hair and nail follicles, GLANDS, NERVE ENDINGS AND BLOOD SUPPLY. THE blood CAPILLARIES are found in the PAPILLARY layer of the dermis

7 HAIR Developes in FOLLICLES located in the EPIDERMAL structures. Developes in FOLLICLES located in the EPIDERMAL structures. The hair root is a group of cells that undergo mitosis to produce the hair shaft The hair root is a group of cells that undergo mitosis to produce the hair shaft Cells die AFTER producing KERATIN and incorporating MELANIN Cells die AFTER producing KERATIN and incorporating MELANIN Eyelashes,eyebrows,keep dust and sweat out of eyes. Nostril hair filters air entering nasal cavities.Hair on head, not sparse body hair, provides for thermal regulation Eyelashes,eyebrows,keep dust and sweat out of eyes. Nostril hair filters air entering nasal cavities.Hair on head, not sparse body hair, provides for thermal regulation

8 NAILS Follicles found at ends of fingers and toes Follicles found at ends of fingers and toes Growth similar to growth of hair, starts in the layer of DERMIS Growth similar to growth of hair, starts in the layer of DERMIS Mitosis in nail root, produces new cells containing keratin. Mitosis in nail root, produces new cells containing keratin. Dead cells form the visible nail Dead cells form the visible nail Protect ends of digits from mechanical injury Protect ends of digits from mechanical injury

9 RECEPTORS SENSORY RECPTORS for the cutaneous senses are located in the DERMIS. SENSORY RECPTORS for the cutaneous senses are located in the DERMIS. FREE nerve endings are receptors for heat, cold and pain FREE nerve endings are receptors for heat, cold and pain ENCAPSULATED nerve endings are for touch and pressure ENCAPSULATED nerve endings are for touch and pressure Sensitivity is = to # of nerve endings present Sensitivity is = to # of nerve endings present

10 Sebaceous glands and sudoriferous glands Sebaceous gland ducts open into hair follicles or directly onto surface of skin Sebaceous gland ducts open into hair follicles or directly onto surface of skin Sebum (a lipid substance) is secreted Sebum (a lipid substance) is secreted Inhibits growth of some bacteria and drying of skin and hair Inhibits growth of some bacteria and drying of skin and hair Sudoriferous glands are SWEAT GLANDS Sudoriferous glands are SWEAT GLANDS 2 kinds: APOCRINE (modified scent glands),and ECCRINE (sweat is secreted onto skin surface) 2 kinds: APOCRINE (modified scent glands),and ECCRINE (sweat is secreted onto skin surface) APOCRINE found in axilla and genital areas. Activated by stress and emotions. APOCRINE found in axilla and genital areas. Activated by stress and emotions.

11 ECCRINE throughout dermis, but more numerous on face, palms, soles; activated by high temperatures or exercise. ECCRINE throughout dermis, but more numerous on face, palms, soles; activated by high temperatures or exercise. Effective cooling mechanism Effective cooling mechanism MODIFIED sweat glands or CERUMINOUS glands are located in the dermis of ear canals MODIFIED sweat glands or CERUMINOUS glands are located in the dermis of ear canals Prevents drying of outer surfaces of ear canal Prevents drying of outer surfaces of ear canal

12 BLOOD VESSELS In the dermis, they serve to provide nourishment. In the dermis, they serve to provide nourishment. ARTERIOLES are involved in body temp. maintenance ARTERIOLES are involved in body temp. maintenance Increased body heat results in vasodilatation, increased blood flow and loss of body heat to air or clothing Increased body heat results in vasodilatation, increased blood flow and loss of body heat to air or clothing Decreased body temp results in vasoconstriction with

13 SUBCUTANEOUS TISSUE Located BETWEEN dermis and muscles Located BETWEEN dermis and muscles Made up of areolar connective tissue and adipose tissue Made up of areolar connective tissue and adipose tissue Contains numerous WBCs (fights pathogens invading through the skin) Contains numerous WBCs (fights pathogens invading through the skin) Adipose tissue cushions some bones, provides for some insulation,but MOST IMPORTANTLY, provides for STORAGE OF FATS for energy needs Adipose tissue cushions some bones, provides for some insulation,but MOST IMPORTANTLY, provides for STORAGE OF FATS for energy needs

14 AGING EFFECTS OF AGING ON THE SKIN IS QUITE VISIBLE EFFECTS OF AGING ON THE SKIN IS QUITE VISIBLE Cell division in the epidermis slows. Cell division in the epidermis slows. Fibroblasts in the dermis die, dont regenerate Fibroblasts in the dermis die, dont regenerate Hair and skin much thinner Hair and skin much thinner Collagen/elastin fibers deteriorate Collagen/elastin fibers deteriorate Sebaceous and sweat glands decrease activity Sebaceous and sweat glands decrease activity

15 Skin frail and dry Skin frail and dry Less subcutaneous fat Less subcutaneous fat Temperature regulation labile in hot or cold weather; more sensitive to changes Temperature regulation labile in hot or cold weather; more sensitive to changes Melanocytes die, hair goes to gray Melanocytes die, hair goes to gray

16 NURSING ASSESSMENT May be only complaint or may be a manifestation of underlying systemic condition/psychological stress May be only complaint or may be a manifestation of underlying systemic condition/psychological stress Visibly communicates the clients health Visibly communicates the clients health WHATSUP questions WHATSUP questions INSPECTION AND PALPATION INSPECTION AND PALPATION Phys. Assessment includes skin,hair nails,scalp, and mucus membranes.Client must be fully disrobed but draped for privacy Phys. Assessment includes skin,hair nails,scalp, and mucus membranes.Client must be fully disrobed but draped for privacy Skin problems are common complaints

17 Well lit and warm room Well lit and warm room Nl skin is intact, warm, smooth, dry, well hydrated, with firm skin turgor. Surface is flexible and soft Nl skin is intact, warm, smooth, dry, well hydrated, with firm skin turgor. Surface is flexible and soft Know color ranges Know color ranges Know developmental changes Know developmental changes Inspect for color, moisture,lesions,edema, breaks in skin integrity, vascular markings, turgor, and cleanliness Inspect for color, moisture,lesions,edema, breaks in skin integrity, vascular markings, turgor, and cleanliness

18 COLOR obj. #6 Factors include temp of client, O2 level, blood flow, exposure to UV rays, positioning, genetic differences Factors include temp of client, O2 level, blood flow, exposure to UV rays, positioning, genetic differences Pallor; a decrease in color due to vasoconstriction, decreased blood flow or < HgB Pallor; a decrease in color due to vasoconstriction, decreased blood flow or < HgB BEST ASSESSED ON FACE, CONJUNCTIVA, NAILBEDS AND LIPS BEST ASSESSED ON FACE, CONJUNCTIVA, NAILBEDS AND LIPS

19 Erythema; reddish discoloration, also may indicate circulatory changes due to vasodilation, incr. blood flow to skin from fever or inflammation Erythema; reddish discoloration, also may indicate circulatory changes due to vasodilation, incr. blood flow to skin from fever or inflammation BEST ASSESSED ON FACE OR AREA OF TRAUMA/RASH BEST ASSESSED ON FACE OR AREA OF TRAUMA/RASH Jaundice (yellow-orange) may occur as result of liver disease. Jaundice (yellow-orange) may occur as result of liver disease. BEST ASSESSED IN SCLERA OF THE EYE BEST ASSESSED IN SCLERA OF THE EYE

20 Cyanosis; bluish discoloration Cyanosis; bluish discoloration Cardiac, pulmonary or perfusion problem Cardiac, pulmonary or perfusion problem BEST ASSESSED LIPS, NAILBEDS, CONJUNCTIVA, PALMS BEST ASSESSED LIPS, NAILBEDS, CONJUNCTIVA, PALMS People of mediterranean descent, may have nl bluish on lips coloration People of mediterranean descent, may have nl bluish on lips coloration Brown coloration due to increased melanin prod. Could be from chr. exposure to sun or due to pregnancy or PVD Brown coloration due to increased melanin prod. Could be from chr. exposure to sun or due to pregnancy or PVD BEST ASSESSED FACE, AREOLA, NIPPLES, AND AREAS EXPOSED TO SUN BEST ASSESSED FACE, AREOLA, NIPPLES, AND AREAS EXPOSED TO SUN

21 LESIONS obj. #7 Any change or injury to tissue Any change or injury to tissue Assessment may help determine cause of skin disorder Assessment may help determine cause of skin disorder Class. As primary; secondary Class. As primary; secondary PRIMARY represent initial reaction to a disease process PRIMARY represent initial reaction to a disease process SECONDARY lesions are the changes that take place in the primary lesion from infection, scratching, trauma or various disease stages SECONDARY lesions are the changes that take place in the primary lesion from infection, scratching, trauma or various disease stages

22 PRIMARY LESIONS Macule; flat, non-palpable, usually smaller than 1cm; freckle Macule; flat, non-palpable, usually smaller than 1cm; freckle Papule; palpable, solid raised lesion; wart, ringworm;1cm or less Papule; palpable, solid raised lesion; wart, ringworm;1cm or less Nodule; solid raised lesion, larger and deep; fibroma Nodule; solid raised lesion, larger and deep; fibroma Vesicle; small fluid filled blister type lesion; 1cm; chicken pox Vesicle; small fluid filled blister type lesion; 1cm; chicken pox

23 Bulla; larger fluid filled blister;>1cm, burns Bulla; larger fluid filled blister;>1cm, burns Pustule; sm. elevation of skin, vesicle or bulla that contains lymph or pus; impetigo/acne Pustule; sm. elevation of skin, vesicle or bulla that contains lymph or pus; impetigo/acne Wheal; round transient elevation of the skin caused by dermal edema; white in the center and red in the periphery; hives, insect bites Wheal; round transient elevation of the skin caused by dermal edema; white in the center and red in the periphery; hives, insect bites Plaque; PATCH, solid or raised lesion on skin OR mucus membrane >1cm in diameter; psoriasis Plaque; PATCH, solid or raised lesion on skin OR mucus membrane >1cm in diameter; psoriasis Cyst; CLOSED SACK OR POUCH; contains solid, semi-solid or liquid material; sebaceous cyst Cyst; CLOSED SACK OR POUCH; contains solid, semi-solid or liquid material; sebaceous cyst

24 SECONDARY LESIONS Scales Scales Crusts Crusts Excoriations Excoriations Fissures Fissures Ulcers Ulcers Lichenification Lichenification scar scar

25 configurations Discrete Discrete Grouped Grouped Confluent Confluent Linear Linear Annular Annular Polycyclic Polycyclic Arciform Arciform reticular reticular

26 NOTE: NOTE: Color Color Size in cm Size in cm Location Location Distribution Distribution Configuration (pattern) Configuration (pattern) Exudate (amt., color, odor, any other s/s) Exudate (amt., color, odor, any other s/s) Read how lesions may present in peoples of color Read how lesions may present in peoples of color

27 Check levels of hydration Check levels of hydration Dryness, moisture, scales and flakes Dryness, moisture, scales and flakes Moisture within skin folds Moisture within skin folds Should normally be smooth and dry Should normally be smooth and dry

28 PALPATION OBJ.#8 Utilized in conjunction with INSPECTION Utilized in conjunction with INSPECTION Dorsum of hand for temp. Dorsum of hand for temp. Palpate lesions with fingertips to deter. Size, contour, consistency Palpate lesions with fingertips to deter. Size, contour, consistency Note level of discomfort with palpation Note level of discomfort with palpation Wear gloves Wear gloves Turgor/texture Turgor/texture Back of forearm, over sternum (best for elderly) Back of forearm, over sternum (best for elderly) Tenting with gradual return= poss. Dehydr., aging Tenting with gradual return= poss. Dehydr., aging

29 Vascular marking Normal Normal Abnormal (petechiae, ecchymosis) Abnormal (petechiae, ecchymosis) Petechiae sm. Purplish hemorrhagic spots <0.5cm Petechiae sm. Purplish hemorrhagic spots <0.5cm Seen best on dark skinned persons on conjunctiva and oral mucosa Seen best on dark skinned persons on conjunctiva and oral mucosa Ecchymosis is a bruise; coloration changes Ecchymosis is a bruise; coloration changes

30 edema Dependent edema; part of body at lowest point; feet, ankles, sacrum Dependent edema; part of body at lowest point; feet, ankles, sacrum Often relieved with elevation and repositioning, elastic stockings, medications Often relieved with elevation and repositioning, elastic stockings, medications Brawny edema Brawny edema Pre-tibial edema Pre-tibial edema

31 Edema Edema Occurs due to build up of fluid in the tissues Occurs due to build up of fluid in the tissues Skin becomes stretched, taut and shiney Skin becomes stretched, taut and shiney Location, distribution and color are determined and documented Location, distribution and color are determined and documented If unilateral, compare to other side If unilateral, compare to other side Measure to track progression or regression Measure to track progression or regression

32 When suspect edema, palpate for tenderness, mobility, and consistency When suspect edema, palpate for tenderness, mobility, and consistency Pressure from finger/thumb 5sec. leaves indentation (pitting edema) Pressure from finger/thumb 5sec. leaves indentation (pitting edema) Classified by depth Classified by depth 1+=1mm depth or trace edema 1+=1mm depth or trace edema 2+= 2mm or small amt. edema 2+= 2mm or small amt. edema 3+=moderate edema 3+=moderate edema 4+ large amount of edema 4+ large amount of edema

33 hair Hair distribution is palpated Hair distribution is palpated Quantity, thickness, and texture Quantity, thickness, and texture Note any areas of ALOPECIA Note any areas of ALOPECIA Terminal hair is hair of scalp, eyebrows, axillae, pubic areas in both sexes and facial and chest hair with men Terminal hair is hair of scalp, eyebrows, axillae, pubic areas in both sexes and facial and chest hair with men VELLUS hairs are soft downey covering body VELLUS hairs are soft downey covering body Normally has uniform distribution Normally has uniform distribution

34 Scalp hair can be thick, thin, coarse, shiney, curly, straight Scalp hair can be thick, thin, coarse, shiney, curly, straight Describe distribution and cleanliness Describe distribution and cleanliness

35 NAILS Reflect general health Reflect general health Color, shape, texture, thickness, any abnormalities Color, shape, texture, thickness, any abnormalities Normally pink, smooth, hard, slightly convex (160 degree) with firm base Normally pink, smooth, hard, slightly convex (160 degree) with firm base Elderly: yellowish-gray, thickening, ridges Elderly: yellowish-gray, thickening, ridges Brown or black pigm. between nail and nail base In persons of color is nl Brown or black pigm. between nail and nail base In persons of color is nl

36 Abnl findings include clubbing (poss. Hypoxia) Abnl findings include clubbing (poss. Hypoxia) Spoon nails (concave)(koilonchia); poss. Anemia Spoon nails (concave)(koilonchia); poss. Anemia Thick nails; (poss. Fungal infection) Thick nails; (poss. Fungal infection) Observe for redness, swelling, tenderness Observe for redness, swelling, tenderness Beaus lines Beaus lines Splinter hemorrhages Splinter hemorrhages paronychia paronychia

37 Diagnostic tests obj.#9 Cultures to show presence of bacteria, fungi, viruses Cultures to show presence of bacteria, fungi, viruses fungi: specimen in 10% KOH; remains at room temp until sent to lab fungi: specimen in 10% KOH; remains at room temp until sent to lab viral: fluid gently expressed from intact vesicle with sterile swab, special culture tube MUST BE KEPT ON ICE until sent to lab ASAP viral: fluid gently expressed from intact vesicle with sterile swab, special culture tube MUST BE KEPT ON ICE until sent to lab ASAP See box 50-2 for instr. On wound cultures See box 50-2 for instr. On wound cultures

38 Skin biopsy Indicated for deeper infection Indicated for deeper infection Eval. For dx and/or efficacy of current tx Eval. For dx and/or efficacy of current tx Excision of small piece of tissue Excision of small piece of tissue Punch bx: plug of tissue for full thickness specimen Punch bx: plug of tissue for full thickness specimen Incisional bx: deep incision with scalpel Incisional bx: deep incision with scalpel ALWAYS REQUIRES CLOSURE WITH SUTURE ALWAYS REQUIRES CLOSURE WITH SUTURE Shave bx removes area of skin just above rest of skin Shave bx removes area of skin just above rest of skin

39 All bx require sterile field/technique All bx require sterile field/technique Prepare client Prepare client Most painful part is ususally injection of local anesthetic Most painful part is ususally injection of local anesthetic

40 WOODS LIGHT is use of UV rays to detect fluorescent substances in hair and skin that are present during certain diseases such as tinea capitis (ringworm) WOODS LIGHT is use of UV rays to detect fluorescent substances in hair and skin that are present during certain diseases such as tinea capitis (ringworm) Hand held black light in darkened room Hand held black light in darkened room

41 Skin testing Patch and scratch when allergic dermatitis is suspected Patch and scratch when allergic dermatitis is suspected Done by dermatolgist on uninvolved skin/upper back, arms, must be shaved Done by dermatolgist on uninvolved skin/upper back, arms, must be shaved SCRATCH; superficial scratch or prick with allergen; IMMEDIATE REACTION SCRATCH; superficial scratch or prick with allergen; IMMEDIATE REACTION Wheal= + reaction Wheal= + reaction MUST HAVE RESUSCITATION EQUIP AVAIL. MUST HAVE RESUSCITATION EQUIP AVAIL.

42 PATCH test: delayed hypersensitivity PATCH test: delayed hypersensitivity Develops in 48-96h Develops in 48-96h Allergens applied under occlusive tape patches Allergens applied under occlusive tape patches Review procedure Review procedure Final reading in 2-5 days Final reading in 2-5 days

43 Therapeutic measures obj.#10 Wet compresses for acute, weeping, crusted, inflammatory, ulcerative lesions Wet compresses for acute, weeping, crusted, inflammatory, ulcerative lesions Decrease inflammation, cleanse and dry the wound Decrease inflammation, cleanse and dry the wound To continue drainage from the area To continue drainage from the area Can be ordered as sterile or clean procedures Can be ordered as sterile or clean procedures Cool tap H2O, Burrows, normal saline, magnesium sulfate Cool tap H2O, Burrows, normal saline, magnesium sulfate applied q3-4 h for 15-20min applied q3-4 h for 15-20min Not prescribed for more than 72h/skin too dry or macerated. Not prescribed for more than 72h/skin too dry or macerated. For cool compr. Reapply q 5-10min For cool compr. Reapply q 5-10min

44 Balneotherapy: therapeutic baths Balneotherapy: therapeutic baths Medicate large areas of skin, remove old medications, debridement, relieve itching and inflammation Medicate large areas of skin, remove old medications, debridement, relieve itching and inflammation Lasts for 15-30min. Lasts for 15-30min. Bathmats are important Bathmats are important Water/saline for weeping, oozing, and erythematous lesions Water/saline for weeping, oozing, and erythematous lesions

45 Colloidal baths for wide area of lesions, to dry and relieve itching Colloidal baths for wide area of lesions, to dry and relieve itching Medicated tar baths for chronic eczema and psoriasis Medicated tar baths for chronic eczema and psoriasis Need WELL VENTILATED ROOM Need WELL VENTILATED ROOM To increase hydration of skin after bath, use lubricating agent applied to damp skin To increase hydration of skin after bath, use lubricating agent applied to damp skin An EMOLLIENT is used for LUBRICATION AND TO RELIEVE ITCHING An EMOLLIENT is used for LUBRICATION AND TO RELIEVE ITCHING

46 Topical medications Include lotions, ointments, creams, gels, pastes, intralesional therapy Include lotions, ointments, creams, gels, pastes, intralesional therapy May need systemic medications as well May need systemic medications as well Review how and why each type of medication is used and how applied. Review how and why each type of medication is used and how applied. Powders should not be used with clients with respiratory or traches Powders should not be used with clients with respiratory or traches

47 DRESSINGS Used to enhance absorption of topical meds, promote retention of moisture, prevent evaporation of medication, reduce pain and itching Used to enhance absorption of topical meds, promote retention of moisture, prevent evaporation of medication, reduce pain and itching Occlusive drsg; to seal wound; airtight plastic film placed over topical agent Occlusive drsg; to seal wound; airtight plastic film placed over topical agent Tube gauze, cotton socks, gloves, etc. Tube gauze, cotton socks, gloves, etc. Medication may be impregnated within drsg (chordran tape Medication may be impregnated within drsg (chordran tape Review nursing care plan for client with occlusive drsg (50-3)pg 946 Review nursing care plan for client with occlusive drsg (50-3)pg 946 Applied ONLY to wound area, not healthy skin Applied ONLY to wound area, not healthy skin

48 Transparent dressings, (Opsite,Tegaderm) Transparent dressings, (Opsite,Tegaderm) Hydrocolloid protect areas exposed to pressure, and treat ulcers in beginning stages Hydrocolloid protect areas exposed to pressure, and treat ulcers in beginning stages Gels, pastes, granules to fill in deep wounds/ulcers to promote granulation and healing Gels, pastes, granules to fill in deep wounds/ulcers to promote granulation and healing

49 TYPES OF TREATMENTS AND REMOVAL OF LESIONS Mohs chemosurgery technique; method of excising tumors of the skin, done in layers until entire tumor removed. Insures complete removal of the tumor. Helpful in tx of basal cell cancers (pg 1375 Tabers) Mohs chemosurgery technique; method of excising tumors of the skin, done in layers until entire tumor removed. Insures complete removal of the tumor. Helpful in tx of basal cell cancers (pg 1375 Tabers)

50 Cryosurgery; use of extremely cold probes to destroy unwanted, or cancerous or infected tissues (508,T.) Cryosurgery; use of extremely cold probes to destroy unwanted, or cancerous or infected tissues (508,T.) Photochemotherapy; use of light and chemical together to treat certain conditions such as psoriasis or cutaneous T-cell lymphoma Photochemotherapy; use of light and chemical together to treat certain conditions such as psoriasis or cutaneous T-cell lymphoma

51 WOUND HEALING OBJ#11 HEAL BY : HEAL BY : FIRST INTENTION; SECOND INTENTION AND THIRD INTENTION FIRST INTENTION; SECOND INTENTION AND THIRD INTENTION Edges approximated and closed with sutures= 1 st intent; minimal scarring. Edges approximated and closed with sutures= 1 st intent; minimal scarring. 2 nd intent=wound left open to heal by granulation; scarring may be extensive 2 nd intent=wound left open to heal by granulation; scarring may be extensive 3 rd intent=infected site may be left open/reopened until all signs of infection are gone, then surgically closed 3 rd intent=infected site may be left open/reopened until all signs of infection are gone, then surgically closed

52 NSG CARE FOR OPEN LESION Assess site minimum 3x day (4h x3) Assess site minimum 3x day (4h x3) Assess for dead tissue, maceration, exudates, Assess for dead tissue, maceration, exudates, Cleanse, pat dry Cleanse, pat dry Apply agent and occlusive drsg Apply agent and occlusive drsg REMOVE for 12h out of 24h REMOVE for 12h out of 24h Assess/eval forprogression/regression Assess/eval forprogression/regression

53 REVIEW ALL LEARNING TIP BOXES REVIEW ALL LEARNING TIP BOXES REVIEW ANY BOXES WITH INFORMATION IN THEM REVIEW ANY BOXES WITH INFORMATION IN THEM

54 PRESSURE ULCERS OBJ.#12-14 SORE CAUSED BY PROLONGED PRESSURE AGAINST SKIN in one position SORE CAUSED BY PROLONGED PRESSURE AGAINST SKIN in one position Weight of body compresses capillaries against a solid object, especially over bony prominences Weight of body compresses capillaries against a solid object, especially over bony prominences Results in tissue anoxia Results in tissue anoxia Start to develop in 20-40min.if pressure not relieved Start to develop in 20-40min.if pressure not relieved

55 Assess at risk client Assess at risk client Use Braden scale or similar scale Use Braden scale or similar scale Assess labs for low serum albumin, anemia, level of immobility and incontinence Assess labs for low serum albumin, anemia, level of immobility and incontinence

56 Other causes include tight splints, casts, traction Other causes include tight splints, casts, traction At risk are the immobile, decreased sensation, decreased circulation, decreased neurological function At risk are the immobile, decreased sensation, decreased circulation, decreased neurological function Mechanical forces are friction, shear and pressure. Mechanical forces are friction, shear and pressure. When pressure to the skin is greater than the capillary bed pressure, there is impairment of cellular metabolism with decreased blood supply to cells causing tissue ischemia. When pressure to the skin is greater than the capillary bed pressure, there is impairment of cellular metabolism with decreased blood supply to cells causing tissue ischemia. The reduction in blood flow causes BLANCHING.(LOSS OF COLOR) The reduction in blood flow causes BLANCHING.(LOSS OF COLOR)

57 FRICTION rubbing of skin surface with an external mechanical force.giving the effect of sheet burns. FRICTION rubbing of skin surface with an external mechanical force.giving the effect of sheet burns. SHEARINGoccurs when pt slides down or is pulled up without lifting buttocks. Skin and subcut. tissues remain stationary; fat, muscle and bone shift in direction of bodys movement SHEARINGoccurs when pt slides down or is pulled up without lifting buttocks. Skin and subcut. tissues remain stationary; fat, muscle and bone shift in direction of bodys movement Damage occurs deep in tissues Damage occurs deep in tissues

58 Prolonged pressure occurs in the elderly due to nl skin changes Prolonged pressure occurs in the elderly due to nl skin changes The obese, because fat cells are poorly vascularized, the thin, because there is little padding over prominences, and those with impaired peripheral circulation The obese, because fat cells are poorly vascularized, the thin, because there is little padding over prominences, and those with impaired peripheral circulation

59 Signs and symptoms Pain at ulcer site Pain at ulcer site Freq. assess at common sites: sacrum, heels, elbows, lateral malleoli, greater trochanters, ischial tuberosities Freq. assess at common sites: sacrum, heels, elbows, lateral malleoli, greater trochanters, ischial tuberosities Describe according to 3 color system Describe according to 3 color system blackened tissue=necrosis blackened tissue=necrosis yellow color and with exudates=infection present yellow color and with exudates=infection present redwounds are pink/red and are in the healing stages redwounds are pink/red and are in the healing stages

60 Treat worst color first Treat worst color first Dead tissue must be removed first or healing will not take place Dead tissue must be removed first or healing will not take place

61 Interventions obj.#13 Box 51-1avoid use of soap and water on dry skin Box 51-1avoid use of soap and water on dry skin Clean and dry between toes Clean and dry between toes Perineal cleansers Perineal cleansers Moisturizing agents without alcohol Moisturizing agents without alcohol Avoid areas of pressure,dont massage areas of redness Avoid areas of pressure,dont massage areas of redness Assess for areas of redness, if stage 1, initiate turn/position schedules Assess for areas of redness, if stage 1, initiate turn/position schedules

62 Short fingernails Short fingernails Use of pillows, pads to maintain good body alignment. Use of specialty mattresses, pads to decrease pressure Use of pillows, pads to maintain good body alignment. Use of specialty mattresses, pads to decrease pressure Encourage activity. Continue to assess skin and position Encourage activity. Continue to assess skin and position Teach patient to shift weight q15min. When lying or sitting Teach patient to shift weight q15min. When lying or sitting If immobile, needs freq. active/passive ROM If immobile, needs freq. active/passive ROM Provide high protein, vitamin rich diet Provide high protein, vitamin rich diet Braden scale to assess for risk Braden scale to assess for risk

63 Heels should not rest on bed Heels should not rest on bed Avoid source of any pressure behind calves if using pillows to elevate heels Avoid source of any pressure behind calves if using pillows to elevate heels Use protectors to alleviate pressure on vulnerable sites Use protectors to alleviate pressure on vulnerable sites NEVER USE A DONUT NEVER USE A DONUT Avoid allowing skin surfaces to rub together Avoid allowing skin surfaces to rub together Use trapeze, draw sheets to move pt in bed Use trapeze, draw sheets to move pt in bed

64 Complications are wound infections, progression to a deeper, larger wound Complications are wound infections, progression to a deeper, larger wound

65 DIAGNOSTIC TESTS All considered to be colonized with bacteria( bacteria present); wound not necessarily infected All considered to be colonized with bacteria( bacteria present); wound not necessarily infected Cleansing and mech. debridement can prevent progression to infection Cleansing and mech. debridement can prevent progression to infection Swab cultures; cultures for sensitivity done to identify causative agent from suspected infected sites Swab cultures; cultures for sensitivity done to identify causative agent from suspected infected sites Must determine between infection and bacterial colonization. If wound is healing by 2 nd intention, will be colonized by flora on skin and in environment. If growth exceeds local tissue defenses, then becomes a true infaction Must determine between infection and bacterial colonization. If wound is healing by 2 nd intention, will be colonized by flora on skin and in environment. If growth exceeds local tissue defenses, then becomes a true infaction

66 When ulcer not healing, invasive/non- invasive blood supply studies are recommended When ulcer not healing, invasive/non- invasive blood supply studies are recommended Wound biopsies may be obtained in the case of large, extensive wounds Wound biopsies may be obtained in the case of large, extensive wounds Medical treatment varies with size, depth and stage of ulcer, pt condition. Medical treatment varies with size, depth and stage of ulcer, pt condition. ALL PRESSURE MUST BE REMOVED FOR HEALING TO OCCUR, cleanliness maintained ALL PRESSURE MUST BE REMOVED FOR HEALING TO OCCUR, cleanliness maintained Debridement, cleansing and wound drsg. To provide moist, healing environment Debridement, cleansing and wound drsg. To provide moist, healing environment

67 Debridement: removal of non-viable tissue from the wound Debridement: removal of non-viable tissue from the wound Non-surgical means: mechanical, enzymatic, autolytic Non-surgical means: mechanical, enzymatic, autolytic Mech.; scissors/forceps; dextranomer beads; whirlpool baths; wet to dry saline gauze Mech.; scissors/forceps; dextranomer beads; whirlpool baths; wet to dry saline gauze

68 Results in non-selective debridement Results in non-selective debridement Usually very painful; pt needs premed Usually very painful; pt needs premed Enzymatic proteolytic agent; selectively digests necrotic tissue. Requires very careful application. Will digest living tissue also Enzymatic proteolytic agent; selectively digests necrotic tissue. Requires very careful application. Will digest living tissue also Autolytic; use of synthetic dressing; a moisture retentive drsg. Eschar is Autolytic; use of synthetic dressing; a moisture retentive drsg. Eschar is self digested due to enzyme action. NOT USED FOR INFECTED WOUNDS self digested due to enzyme action. NOT USED FOR INFECTED WOUNDS

69 SURGICAL debridement removal by scalpel, of devitalized tissue, thick adherent eschar. SURGICAL debridement removal by scalpel, of devitalized tissue, thick adherent eschar. May need a graft to close wound, espec. For full thickness ulcer or loss of joint funct involves a donor site May need a graft to close wound, espec. For full thickness ulcer or loss of joint funct involves a donor site Needs continual assess for pain during procedure Needs continual assess for pain during procedure

70 Wound cleansing Should be cleansed with whirlpool or shower head/irrigation with between 4- 15lbs per sq. inch(psi) Should be cleansed with whirlpool or shower head/irrigation with between 4- 15lbs per sq. inch(psi) Less than 4psi does not effectively cleanse. Greater than 15psi may damage good tissue Less than 4psi does not effectively cleanse. Greater than 15psi may damage good tissue If wound debris or light layer of eschar present, use 30ml syringe with 18g needle/250ml of NS If wound debris or light layer of eschar present, use 30ml syringe with 18g needle/250ml of NS This pressure will also remove bacteria This pressure will also remove bacteria

71 If wound healing and tissue is red ( sign of new granulation tissue), use 30-60ml NEEDLELESS syringe to prevent trauma to new fragile tissue. After cleansing/dbr. Apply occlusive drg If wound healing and tissue is red ( sign of new granulation tissue), use 30-60ml NEEDLELESS syringe to prevent trauma to new fragile tissue. After cleansing/dbr. Apply occlusive drg Wounds need moist env, minimal bacterial colonization and a healing temp; takes 12h to occur.if freq removed, may not reach healing temp Wounds need moist env, minimal bacterial colonization and a healing temp; takes 12h to occur.if freq removed, may not reach healing temp Infected wounds are NOT covered with occlusive Infected wounds are NOT covered with occlusive

72 Wound dressings Vary according to size, location, depth, stage of ulcer Vary according to size, location, depth, stage of ulcer Commonly used materials; hydrogel, polyurethane, hydocolloid wafers, biologic agents, alginates and cotton gauze Commonly used materials; hydrogel, polyurethane, hydocolloid wafers, biologic agents, alginates and cotton gauze Use hypoallergenic tape to secure Use hypoallergenic tape to secure PRESSURE MUST BE KEPT OFF OF ULCER PRESSURE MUST BE KEPT OFF OF ULCER

73 Nursing assessment Ongoing assessment Ongoing assessment Recognize causative factors and any impediments to healing Recognize causative factors and any impediments to healing Wound measurements including depth Wound measurements including depth Probe gently with q-tip to detect and measure tunneling Probe gently with q-tip to detect and measure tunneling

74 Wound staging 1; skin intact but red and does NOT blanch; may have warmth, hardness and deeper tissue damage 1; skin intact but red and does NOT blanch; may have warmth, hardness and deeper tissue damage 2; break in skin with PARTIAL THICKNESS LOSS OF EPIDERMIS/DERMIS. Appears as a shallow crater, abrasion, or a blister 2; break in skin with PARTIAL THICKNESS LOSS OF EPIDERMIS/DERMIS. Appears as a shallow crater, abrasion, or a blister

75 3; full thickness skin loss that extends to the subcutaneous tissue, BUT NOT THE FASCIA. There may be undermining of adjacent tissue. Looks like a deep crater, may have eschar 3; full thickness skin loss that extends to the subcutaneous tissue, BUT NOT THE FASCIA. There may be undermining of adjacent tissue. Looks like a deep crater, may have eschar 4; full thickness loss with damage into the muscle, bone, other support structures. May have undermining and sinus tracts 4; full thickness loss with damage into the muscle, bone, other support structures. May have undermining and sinus tracts

76 Assess the wound exudate Assess the wound exudate Will be serosanguiness or may be purulent Will be serosanguiness or may be purulent Purulent may have color and odor depending on the infecting agent Purulent may have color and odor depending on the infecting agent Yellow = staph Yellow = staph Beige and fishy=proteus Beige and fishy=proteus Green-blue /fruity=pseudomonas Green-blue /fruity=pseudomonas Brown/fecal=bacteroides Brown/fecal=bacteroides

77 Assess for granulation Assess for granulation Should be pink/red and slightly spongey Should be pink/red and slightly spongey Assess ulcer min. q24h; color, size, exudate Assess ulcer min. q24h; color, size, exudate Assess pt temp Assess pt temp Provide wound care/sterile technique Provide wound care/sterile technique Assess pt for pain/can pt sleep, eat Assess pt for pain/can pt sleep, eat

78 Inflammatory skin problems dermatitis obj15-17 Char. by itching, redness, lesions of varying sizes and distribution Char. by itching, redness, lesions of varying sizes and distribution Often caused by exposure to allergens, irritants,: can be precipitated by emotional stress and genetic factors Often caused by exposure to allergens, irritants,: can be precipitated by emotional stress and genetic factors Eczema ( non-specific term) and dermatitis used interchangeably Eczema ( non-specific term) and dermatitis used interchangeably

79 Contact dermatitis: acute/chronic Contact dermatitis: acute/chronic Caused by DIRECT CONTACT WITH IRRITATING SUBSTANCE; SOAP, MEDICINE Caused by DIRECT CONTACT WITH IRRITATING SUBSTANCE; SOAP, MEDICINE Allergic: contact with an allergen resulting in A CELL MEDIATED IMMUNE RESPONSE Allergic: contact with an allergen resulting in A CELL MEDIATED IMMUNE RESPONSE Atopic: chronic, inherited, assoc with asthma. Lesions often become lichenified and hyperpigmented Atopic: chronic, inherited, assoc with asthma. Lesions often become lichenified and hyperpigmented

80 Seborrheic: chronic inflammatory, see seborrhea,excessive production of sebaceous secretions ( scalp face, axilla, genitocrural areas), greasy scales,yellow or pink-yellow crusts Seborrheic: chronic inflammatory, see seborrhea,excessive production of sebaceous secretions ( scalp face, axilla, genitocrural areas), greasy scales,yellow or pink-yellow crusts Assoc. with emot. Stress, often a genetic pre-disposition Assoc. with emot. Stress, often a genetic pre-disposition

81 3 types are common 3 types are common Atopic, contact, seborreic Atopic, contact, seborreic Chronic, usually respond to tx, but recur Chronic, usually respond to tx, but recur See preventive measures See preventive measures Present as dry flakey scales, yellow crusts, fissures, macules, papules Present as dry flakey scales, yellow crusts, fissures, macules, papules Worsen with continued irritation and exposure to offending agents Worsen with continued irritation and exposure to offending agents

82 Dx based on hx, s/s, clinical findings. Dx based on hx, s/s, clinical findings. Review table 51-1 Review table 51-1 Tx based upon s/s Tx based upon s/s Control itching, pain, decrease inflammation, control or prevent crust formations, prevent further skin damage, infection Control itching, pain, decrease inflammation, control or prevent crust formations, prevent further skin damage, infection

83 Measures to control s/s are: Measures to control s/s are: Use of antihistamines, anti-puretics and analgesics to control itching and pain Use of antihistamines, anti-puretics and analgesics to control itching and pain Use of steroids topically, intralesionally or systemically to control inflammation Use of steroids topically, intralesionally or systemically to control inflammation Topical is preferred as systemic use over the long term can cause side effects and adrenal suppression Topical is preferred as systemic use over the long term can cause side effects and adrenal suppression Read page 325 in Davis 10 th edit. For s/e to corticosteroids Read page 325 in Davis 10 th edit. For s/e to corticosteroids

84 Use whatsup for nsg assess. Be sure to include assessment for altered body image Use whatsup for nsg assess. Be sure to include assessment for altered body image Review your NANDA dx; impaired skin integrity, disturbed body image, and defic. Knowledge related to disease and tx Review your NANDA dx; impaired skin integrity, disturbed body image, and defic. Knowledge related to disease and tx Goals of tx to keep skin intact, or improve, prevent infect., maintain comfort Goals of tx to keep skin intact, or improve, prevent infect., maintain comfort

85 Give me at least 10 questions with rationales from whatsup, 50-1 Give me at least 10 questions with rationales from whatsup, 50-1 Display an accepting attitude Display an accepting attitude Teaching for how to apply medications, robin Teaching for how to apply medications, robin How are you able to measure your goals for effectiveness of tx How are you able to measure your goals for effectiveness of tx Controlled or in remission, itching or discomfort minimal, able to socialize, pt able to describe and demonstrate self care Controlled or in remission, itching or discomfort minimal, able to socialize, pt able to describe and demonstrate self care

86 Psoriasis Chr. Inflammatory disorder in which the EPIDERMAL CELLS proliferate abnormally fast. Ordinarily takes 27 days. With psoriasis, takes only 4-5 Chr. Inflammatory disorder in which the EPIDERMAL CELLS proliferate abnormally fast. Ordinarily takes 27 days. With psoriasis, takes only 4-5 The abnl keratin forms loosly adherent scales on reddened base The abnl keratin forms loosly adherent scales on reddened base Exacerbations/remissions Exacerbations/remissions Cause unknown, but has large familial component Cause unknown, but has large familial component

87 Onset can be any age with 27y being the average Onset can be any age with 27y being the average Severe if starts in childhood Severe if starts in childhood Sun /humidity may suppress Sun /humidity may suppress Strep pharyngitis, stress, hormonal changes, weather, skin trauma and meds ( antimalarials, beta blockers and lithium) may exacerbate Strep pharyngitis, stress, hormonal changes, weather, skin trauma and meds ( antimalarials, beta blockers and lithium) may exacerbate

88 No known true prevention, but avoid stress, meds, trauma, resp. infections if poss. No known true prevention, but avoid stress, meds, trauma, resp. infections if poss. s/s vary with type of psoriasis s/s vary with type of psoriasis Lesions usually are red papules that join to form plaques with DISTINCT BORDERS silvery scales form on untreated lesions Lesions usually are red papules that join to form plaques with DISTINCT BORDERS silvery scales form on untreated lesions Most affected areas are: ELBOWS, KNEES, SCALP, UMBILICUS, GENITALS Most affected areas are: ELBOWS, KNEES, SCALP, UMBILICUS, GENITALS May see nail involvement, dry, brittle hair May see nail involvement, dry, brittle hair

89 Complications may include secondary infections, psoriatic arthritis Complications may include secondary infections, psoriatic arthritis Systemic s/s and lymphadenopathy Systemic s/s and lymphadenopathy Tests would depend on severity Tests would depend on severity Usually done on phys. Findings Usually done on phys. Findings Testing done to dx a concurrent disease or secondary infect. Testing done to dx a concurrent disease or secondary infect.

90 Anthralin, a strong irritant, may be used with salicylic acid as a paste. Anthralin, a strong irritant, may be used with salicylic acid as a paste. Can cause a chemical burn, not on for >2h Can cause a chemical burn, not on for >2h Used with tar and UV light under close medical supervision Used with tar and UV light under close medical supervision UVB (short wave) and UVA (long wave) amount of exposure dtermined by pts condit., pigmentation and susceptibility UVB (short wave) and UVA (long wave) amount of exposure dtermined by pts condit., pigmentation and susceptibility

91 Occlusive drsgs enhance penetration of meds Occlusive drsgs enhance penetration of meds Keratolytics enhance effects of salicylic acid to loosen, remove scales Keratolytics enhance effects of salicylic acid to loosen, remove scales Tars are usually prescribed along with steroids. Tars act to slow cell division in the epidermal layers Tars are usually prescribed along with steroids. Tars act to slow cell division in the epidermal layers Never use occlusive drsgs with tars Never use occlusive drsgs with tars

92 Must WEAR EYE GUARDS during tx Must WEAR EYE GUARDS during tx PUVA tx is oral Psoralen used in conjunct with UVA tx. This tx temporarily inhibits DNA synthesis PUVA tx is oral Psoralen used in conjunct with UVA tx. This tx temporarily inhibits DNA synthesis Pt MUST WEAR DARK GLASSES DURING TX AND FOR ENTIRE DAY AFTER TX. Longterm effects are unknown. Possible incr. risk of skin cancers, premature aging and actinic keratosis Pt MUST WEAR DARK GLASSES DURING TX AND FOR ENTIRE DAY AFTER TX. Longterm effects are unknown. Possible incr. risk of skin cancers, premature aging and actinic keratosis

93 Observe pt closely for redness, tenderness, edema and eye changes Observe pt closely for redness, tenderness, edema and eye changes Depending upon pt condition, initial and f/u eye exams, skin bx, urinalysis and blood work may be ordered Depending upon pt condition, initial and f/u eye exams, skin bx, urinalysis and blood work may be ordered Antimetabolites..a last resort Antimetabolites..a last resort Methotrexate most common agent, can lead to hepatotoxicity. Liver bx and labs are routinely done prior to tx. Contraindicated in persons with any liver, renal or bone marrow disease Methotrexate most common agent, can lead to hepatotoxicity. Liver bx and labs are routinely done prior to tx. Contraindicated in persons with any liver, renal or bone marrow disease

94 Nursing care would be the same as for any pt with a dermatitis, but be sure to emphasize freq. periods of rest to enhance the antimitotic effects of the medications Nursing care would be the same as for any pt with a dermatitis, but be sure to emphasize freq. periods of rest to enhance the antimitotic effects of the medications

95 Usually females pred. In males, often have Rhinophyma (enlarged, redenned/purplish nose Usually females pred. In males, often have Rhinophyma (enlarged, redenned/purplish nose Heat/cold, spicey foods Heat/cold, spicey foods Avoid temp. extremes/alcohol/stress Avoid temp. extremes/alcohol/stress

96

97 Rosacea Chronic acneform disorder of face Chronic acneform disorder of face Increased reactions of capillaries to heat Increased reactions of capillaries to heat Often exists with acne Often exists with acne Often cause of significant facial cosmetic disfigurement Often cause of significant facial cosmetic disfigurement Age 30-50y Age 30-50y

98 INFECTIOUS SKIN DISORDERS Impetigo contagiosa Impetigo contagiosa Common, infectious, inflammatory skin disorder Common, infectious, inflammatory skin disorder Strep or staph Strep or staph Pools, pets, dirt fingernails, contaminated materials, or secondary to scrapes, cuts, etc. Pools, pets, dirt fingernails, contaminated materials, or secondary to scrapes, cuts, etc.

99 Primary infection appears on exposed areas, extrem., hands, face, neck, skin folds Primary infection appears on exposed areas, extrem., hands, face, neck, skin folds OOZING, THIN ROOFED VESICLE that grows rapidly and produces a HONEY COLORED CRUST; EASILY REMOVED, replaced with new ones OOZING, THIN ROOFED VESICLE that grows rapidly and produces a HONEY COLORED CRUST; EASILY REMOVED, replaced with new ones Heal in 1-2wks if allowed to dry Heal in 1-2wks if allowed to dry

100 COMPLICATIONS GLOMERULONEPHRITIS FROM A PARTICULAR STRAIN OF STREP(PG 599) GLOMERULONEPHRITIS FROM A PARTICULAR STRAIN OF STREP(PG 599) EASILY SPREAD TO OTHER PARTS OF BODY EASILY SPREAD TO OTHER PARTS OF BODY Will persist if lesions not allowed to dry Will persist if lesions not allowed to dry Secondary PYODERMA..ACUTE, INLAMMATORY PURULENT DERMATITIS, if lesions not responsive to tx Secondary PYODERMA..ACUTE, INLAMMATORY PURULENT DERMATITIS, if lesions not responsive to tx

101 TREATMENT SYSTEMIC ANTIBIOTICS SYSTEMIC ANTIBIOTICS TOPICALANTIBIOTICS AFTER REMOVAL OF CRUSTS TOPICALANTIBIOTICS AFTER REMOVAL OF CRUSTS Gentle washing with mild soap and warm water to remove crusts Gentle washing with mild soap and warm water to remove crusts Antipyretics Antipyretics Clean hands/nails, mitts, GOOD HYGIENE Clean hands/nails, mitts, GOOD HYGIENE REMAIN HOME UNTIL ALL LESIONS ARE HEALED REMAIN HOME UNTIL ALL LESIONS ARE HEALED Observe for 6-7 weeks for s/s glomerular nephritis Observe for 6-7 weeks for s/s glomerular nephritis

102 HERPES SIMPLEX common viral infection Hsv1 and hsv2 Hsv1 and hsv2 HSV-1 occurs above the waist, typical cold sore on mouth HSV-1 occurs above the waist, typical cold sore on mouth HSV-2 occurs below the waist and causes genital herpes HSV-2 occurs below the waist and causes genital herpes Primary infection occurs thru direct contact, respiratory droplet or exposure to fluid filled vesicles Primary infection occurs thru direct contact, respiratory droplet or exposure to fluid filled vesicles

103 Lies dormant in nerve ganglia near the spinal cord…immune system cant destroy it. At this time, pt has no s/s, may first present with pain, itching, burning at site of breakout Lies dormant in nerve ganglia near the spinal cord…immune system cant destroy it. At this time, pt has no s/s, may first present with pain, itching, burning at site of breakout Recurrence is spontaneous; stress, lowered immune, fatigue, injury Recurrence is spontaneous; stress, lowered immune, fatigue, injury Secondary lesion may be single or as a group of vesicles or pustueles on an erythematous base Secondary lesion may be single or as a group of vesicles or pustueles on an erythematous base Crusts form, dry, heal in approx. 1 wk Crusts form, dry, heal in approx. 1 wk

104 LESIONS ARE CONTAGIOUS for 2-4 days before dry crusts form LESIONS ARE CONTAGIOUS for 2-4 days before dry crusts form Can be red lesions without vesicles Can be red lesions without vesicles Virus sheds Virus sheds Avoid contact with a known infected lesion during the blistering phase can prevent the primary infection Avoid contact with a known infected lesion during the blistering phase can prevent the primary infection Attacks diminish with age..contagious until scabs form Attacks diminish with age..contagious until scabs form

105 If herpes simples is present in the vagina at childbirth, the newborn may be infected and develop meningoencephalitis or panvisceral infection If herpes simples is present in the vagina at childbirth, the newborn may be infected and develop meningoencephalitis or panvisceral infection If rub lesion and rub eyes, can develop HSV infection in eyes, possible blindness, brain infection If rub lesion and rub eyes, can develop HSV infection in eyes, possible blindness, brain infection

106 Culture provides definite dx Culture provides definite dx Usual dx based on s/s, hx Usual dx based on s/s, hx NO COMPLETE CURE NO COMPLETE CURE Topical acyclovir drug of choice to tx primary lesions to suppress multiplication of vesicles.DOES NOT WORK ON SECONDARY LESIONS. Topical acyclovir drug of choice to tx primary lesions to suppress multiplication of vesicles.DOES NOT WORK ON SECONDARY LESIONS. Oral acyclovir may be recommended for severe or freq. attacks.; people who are immunocompr. Creams. Ointments may be prescribed to speed drying, healing..may need addit. Of oral antibiotics Oral acyclovir may be recommended for severe or freq. attacks.; people who are immunocompr. Creams. Ointments may be prescribed to speed drying, healing..may need addit. Of oral antibiotics

107 Nursing education of pt is PRIMARY IMPORTANCE; INSTRUCTION ON HOW TO AVOID INFECTION, WHEN IT IS CONTAGIOUS, AND how to prevent spreading to other body parts Nursing education of pt is PRIMARY IMPORTANCE; INSTRUCTION ON HOW TO AVOID INFECTION, WHEN IT IS CONTAGIOUS, AND how to prevent spreading to other body parts

108 Furuncles and carbuncles Furncle; small tender boil; occurs deep in one or more hair follicles, spreads to dermis Furncle; small tender boil; occurs deep in one or more hair follicles, spreads to dermis Usually caused by Staph Usually caused by Staph Areas of excessive perspiration, friction and irritation Areas of excessive perspiration, friction and irritation Yellow, black or whitehead Yellow, black or whitehead Pain, tenderness, erythema, surrounding cellulitis, poss. lymphadenopathy Pain, tenderness, erythema, surrounding cellulitis, poss. lymphadenopathy

109 Carbuncle; extension of furuncle Carbuncle; extension of furuncle Abscess of skin and subcutan. Tissue Abscess of skin and subcutan. Tissue Where skin is thick, non-elastic, fibrous Where skin is thick, non-elastic, fibrous Upper back, back of neck, buttocks Upper back, back of neck, buttocks Fevers, pain, leukocytosis, collapse Fevers, pain, leukocytosis, collapse Debilitated clients and diabetics Debilitated clients and diabetics

110 Furuncles can progress to carbuncles Furuncles can progress to carbuncles Systemic infection Systemic infection Can spread infection to others (staph) Can spread infection to others (staph) Scarring can occur, may require I&D, and systemic antibiotics Scarring can occur, may require I&D, and systemic antibiotics

111 DO NOT SQUEEZE AND IRRITATE Use antibacterial soaps to cleanse/ointment Surg. I&d Cover lesion with DSD DOUBLE BAG ALL SOILED DRESSINGS Analgesia/antipyretics Bed rest advised with carbuncles/or furuncles located in the perineal/anal areas (Forniers gangrene) Cleans living area and equipment daily, laundry after each use Strict hand washing

112 HERPES ZOSTER (SHINGLES) Different virus than HSV Different virus than HSV This is caused by Varicella zoster, thought to be identical to virus causing chickenpox This is caused by Varicella zoster, thought to be identical to virus causing chickenpox Presents as acute, inflammatory and infectious outbreak of painful vesicles on erythematous base. Out break occurs along the dermatone(s) of one or more cutaneous sensory nerves Presents as acute, inflammatory and infectious outbreak of painful vesicles on erythematous base. Out break occurs along the dermatone(s) of one or more cutaneous sensory nerves Usually unilateral Usually unilateral

113 Thought to be a reactivation of latent zoster virus Thought to be a reactivation of latent zoster virus Incubation 7-21 days Incubation 7-21 days Vesicles appear in 3-4 days Vesicles appear in 3-4 days Eruption generally occurs posteriorly and progresses anteriorly and peripherally along the dermatone Eruption generally occurs posteriorly and progresses anteriorly and peripherally along the dermatone Duration can vary from 10days to 5+ weeks Duration can vary from 10days to 5+ weeks

114 Occurs most commonly in elderly Occurs most commonly in elderly Or immune suppressed, immun- suppr. Agents or with malignancies, injuries to spine or cranial nerves Or immune suppressed, immun- suppr. Agents or with malignancies, injuries to spine or cranial nerves Avoid contagion by avoiding contact with person with this disease. Avoid contagion by avoiding contact with person with this disease. Contagion possible a few days before eruption of vesicles and until dry Contagion possible a few days before eruption of vesicles and until dry

115 May present with vesicles and plaques May present with vesicles and plaques Irritation, itching, fever, malaise Irritation, itching, fever, malaise May be very painful, pain likely to increase with age of pt and remain after healing in the elderly May be very painful, pain likely to increase with age of pt and remain after healing in the elderly Condition referred to as hyperesthesia; any measures to increase comfort should be used; cold compresses Condition referred to as hyperesthesia; any measures to increase comfort should be used; cold compresses

116 Dx by clinical presentation and assoc. s/s. may do cultures for suspected secondary infection Dx by clinical presentation and assoc. s/s. may do cultures for suspected secondary infection If in more than two dermatones, pt will need isolation room in hospital If in more than two dermatones, pt will need isolation room in hospital Some evidence can be airborn Some evidence can be airborn

117 complications Post herpetic neuralgia Post herpetic neuralgia Persistent dermatomal pain, can last for months and years. Can have severe negative impact on quality of life Persistent dermatomal pain, can last for months and years. Can have severe negative impact on quality of life Opthalmic herpes zoster affects 5 th cranial nerve; serious complication, can lose sight, hearing loss, facial paralysis, vertigo Opthalmic herpes zoster affects 5 th cranial nerve; serious complication, can lose sight, hearing loss, facial paralysis, vertigo Full thickness skin necrosis and systemic viremia Full thickness skin necrosis and systemic viremia Can cause chickenpox in others Can cause chickenpox in others

118 Treatment Aimed towards controlling s/s and preventing complications. Should start within 72h Aimed towards controlling s/s and preventing complications. Should start within 72h Acyclovir, topical, oral, IV may be used at initial outbreak, early stages as well as Famciclovir and Valacyclovir Acyclovir, topical, oral, IV may be used at initial outbreak, early stages as well as Famciclovir and Valacyclovir Doesnt cure, but helps suppress the viral outbreak Doesnt cure, but helps suppress the viral outbreak Analgesics for pain; of limited value, corticosteroids to reduce pain, but NOT with opthalmic involvement. Topicals, tricyclics, anticonvulsants Analgesics for pain; of limited value, corticosteroids to reduce pain, but NOT with opthalmic involvement. Topicals, tricyclics, anticonvulsants Antihistamines, antibiotics, medicated baths Antihistamines, antibiotics, medicated baths

119 Only reliable way to differentiate from HSV is culture, serum PCR/IFA Only reliable way to differentiate from HSV is culture, serum PCR/IFA Use of new vaccine, Zostavax in people age 60 and younger Use of new vaccine, Zostavax in people age 60 and younger

120 FUNGAL INFECTIONS DERMATOPHYTOSIS a fungal infection of the skin that occurs when there is a break in skin integrity in the presence of warmth and moisture. DERMATOPHYTOSIS a fungal infection of the skin that occurs when there is a break in skin integrity in the presence of warmth and moisture. Occurs with direct contact with infected humans,animals or objects Occurs with direct contact with infected humans,animals or objects TINEA IS THE OPERATIVE NOUN. TINEA IS THE OPERATIVE NOUN. The second name stands for the body site affected The second name stands for the body site affected

121 TINEA pedis(athletes foot), common. TINEA pedis(athletes foot), common. Chronic plantar scaling, acute vesicular, and interdigital Chronic plantar scaling, acute vesicular, and interdigital Chronic plantar scaling in fold lines, itching not usually present Chronic plantar scaling in fold lines, itching not usually present Acute vesic. Eruption of tiny painful itching blisters Acute vesic. Eruption of tiny painful itching blisters Interdigital, common form, erosion, scaling, fissuring in toe webs, painful, burning, itchy with offensive odor Interdigital, common form, erosion, scaling, fissuring in toe webs, painful, burning, itchy with offensive odor

122 Chronic planatr treated with keratolytics, topical antifungals. NOT CURATIVE Chronic planatr treated with keratolytics, topical antifungals. NOT CURATIVE ACUTE SOAKS OR BATHS 2-3X DAY TO DRY BLISTERS astringent paint applied to unroofed blisters ACUTE SOAKS OR BATHS 2-3X DAY TO DRY BLISTERS astringent paint applied to unroofed blisters Interdigital treated with combinations antifungals, antibiotics and foot soaks with Burrows Interdigital treated with combinations antifungals, antibiotics and foot soaks with Burrows

123 Pt teaching important Pt teaching important Feet dry, avoid plastic/rubbersoled shoes Feet dry, avoid plastic/rubbersoled shoes Water shoes in public showers Water shoes in public showers Cotton socks to absorb perspiration Cotton socks to absorb perspiration

124 Tinea capitas; ringworm of scalp Tinea capitas; ringworm of scalp Contagious; loss of hair in children Contagious; loss of hair in children Presents as scattered round red scaly patches, may have small pustules Presents as scattered round red scaly patches, may have small pustules Brittle hair at site, breaks off, mild itching and kerion inflammation Brittle hair at site, breaks off, mild itching and kerion inflammation

125 Treat with systemic antifungals because of high relapse rate with just topicals Treat with systemic antifungals because of high relapse rate with just topicals Highly contagious Highly contagious Teach med side effects, never share combs, headgear, pillows, brushes Teach med side effects, never share combs, headgear, pillows, brushes Check pets for s/s of infection Check pets for s/s of infection

126 Tinea corporis; ringworm of body Tinea corporis; ringworm of body Erythematous macule that progresses to rings of vesicles, alone or in groups, on exposed areas of body, may be intensely itchy Erythematous macule that progresses to rings of vesicles, alone or in groups, on exposed areas of body, may be intensely itchy Infected pets are freq. source Infected pets are freq. source Topical/oral antifungals, topical steroids Topical/oral antifungals, topical steroids Keep skin dry, wear cotton Keep skin dry, wear cotton

127 Tinea cruris (jock itch) Tinea cruris (jock itch) Ringworm of groin may extend to inner thighs and buttocks. Often present along with tinea pedis Ringworm of groin may extend to inner thighs and buttocks. Often present along with tinea pedis Small scaly patch, then sharply demarcated plaque with elevated scaly or vesicular borders Small scaly patch, then sharply demarcated plaque with elevated scaly or vesicular borders May be intensely itchy May be intensely itchy

128 Teach to avoid heat, moisture, friction Teach to avoid heat, moisture, friction Topical anitfungals; spread beyond lesion borders Topical anitfungals; spread beyond lesion borders Oral antifungals/steroids may be needed to control/cure Oral antifungals/steroids may be needed to control/cure Remember to discuss possible med side effects, short and long term with client Remember to discuss possible med side effects, short and long term with client

129 Tinea unguium (onychomycosis) fungal infection of fingernails and toenails Tinea unguium (onychomycosis) fungal infection of fingernails and toenails Usually lifelong Usually lifelong Yellow thickening of nailplate, crumbly debris; nail plates become separated, eventually nail is destroyed Yellow thickening of nailplate, crumbly debris; nail plates become separated, eventually nail is destroyed

130 Topicals usually not effective Topicals usually not effective May need nail avulsion (removal) May need nail avulsion (removal) High rate of relapse High rate of relapse

131 CELLULITIS Inflammation of skin cells and or cellular or connective tissue from a generalized infection with Staph or Strep Inflammation of skin cells and or cellular or connective tissue from a generalized infection with Staph or Strep Result of skin trauma or secondary infection of an ope wound, or may have no immediately known cause Result of skin trauma or secondary infection of an ope wound, or may have no immediately known cause Most freq. occurs in lower extremities Most freq. occurs in lower extremities Good hygiene and prevention of cross contamination Good hygiene and prevention of cross contamination

132 Presents with warmth, pain, edema, erythema, tenderness, fever locally and progresses rapidlyif not treated Presents with warmth, pain, edema, erythema, tenderness, fever locally and progresses rapidlyif not treated C&S of pustule or lesions to identify organism. May need blood cultures if bacteremia suspected C&S of pustule or lesions to identify organism. May need blood cultures if bacteremia suspected Always be aware of your patients immune status Always be aware of your patients immune status

133 Topical and oral or IV antibiotics Topical and oral or IV antibiotics Get good hx; recent trauma?, abnl temp, v/s Get good hx; recent trauma?, abnl temp, v/s Use of good hand hygiene at all times for you and the patient, wash linens and clothes Use of good hand hygiene at all times for you and the patient, wash linens and clothes Much CA-MRSA now Much CA-MRSA now

134 ACNE VULGARIS COMMON SKIN DISORDER OF THE SEBACEOUS GLANDS COMMON SKIN DISORDER OF THE SEBACEOUS GLANDS Occurs freq. on upper back, face, shoulders, whereever there are numerous hair follicles Occurs freq. on upper back, face, shoulders, whereever there are numerous hair follicles Multifocal causes, often hormonal Multifocal causes, often hormonal Sebaceous glands under endocrine system control; androgens Sebaceous glands under endocrine system control; androgens

135 Stimulation of glands causes more sebum to be produced Stimulation of glands causes more sebum to be produced This with grad. Obstr. Of pilosebaceous ducts with debris, leads to inflammation and rupture of seb. Gl. This with grad. Obstr. Of pilosebaceous ducts with debris, leads to inflammation and rupture of seb. Gl. This leads to greater infl., formation of pustules, nodules and cysts This leads to greater infl., formation of pustules, nodules and cysts

136 Hereditary factors, stress, strong soaps contribute Hereditary factors, stress, strong soaps contribute NOT RELATED TO CHOCOLATE, DIET, CLEANLINESS NOT RELATED TO CHOCOLATE, DIET, CLEANLINESS Can occur regardless of interventions Can occur regardless of interventions Initial lesions are comeodones, closed whiteheads, lead to open lesions with blackheads, lipids and melanin pigments Initial lesions are comeodones, closed whiteheads, lead to open lesions with blackheads, lipids and melanin pigments

137 Effective topical agents; benzol peroxide, an anticiotic, erythromycin and tetracycline(teeth)to kill bacteria in follicles Effective topical agents; benzol peroxide, an anticiotic, erythromycin and tetracycline(teeth)to kill bacteria in follicles Vitamin A acid (retin-A to loosen pore plugs and prevent new form. Vitamin A acid (retin-A to loosen pore plugs and prevent new form. Antibiotics usually reserved for severe cases, espec Retin-A must be closely monitored Antibiotics usually reserved for severe cases, espec Retin-A must be closely monitored Must be tested to be sure not pregnant, use 2 forms of birthcontrol 1 mo before, during and after Must be tested to be sure not pregnant, use 2 forms of birthcontrol 1 mo before, during and after

138 Parasitic disorders infestations Infestation by lice Infestation by lice Pediculosis capitas,corporis, pubis Pediculosis capitas,corporis, pubis Bite skin and feed on human blood Bite skin and feed on human blood Leave eggs and excrement Leave eggs and excrement Causes intense itching Causes intense itching Lice are oval and 2mm in length Lice are oval and 2mm in length

139 P. capitas, female lays eggs(nits) close to scalp hair and behind ears P. capitas, female lays eggs(nits) close to scalp hair and behind ears Silvery white Silvery white Transmitted dy direct contact with infested organisms or objects(fomites) Transmitted dy direct contact with infested organisms or objects(fomites) Most common in children and people with long hair Most common in children and people with long hair May not be itchy May not be itchy

140 P.corporis; body lice that lay eggs in seams of clothing, then pierce skin P.corporis; body lice that lay eggs in seams of clothing, then pierce skin Neck, trunk thighs Neck, trunk thighs Intense itching, excoriations Intense itching, excoriations P. pubic(crabs) usually in genital area, but can be hairs of chest, axilla,eyelashes, beard P. pubic(crabs) usually in genital area, but can be hairs of chest, axilla,eyelashes, beard Often thru sexual contact,less often infested bed linen Often thru sexual contact,less often infested bed linen Intensely itchy Intensely itchy

141 Prevent by avoiding contact with infested persons/objects Prevent by avoiding contact with infested persons/objects Dont share equip.,routine washing of clothing Dont share equip.,routine washing of clothing

142 Secondary infections/impetigo, boils Secondary infections/impetigo, boils Mrsa Mrsa Parallel linear scratches,Hyperemia, hyperpigmentation Parallel linear scratches,Hyperemia, hyperpigmentation Can be vectors for rickettsial diseases Can be vectors for rickettsial diseases Through hx and exam, may also want to test for STDs Through hx and exam, may also want to test for STDs Pediculocides/nix Pediculocides/nix Complications with other meds Complications with other meds

143 Goal to kill the parasites and mechanically remove nits Goal to kill the parasites and mechanically remove nits Use of pediculocides ie permethrin or pyrethrum are commonly used Use of pediculocides ie permethrin or pyrethrum are commonly used Some lice may exhibit resistance Some lice may exhibit resistance NIX or permethrin active for approx. 1wk, kills adult lice immediately and nits as they hatch NIX or permethrin active for approx. 1wk, kills adult lice immediately and nits as they hatch

144 Rid, A-200 pyrinate must be re- applied in one week Rid, A-200 pyrinate must be re- applied in one week Physostigmine opthal. Oint to eyebrows, lashes, no other meds Physostigmine opthal. Oint to eyebrows, lashes, no other meds

145 Nursing care; give full instructions on the medications used, possible side effects, how, when and where the medication is used and for how long. Nursing care; give full instructions on the medications used, possible side effects, how, when and where the medication is used and for how long. How to remove nits How to remove nits How to remove lice from body, hair and linens How to remove lice from body, hair and linens Children out of school until adequately treated Children out of school until adequately treated

146 SCABIES Contagious and caused by Sarcoptes scabiei Contagious and caused by Sarcoptes scabiei Intimate or prolonged contact with infected clothing, bedding, animals Intimate or prolonged contact with infected clothing, bedding, animals Mites burrow into superficial layers of skin; show as short, wavy brown or blacklines. Mites burrow into superficial layers of skin; show as short, wavy brown or blacklines. Most contagious at this time, but pt may be asymptomatic Most contagious at this time, but pt may be asymptomatic

147 s/s may not appear for 4 wks s/s may not appear for 4 wks Mites live for 24h only without human contact Mites live for 24h only without human contact All infected Persons and animals need to have tx at same time All infected Persons and animals need to have tx at same time Linen and clothing washed, but furniture does not require cleaning Linen and clothing washed, but furniture does not require cleaning

148 s/s = itching and rash, espec. At night. Itching starts 1mo after infestation and may continue for days and weeks after tx s/s = itching and rash, espec. At night. Itching starts 1mo after infestation and may continue for days and weeks after tx Signs may be concentrated in webs of fingers, axilla, wrist folds, groin, genitals, excoriations from scratching Signs may be concentrated in webs of fingers, axilla, wrist folds, groin, genitals, excoriations from scratching On penis, groin On penis, groin

149 Hypersensitivity to mite can result in crusted lesions, infection Hypersensitivity to mite can result in crusted lesions, infection Dx confirmed by superficial shaving of a lesion and microscopic eval. For mites, eggs or feces Dx confirmed by superficial shaving of a lesion and microscopic eval. For mites, eggs or feces

150 Topical scabicides are used for disinfection Topical scabicides are used for disinfection Entire body, neck to feet and folds, left on for 8-12h, then washed off. One tx usually suffic. If not re-infected Entire body, neck to feet and folds, left on for 8-12h, then washed off. One tx usually suffic. If not re-infected Caution pt that itching may return after tx until the allergic reaction subsides Caution pt that itching may return after tx until the allergic reaction subsides Dead mites remain in theepidermis until exfoliated Dead mites remain in theepidermis until exfoliated

151 PEMPHIGUS Acute or chronic serious skin disease characterized by the development of large bullae on normal skin and mucus membranes, usually affects older poulation Acute or chronic serious skin disease characterized by the development of large bullae on normal skin and mucus membranes, usually affects older poulation When they rupture, leave open, raw, painful, eroded, oozing partial thickness wounds, that form crusts When they rupture, leave open, raw, painful, eroded, oozing partial thickness wounds, that form crusts Originates in the oral mucosa and spreads to the trunk, involving large areas of body Originates in the oral mucosa and spreads to the trunk, involving large areas of body

152 May also experience pain, burning, itching and may develop foul smell May also experience pain, burning, itching and may develop foul smell Interferes with chewing, talking, swallowing, pt miserable Interferes with chewing, talking, swallowing, pt miserable Likely to develop a secondary bacterial infection..high mortality rate with this disease Likely to develop a secondary bacterial infection..high mortality rate with this disease

153 Dx by +Nikolskis sign (sloughing or blistering of nl skin when pressure applied) Dx by +Nikolskis sign (sloughing or blistering of nl skin when pressure applied) Bx will reveal acantholysis (separation of epidermal cells from each other Bx will reveal acantholysis (separation of epidermal cells from each other

154 Medical Tx consists of trying to control s/s and infection, body fluid and protein losses, promote healing Medical Tx consists of trying to control s/s and infection, body fluid and protein losses, promote healing Corticosteroids in large doses, cytotoxic agents, analgesics, antipyretics Corticosteroids in large doses, cytotoxic agents, analgesics, antipyretics Needs high protein/high calorie diets to maintain nutrition and fluid replacement Needs high protein/high calorie diets to maintain nutrition and fluid replacement

155 Nursing care Educate pt on effects and side effects of medications Educate pt on effects and side effects of medications Maintain I&O, body wt, b/p Maintain I&O, body wt, b/p Potassium permanganate baths to cleanse, disinfect and remove odors. Thoroughly dissolve these crystals Potassium permanganate baths to cleanse, disinfect and remove odors. Thoroughly dissolve these crystals Offer fluids, provide appropriate psycho-social support Offer fluids, provide appropriate psycho-social support

156 At risk for alterations in self image At risk for alterations in self image At risk for nutritional deficits At risk for nutritional deficits At risk for infections At risk for infections At risk for alterations in fluid/electrolyte balance At risk for alterations in fluid/electrolyte balance At risk for medication side effects of steroids At risk for medication side effects of steroids At risk for alterations in comfort At risk for alterations in comfort At risk for grief reaction/mortality At risk for grief reaction/mortality

157 BURNS pages ; in PEDS Wounds caused by energy transfer from a heat source to body tissue, causing tissue damage Wounds caused by energy transfer from a heat source to body tissue, causing tissue damage Infants under age 2 and adults over age 60 have highest mortality rates Infants under age 2 and adults over age 60 have highest mortality rates Heat denatures proteins and interrupts blood supply Heat denatures proteins and interrupts blood supply 3 zones of tissue damage 3 zones of tissue damage EPIDERMIS; hyperemia; no interruption of blood supply; no cell death; area least affected by heat EPIDERMIS; hyperemia; no interruption of blood supply; no cell death; area least affected by heat

158 DERMIS; stasis injury; temp. incr. on tissue edema; vasoconstriction, sludging of red blood cells; red, + blanching; fragile area prone to necrosis/infection DERMIS; stasis injury; temp. incr. on tissue edema; vasoconstriction, sludging of red blood cells; red, + blanching; fragile area prone to necrosis/infection SUBCUTANEOUS TISSUE; coagulation injury; irreversible cell death; white/gray; no blanching SUBCUTANEOUS TISSUE; coagulation injury; irreversible cell death; white/gray; no blanching

159 Damage related to: temperature of agent, type of agent, length of exposure, conductivity of tissue, thickness of tissue involved Damage related to: temperature of agent, type of agent, length of exposure, conductivity of tissue, thickness of tissue involved Loss of large areas of skin= loss of protective functions, impaired temp. regulation, possible infection, loss of fluids, sensory deficits, impaired skin regeneration, impaired secretory/excretory function Loss of large areas of skin= loss of protective functions, impaired temp. regulation, possible infection, loss of fluids, sensory deficits, impaired skin regeneration, impaired secretory/excretory function

160 Alterations in skin function affects most all body systems Alterations in skin function affects most all body systems Increased capillary permeability leads to leakage of plasma and proteins into tissues; leads to edema and loss of intravascular volume (HYPOVOLEMIA) Increased capillary permeability leads to leakage of plasma and proteins into tissues; leads to edema and loss of intravascular volume (HYPOVOLEMIA) Evaporative water loss, greater than 4- 15x nl Evaporative water loss, greater than 4- 15x nl Incr. metabolism= incr. water loss thru resp. system Incr. metabolism= incr. water loss thru resp. system

161 Cardiac funct.; decre.output, that worsens due to lower circ. Plasma vol. As plasma leaks into interstitial tissues,for first 48h, leads to severe hypovolemia; if untreated, hypovolemic shock. At risk for 72h after burn. Must have fluid replacement. There is an increase in Hct., and red blood cell destruction; decreases platelet function (pg 367)intravenous fluids as ordered, check urinary output, likely will require indwelling catheter Cardiac funct.; decre.output, that worsens due to lower circ. Plasma vol. As plasma leaks into interstitial tissues,for first 48h, leads to severe hypovolemia; if untreated, hypovolemic shock. At risk for 72h after burn. Must have fluid replacement. There is an increase in Hct., and red blood cell destruction; decreases platelet function (pg 367)intravenous fluids as ordered, check urinary output, likely will require indwelling catheter

162 Increased metabolic demands; body maintains high metabolic rate for healing Increased metabolic demands; body maintains high metabolic rate for healing Severe catabolism (breakdown of body tissues and cellular structures) results in neg. nitrogen balance, wt. loss, and decre. Wound healing Severe catabolism (breakdown of body tissues and cellular structures) results in neg. nitrogen balance, wt. loss, and decre. Wound healing Stress triggers elevated catecholamine levels (epinepherine, norepinepherine) which causes elevated glucagon levels and hyperglycemia Stress triggers elevated catecholamine levels (epinepherine, norepinepherine) which causes elevated glucagon levels and hyperglycemia

163 GI problems ie. Gastric dilation, Curlings ulcer (peptic ulcer from stress), paralytic ileus, and superior mesenteric artery syndrome (intestinal angina from occlusion) GI problems ie. Gastric dilation, Curlings ulcer (peptic ulcer from stress), paralytic ileus, and superior mesenteric artery syndrome (intestinal angina from occlusion) Acute renal insufficiency Acute renal insufficiency Electrical burns can result in tubular necrosis as a result of myoglobin casts (muscle damage) Electrical burns can result in tubular necrosis as a result of myoglobin casts (muscle damage)

164 Pulmonary effects mostly related to smoke inhalation, and very common in burns to face and chest. Hyperventilation in proportion to severity of burn Incr. O2 consumption. Rapid swelling/edema of the respiratory passages, hoarse voice. Elevate head of bed to 30 degrees, continuous assessment, provide O2, prepare pt for intubation if nec. Pulmonary effects mostly related to smoke inhalation, and very common in burns to face and chest. Hyperventilation in proportion to severity of burn Incr. O2 consumption. Rapid swelling/edema of the respiratory passages, hoarse voice. Elevate head of bed to 30 degrees, continuous assessment, provide O2, prepare pt for intubation if nec. Immune system severely compromised from loss of substantial portion of skin barrier and first line defense macrophages. Immune system severely compromised from loss of substantial portion of skin barrier and first line defense macrophages.

165 Common burns Common burns Thermal/steam/scalds Thermal/steam/scalds Radiation Radiation Chemical; acids or alkali, cancause skin and pulmonary burns; dry chemicals must be brushed off Chemical; acids or alkali, cancause skin and pulmonary burns; dry chemicals must be brushed off Flames Flames Contact Contact Electrical; more serious than appears; lightening in excess of 50,000 degrees; may present with feathery, branching appearance Electrical; more serious than appears; lightening in excess of 50,000 degrees; may present with feathery, branching appearance

166 Burn classifications Partial thickness (1 st -2 nd degree) Partial thickness (1 st -2 nd degree) Superficial; comprised of epidermis, poss. Papillae of dermis Superficial; comprised of epidermis, poss. Papillae of dermis Bright red to pink, blanches, fluid filled blisters, glistening, moist Bright red to pink, blanches, fluid filled blisters, glistening, moist Very sensitive to air, temp. and touch Very sensitive to air, temp. and touch Heals in 7-10 days Heals in 7-10 days

167 MINOR BURNS MINOR BURNS 15% of TBSA NOT involving face, hands, genitalia or 15% of TBSA NOT involving face, hands, genitalia or Full thickness burn less than 2% of TBSA Full thickness burn less than 2% of TBSA

168 Partial thickness (deep; 2 nd degr.); Partial thickness (deep; 2 nd degr.); Appendage usually involved Appendage usually involved ½-7/8 dermis ½-7/8 dermis Blisters may be present Blisters may be present Pink, light red, white, blanchable Pink, light red, white, blanchable Exposed nerve endings Exposed nerve endings days for healing days for healing May need grafting to prevent scars May need grafting to prevent scars

169 MODERATE BURNS MODERATE BURNS 15-25% of TBSA or 15-25% of TBSA or Full thickness burns that are 10% of TBSA Full thickness burns that are 10% of TBSA

170 Full thickness (3-4 th degree) Full thickness (3-4 th degree) Epidermis down thru bone Epidermis down thru bone 3 rd degr. Involves entire dermis and portions of subcutaneous tissue, fatty tissue showing 3 rd degr. Involves entire dermis and portions of subcutaneous tissue, fatty tissue showing Red, Snow white, gray, brown, leathery, dry Red, Snow white, gray, brown, leathery, dry Nerve endings destroyed, no pain unless close to lesser degree burns Nerve endings destroyed, no pain unless close to lesser degree burns Needs grafting Needs grafting

171 MAJOR BURNS MAJOR BURNS Partial thickness burn greater than 25% of TBSA or Partial thickness burn greater than 25% of TBSA or Full thickness burn involving greater than 10% of TBSA or involving face, hands, feet or genitalia Full thickness burn involving greater than 10% of TBSA or involving face, hands, feet or genitalia

172 sizing Done by rule of nines or Lund and Browder chart Done by rule of nines or Lund and Browder chart Figure 51-11, see difference in adult and child configurations on nines Figure 51-11, see difference in adult and child configurations on nines This formula NOT accurate in formulating burn percentages for children, so note differences This formula NOT accurate in formulating burn percentages for children, so note differences

173 Common labs ordered Dx thru clinical manifestations and hx Dx thru clinical manifestations and hx labs: CBC,BUN, fasting glucose, electrolytes, labs: CBC,BUN, fasting glucose, electrolytes, ABGs, pulse oximetry ABGs, pulse oximetry Blood protein; albumin Blood protein; albumin Urinalysis; specific gravity Urinalysis; specific gravity Ekg Ekg Bronchoscopy Bronchoscopy Pulm. Funct, (spirometer, lung vol, diffusion capacity(bodys ability to extract O2 from lungs) Pulm. Funct, (spirometer, lung vol, diffusion capacity(bodys ability to extract O2 from lungs)

174 Emergent phase onset of injury to completion of fluid resuscitation BURNING PROCESS MUST BE STOPPED/REMOVE VICTOM FROM SOURCE OF BURN. and airway patency,breathing, and circulation assured BURNING PROCESS MUST BE STOPPED/REMOVE VICTOM FROM SOURCE OF BURN. and airway patency,breathing, and circulation assured Assess percentage and depth of burns (#2) Assess percentage and depth of burns (#2) Clothing must be removed and jewelry (#1) Clothing must be removed and jewelry (#1) Wound is cooled with tepid water only if TBSA is 10% or less, however,lavage for 20min. Needed for chemical burns.dry chemicals must be brushed off. Use precautions Wound is cooled with tepid water only if TBSA is 10% or less, however,lavage for 20min. Needed for chemical burns.dry chemicals must be brushed off. Use precautions Person covered with sterile or clean sheet to decrease shivering/contamination Person covered with sterile or clean sheet to decrease shivering/contamination

175 DO NOT APPLY ICE DO NOT APPLY ICE Assist in wound debridement/medicate for pain prior to txs Assist in wound debridement/medicate for pain prior to txs

176 Assess for hypovolemia (decreased B/P, incr. HR, and respirations) Assess for hypovolemia (decreased B/P, incr. HR, and respirations) Monitor ABGs, and carboxyhemoglobin levels Monitor ABGs, and carboxyhemoglobin levels

177 Initiate intravenous access, USUALLY LACTATED Ringers, 0.9% saline or plasma Initiate intravenous access, USUALLY LACTATED Ringers, 0.9% saline or plasma Possible need for TPN Possible need for TPN Monitor v/s; CLOSE, ACCURATE I&O Monitor v/s; CLOSE, ACCURATE I&O Maintain NPO Maintain NPO Insert indwelling catheter Insert indwelling catheter Administer pain medication as prescribed Administer pain medication as prescribed Administer Tetanus toxoid as prescribed Administer Tetanus toxoid as prescribed Monitor extr for any circumferential burns Monitor extr for any circumferential burns

178 Check extremities for any circumferential burns. Will act like a tourniquet, causing compartment syndrome/respiratory insufficiency. Pt will need an escharotomy; incision thru eschar and superficial fat. Check extremities for any circumferential burns. Will act like a tourniquet, causing compartment syndrome/respiratory insufficiency. Pt will need an escharotomy; incision thru eschar and superficial fat. Common sites are extremities, trunk and chest Common sites are extremities, trunk and chest

179 Patients, especially children, may quickly become hypervolemic (within 24-96h) even to having pulmonary edema Patients, especially children, may quickly become hypervolemic (within 24-96h) even to having pulmonary edema

180 Sterile technique/hand washing Sterile technique/hand washing Prevent infection/sepsis Prevent infection/sepsis

181 Stage 2 (acute) from start of diuresis to near completion of wound closure Goals are wound closure Goals are wound closure No infections No infections Minimum scarring/lack of contracture Minimum scarring/lack of contracture Maintainance of comfort Maintainance of comfort Adequate nutrit support Adequate nutrit support

182 Dialy wound cleansing and debridement Dialy wound cleansing and debridement MEDICATE FOR PAIN MEDICATE FOR PAIN Hubbard tank or showering for cleansing Hubbard tank or showering for cleansing Debridement; mech. Chemical, surgical or combination Debridement; mech. Chemical, surgical or combination

183 Dressings Open or closed, biologic or synthetic or combo Open or closed, biologic or synthetic or combo Open involves topical agent no dressing Open involves topical agent no dressing Closed involves occlusive drsg over the wound Closed involves occlusive drsg over the wound

184 Limit bulk Limit bulk No skin surface to surface; donut gauze around ear No skin surface to surface; donut gauze around ear Base drsgs on wound size, absorption needs, protection and type of debridement being done Base drsgs on wound size, absorption needs, protection and type of debridement being done Wrap extremities DISTAL TO PROXIMAL Wrap extremities DISTAL TO PROXIMAL ELEVATE ALL AFFECTED EXTREMITIES ABOVE LEVEL OF HEART ELEVATE ALL AFFECTED EXTREMITIES ABOVE LEVEL OF HEART

185 BIOLOGIC DRESSINGS TISSUE FROM LIVING OR DECEASED HUMANS OR ANIMALS TISSUE FROM LIVING OR DECEASED HUMANS OR ANIMALS These dressings may be used as donor site dressings; to manage a partial thickness burn and cover a clean, excised wound before autografting These dressings may be used as donor site dressings; to manage a partial thickness burn and cover a clean, excised wound before autografting Assist with wound healing and stimulate epithelialization Assist with wound healing and stimulate epithelialization

186 Synthetic dressings Synthetic dressings Are used in management of partial thickness burns and donor sites Are used in management of partial thickness burns and donor sites More available, less costly, easier to store than biologics More available, less costly, easier to store than biologics Variety of materials and sizes Variety of materials and sizes Rarely contain antimicrobial agents Rarely contain antimicrobial agents

187 Biologic and synthetic dressings are TEMPORARY wound coverings for clean partial- thickness AND full thickness injuries Biologic and synthetic dressings are TEMPORARY wound coverings for clean partial- thickness AND full thickness injuries Maintain wound surface until healing occurs, a donor site is available or wound is ready for autografting Maintain wound surface until healing occurs, a donor site is available or wound is ready for autografting

188 SKIN GRAFTING Autograft is skin graft from the PATIENTS unburned skin to be placed on clean excised burn site Autograft is skin graft from the PATIENTS unburned skin to be placed on clean excised burn site 2 types; STSG ( ) and FTSG ( ) inches in thickness 2 types; STSG ( ) and FTSG ( ) inches in thickness STSG includes epidermis and part of dermis STSG includes epidermis and part of dermis FTSG includes epidermis and entire DERMAL AREA FTSG includes epidermis and entire DERMAL AREA

189 STSG may be applied as a sheet graft or meshed graft STSG may be applied as a sheet graft or meshed graft Sheet graft used primarily for cosmetic effect; face, chest, breasts, or hands, placed on as a full sheet Sheet graft used primarily for cosmetic effect; face, chest, breasts, or hands, placed on as a full sheet Meshed graft, tiny splits, looks like fishnet; allows skin to expand times its original size Meshed graft, tiny splits, looks like fishnet; allows skin to expand times its original size Allows for coverage of large area with small piece of skin. Good for extensive burn areas Allows for coverage of large area with small piece of skin. Good for extensive burn areas Graft take or revascularization in 3-5 days Graft take or revascularization in 3-5 days

190 Disadvantages include: Disadvantages include: Prone to chronic breakdown Prone to chronic breakdown More likely to hypertrophy More likely to hypertrophy More likely to contract More likely to contract

191 FTSG can be sheet grafts or pedicle flaps FTSG can be sheet grafts or pedicle flaps Used over areas of muscle mass, soft tissue loss, hands feet, eyelids Used over areas of muscle mass, soft tissue loss, hands feet, eyelids Pedicle attached to blood supply and area to area in need of grafting Pedicle attached to blood supply and area to area in need of grafting Pedicle not used for extensive wounds; not as popular as free skin grafts Pedicle not used for extensive wounds; not as popular as free skin grafts

192 FTSGs allows more elasticity over joints FTSGs allows more elasticity over joints Soft, pliable Soft, pliable May allow hair regrowth May allow hair regrowth Provides good color match Provides good color match Less hyperpigmentation Less hyperpigmentation Donor sites take longer to heal Donor sites take longer to heal Requires split-thickness graft to heal or closure from wound edges Requires split-thickness graft to heal or closure from wound edges

193 Promoting factors Adequate hemostasis Adequate hemostasis Anatomic location of graft Anatomic location of graft Smooth contour Smooth contour Non-joints Non-joints Graft well secured Graft well secured Immobilization of graft area Immobilization of graft area Good nutitional status Good nutitional status

194 Inhibiting factors Infection Infection Necrotic skin Necrotic skin Location on perineum, axilla, buttocks Location on perineum, axilla, buttocks Poor quality donor skin Poor quality donor skin Poor nutritional status Poor nutritional status Bleeding Bleeding Mechanical trauma Mechanical trauma Shock+ Shock+

195 DONOR SITES Donor sites are considered to be PARTIAL THICKNESS WOUNDS Donor sites are considered to be PARTIAL THICKNESS WOUNDS Try to get healed in days, but many variables affect this time-table Try to get healed in days, but many variables affect this time-table Nursing considerations include promoting comfort, preventing trauma and infection Nursing considerations include promoting comfort, preventing trauma and infection Outer dressing to apply pressure to maintain homeostasis remains in place 1- 2 days. Dry exposure may require avoidance of pressure, and a heat lamp wts, KEPT 2 FEET AWAY FROM SITE. Loose separating gauze is trimmed Outer dressing to apply pressure to maintain homeostasis remains in place 1- 2 days. Dry exposure may require avoidance of pressure, and a heat lamp wts, KEPT 2 FEET AWAY FROM SITE. Loose separating gauze is trimmed

196 MUST KNOW THE DONOR SITE IS VERY PAINFUL THE DONOR SITE IS VERY PAINFUL THE GRAFT SITE MUST BE KEPT IMMOBILE UNTIL THE GRAFT TAKES. THE GRAFT SITE MUST BE KEPT IMMOBILE UNTIL THE GRAFT TAKES. SKIN GRAFT MUST NOT SLIP SKIN GRAFT MUST NOT SLIP GRAFT SITE DRESSINGS MAY BE BULKY AND MUST NOT BE DISTURBED GRAFT SITE DRESSINGS MAY BE BULKY AND MUST NOT BE DISTURBED MUST HAVE FREQ. CIRC. CHECKS AND ANY INVOLVED EXTREMITY MUST BE ELEVATED MUST HAVE FREQ. CIRC. CHECKS AND ANY INVOLVED EXTREMITY MUST BE ELEVATED

197 GOAL: GOOD ADHERENCE OF GRAFT AND NO WOUND INFECTION GOAL: GOOD ADHERENCE OF GRAFT AND NO WOUND INFECTION

198 MEDICATIONS USED Silver sulfadiazine: buttered on, covered with a light dressing 1-2x day Silver sulfadiazine: buttered on, covered with a light dressing 1-2x day Broad spectrum, low toxicity, Can still have burning sensation can be used with/wo dressings Broad spectrum, low toxicity, Can still have burning sensation can be used with/wo dressings Intermediate penetration of eschar Intermediate penetration of eschar Leukopenia (fever, sore throat, cough) Leukopenia (fever, sore throat, cough) Thrombocytopenia (easy bruising, unusual bleeding) Thrombocytopenia (easy bruising, unusual bleeding)

199 Sulfamylon: buttered on 3-4x day Sulfamylon: buttered on 3-4x day Broad spectrum, rapid deep penetration of eschar, excreted rapidly Broad spectrum, rapid deep penetration of eschar, excreted rapidly Causes pain with application Causes pain with application Pulmonary toxicity, metabolic acidosis, may inhibit wound healing Pulmonary toxicity, metabolic acidosis, may inhibit wound healing With any sulfa med, may have adverse reaction, Stevens- Johnson syndrome,MUST MAINTAIN ADEQUATE FLUID INTAKE With any sulfa med, may have adverse reaction, Stevens- Johnson syndrome,MUST MAINTAIN ADEQUATE FLUID INTAKE

200 Silver Nitrate solution: wet dressing change BID, resoak q2h; broad spectrum, nonallergenic, low toxicity, inexpensive, wont interfere with healing Silver Nitrate solution: wet dressing change BID, resoak q2h; broad spectrum, nonallergenic, low toxicity, inexpensive, wont interfere with healing Poor penetration of eschar; ineffective on established wound infections Poor penetration of eschar; ineffective on established wound infections

201 Bacitration: buttered on q4-6h Bacitration: buttered on q4-6h No pain, odorless, softens eschar, but..poor penetration of eschar. Ineffective on established wound infections No pain, odorless, softens eschar, but..poor penetration of eschar. Ineffective on established wound infections Gentamicin: apply gently 3-4x day Gentamicin: apply gently 3-4x day Broad spec., covered or left open Broad spec., covered or left open Ototoxic, nephrotoxic, pain with application Ototoxic, nephrotoxic, pain with application

202 Nitofurazone: THIN LAYER dierectly on wound or impregnate gauze. Change drsg. BID, Nitofurazone: THIN LAYER dierectly on wound or impregnate gauze. Change drsg. BID, Broad spec., bacteriocidal Broad spec., bacteriocidal PAINFUL APLLICATION PAINFUL APLLICATION May support overgrowth of fungus and/or Pseudomonas May support overgrowth of fungus and/or Pseudomonas

203 STAGE 3 from wound closure to return of optimum function on all levels Rehabilitation Rehabilitation therapy STARTS IN ACUTE PHASE CONTINUES THRU REHAB therapy STARTS IN ACUTE PHASE CONTINUES THRU REHAB Reconstructive can take many years Reconstructive can take many years 2 major nsg considerations; the most comfortable position is the position of CONTRACTURE and the burn site will contin. to shorten until it meets an opposing force 2 major nsg considerations; the most comfortable position is the position of CONTRACTURE and the burn site will contin. to shorten until it meets an opposing force

204 MAJOR GOAL IS TO AVOID CONTRACTURE MAJOR GOAL IS TO AVOID CONTRACTURE Exercise program within 24-48h Exercise program within 24-48h Use of splinting devices for positioning and stretching ie pressure garment Use of splinting devices for positioning and stretching ie pressure garment Great psychosocial effect Great psychosocial effect Important to return to abilities of preburn level. Requires work of many disciplines and the patient Important to return to abilities of preburn level. Requires work of many disciplines and the patient

205 Nursing process Assessment includes: medical hx, known allergies, current medications if any, Assessment includes: medical hx, known allergies, current medications if any, Extent, depth, burn agent, duration of contact, location of pain, level of pain, associated injuries Extent, depth, burn agent, duration of contact, location of pain, level of pain, associated injuries Determine first aid needs Determine first aid needs Additional losses, how burn ocurred Additional losses, how burn ocurred

206 Nursing diagnosis Primary are: Primary are: Impaired skin integrity Impaired skin integrity Impaired gas exchange Impaired gas exchange Deficient fluid volume Deficient fluid volume Ineffective tissue perfusion Ineffective tissue perfusion Imbalanced nutrition Imbalanced nutrition Activity intolerance Activity intolerance Selfcare deficit Selfcare deficit Disturbed body image Disturbed body image Ineffective coping Ineffective coping

207 Deficient fluid volume Deficient fluid volume Check urine output/replacement 50ml/h in adults; HR AT NL TO 100BPM, stable body wt Check urine output/replacement 50ml/h in adults; HR AT NL TO 100BPM, stable body wt Wt daily Wt daily Record I&O, insert indwelling catheter Record I&O, insert indwelling catheter Assess for s/s hypovolemia(

208 Administer osmotic diuretics Administer osmotic diuretics Assess gi funct.for paralytic ileus Assess gi funct.for paralytic ileus Maintain nasogastric tube/tube patency Maintain nasogastric tube/tube patency

209 Impaired gas exchange related To upper airway edema, carbon monoxide poisoning, edema of capillary aveolar membranes To upper airway edema, carbon monoxide poisoning, edema of capillary aveolar membranes Goal: pt will have patent airway; CO level< 10%, clear lung sounds, PAO mmhg; PACO mmHg, alert and aware Goal: pt will have patent airway; CO level< 10%, clear lung sounds, PAO mmhg; PACO mmHg, alert and aware No s/s stridor, nasal flaring, retractions No s/s stridor, nasal flaring, retractions

210 Pain related to burns or graft donor sites Pt will have good pain control as evidenced by verbal and non-verbal cues Pt will have good pain control as evidenced by verbal and non-verbal cues Does pt verbalize this, how many hours of sleep in 24h, does he/she feel rested Does pt verbalize this, how many hours of sleep in 24h, does he/she feel rested

211 Risk for sepsis related to wound infection Pt will not develop a wound infection Pt will not develop a wound infection Healthy granulation tissue? Healthy granulation tissue? Unhealed, open area with <10 colonies of bacteria Unhealed, open area with <10 colonies of bacteria Donor sites free of infection? Donor sites free of infection? Did graft take Did graft take Nl temp/nl WBC? Nl temp/nl WBC?

212 Skin lesions Non-cancerous Non-cancerous Premalignant Premalignant malignant malignant

213 Benign include: cysts, seborrheic keratosis, keloids, pigmented nevi,which must be watched for change in color or moles>1cm, size, inflammation, itching, oozing, bleeding, varigated colors(bluish), irregular borders, warts, hemangiomas Benign include: cysts, seborrheic keratosis, keloids, pigmented nevi,which must be watched for change in color or moles>1cm, size, inflammation, itching, oozing, bleeding, varigated colors(bluish), irregular borders, warts, hemangiomas

214 Malignant lesions Basal cell carcinoma arises from basal cell layer of epidermis Basal cell carcinoma arises from basal cell layer of epidermis Most common type Most common type Sun exposed areas on body Sun exposed areas on body Rolled waxy edge, depressed center, can be pearly, crusting and ulceration Rolled waxy edge, depressed center, can be pearly, crusting and ulceration Rarely metastatic, but can be locally invasive/disfiguring Rarely metastatic, but can be locally invasive/disfiguring

215 Squamous cell ca., also from epidermis and sun exposed areas of skin and the mucus membranes Squamous cell ca., also from epidermis and sun exposed areas of skin and the mucus membranes Lower lip, neck, tongue, head and dorsa of hands, poss. develops on preexisting lesion (actinic keratosis) Lower lip, neck, tongue, head and dorsa of hands, poss. develops on preexisting lesion (actinic keratosis) Single crusted, scaled, eroded papule, nodule or plaque, fragile, prone to oozing, bleeding Single crusted, scaled, eroded papule, nodule or plaque, fragile, prone to oozing, bleeding Highly invasive with mets Highly invasive with mets

216 Malignant melanoma Malignant melanoma Malignant growth of pigment cells Malignant growth of pigment cells Highly metastatic/high mortality rate Highly metastatic/high mortality rate Can occur anywhere on body Can occur anywhere on body Many arise out of pre existing moles or nevi Many arise out of pre existing moles or nevi

217 Three types: Three types: Lentigo maligna; slow growing dark macule on exposed skin surfaces (face of elderly pts) irreg. borders, brown, black, tan. Prognosis good if treated early Lentigo maligna; slow growing dark macule on exposed skin surfaces (face of elderly pts) irreg. borders, brown, black, tan. Prognosis good if treated early Superficial spreading; most common type, can occur anywhere on body espec of elderly; slightly elevated plaque with irreg border, varies in color, may bleed or ooze Superficial spreading; most common type, can occur anywhere on body espec of elderly; slightly elevated plaque with irreg border, varies in color, may bleed or ooze

218 Eventually develops into a nodule Eventually develops into a nodule Prognosis is poor at this stage Prognosis is poor at this stage Nodular melanoma appears suddenly Nodular melanoma appears suddenly Spherical papule or nodule on skin or in a mole Spherical papule or nodule on skin or in a mole Color blue-black, blue gray, reddish-blue Color blue-black, blue gray, reddish-blue Fragile, bleeds easily Fragile, bleeds easily Mets occurs rapidly, least favorable prognosis Mets occurs rapidly, least favorable prognosis

219 prevention Prevention is primary Prevention is primary Limit or avoid direct exposure to UV rays, sun (10a-2p), tanning booths Limit or avoid direct exposure to UV rays, sun (10a-2p), tanning booths Wear sunblock 15 or> Wear sunblock 15 or> Protective clothing Protective clothing Self examination weekly/monthly Self examination weekly/monthly See md for suspicious lesions or changes. Have moles or nevi in areas of constant friction removed See md for suspicious lesions or changes. Have moles or nevi in areas of constant friction removed Fair skinned people, and/or those with a lot of moles, freckles be more cautious, less melanin protection Fair skinned people, and/or those with a lot of moles, freckles be more cautious, less melanin protection

220 Preliminary based on presentation of lesion Preliminary based on presentation of lesion Definitive from biopsy; further testing done if + Definitive from biopsy; further testing done if +

221

222 Miliaria rubra Prickly heat Prickly heat Pinsized erythematous papules Pinsized erythematous papules Sweat glands, folds Sweat glands, folds Itching Itching Prevention Prevention No bundling No bundling Tepid baths Tepid baths

223 Diaper rash Rash from ammonia Rash from ammonia Burning erythematous rash Burning erythematous rash Must consider yeast Must consider yeast Primary is prevention Primary is prevention Expose to air Expose to air Avoid baby powders Avoid baby powders Wash and dry thoroughly Wash and dry thoroughly

224 C. albicans Causative agent for thrush and some diaper rash Causative agent for thrush and some diaper rash If mother has vaginitis If mother has vaginitis Milk curds Milk curds Antibiotic therapy Antibiotic therapy Mycostatin/nystatin q6h, thin layer Mycostatin/nystatin q6h, thin layer Cleanliness/open to air as much as possible Cleanliness/open to air as much as possible

225 impetigo Superficial bacterial infection Superficial bacterial infection In newborn/staph aureus In newborn/staph aureus Older child group A beta-hemolytic strep Older child group A beta-hemolytic strep Newborn presents as bullous(blisters) Newborn presents as bullous(blisters) Older child non-bullous Older child non-bullous Highly infectious Follow skin/contact precautions Highly infectious Follow skin/contact precautions

226 Gown and gloves Gown and gloves Infant needs to be segregated from others Infant needs to be segregated from others Appears on face, spreads, crusts and drainage are contagious Appears on face, spreads, crusts and drainage are contagious Soak off crusts, follow with Bacitracin/neosporin Soak off crusts, follow with Bacitracin/neosporin Careful handwashing Careful handwashing Older child treated in home with careful teaching of caregivers Older child treated in home with careful teaching of caregivers

227 Very itchy, trim nails Medical treatment can be Peniciilen or erythromycin for ten days Very itchy, trim nails Medical treatment can be Peniciilen or erythromycin for ten days Daily wash off crusts,/bactroban Daily wash off crusts,/bactroban ****If older child and organism is strep, infection can be rheumatic fever or acute glomeruloephritis***** ****If older child and organism is strep, infection can be rheumatic fever or acute glomeruloephritis*****

228 Acute infantile eczema Atopic dermatitis often as a result of reaction to an irritant Atopic dermatitis often as a result of reaction to an irritant Common first year of life, after 3mos Common first year of life, after 3mos Uncommon in breastfed babies Uncommon in breastfed babies Hereditary predisposition Hereditary predisposition Hypersensitivity in deep skin layers to protein or protein like allergens Hypersensitivity in deep skin layers to protein or protein like allergens

229 Allergens may be inhaled, ingested, absorbed thru direct contact Allergens may be inhaled, ingested, absorbed thru direct contact House dust,mites, egg white, wool House dust,mites, egg white, wool Infants may develop hay fever or asthma later in life Infants may develop hay fever or asthma later in life

230 Starts on cheeks, spreads to extensor surfaces of arms and legs, then entire trunk Starts on cheeks, spreads to extensor surfaces of arms and legs, then entire trunk Initially red skin, then papule and vesicle formation Initially red skin, then papule and vesicle formation INTENSE ITCHING causing weeping and crusting, may quickly become infected by strep or staph INTENSE ITCHING causing weeping and crusting, may quickly become infected by strep or staph

231 Common allergens are foods; egg whites, cows milk, wheats, orange juice, tomato juice Common allergens are foods; egg whites, cows milk, wheats, orange juice, tomato juice Inhalants, dust, pollens, animal dander Inhalants, dust, pollens, animal dander Materials; wools, nylons, plastic Materials; wools, nylons, plastic

232 Dx, by process of elimination Dx, by process of elimination Elimination diet/ assess often for s/s malnutrition Elimination diet/ assess often for s/s malnutrition Serious condition eczema vaccinatum Serious condition eczema vaccinatum High mortality rate High mortality rate Avoid herpes infection/exposure Avoid herpes infection/exposure Severe pain and illness Severe pain and illness

233 Treatment may include oral antibiotics, antihistamines, sedatives Treatment may include oral antibiotics, antihistamines, sedatives Cortisone creams only if there is no infection, wet soaks (colloidal), tepid water, emollients Cortisone creams only if there is no infection, wet soaks (colloidal), tepid water, emollients Parents are exhausted, frustrated Parents are exhausted, frustrated Usually clears by age 2 Usually clears by age 2

234 Nursing diagnoses Impaired skin integrity Impaired skin integrity Disturbed sleep patterns(itching/discomfort) Disturbed sleep patterns(itching/discomfort) Imbalanced nutrition (elimination diet) Imbalanced nutrition (elimination diet) Risk for infection Risk for infection Deficient knowledge of caregivers Deficient knowledge of caregivers

235 goals Preserve skin integrity Preserve skin integrity Maintain comfort Maintain comfort Maintain good nutrition Maintain good nutrition Prevent infection Prevent infection Increase family/caregiver knowledge Increase family/caregiver knowledge

236 What are the interventions available to implement goals? What are the interventions available to implement goals? Cover skin, prevent scratching, wet dressings, dont allow to dry Cover skin, prevent scratching, wet dressings, dont allow to dry Weighing daily**** Weighing daily**** Aseptic technique/avoid hospitalization Aseptic technique/avoid hospitalization Read labels carefully Read labels carefully Instruct caregivers/ provide support/referrals to community services Instruct caregivers/ provide support/referrals to community services Small papule on scalp;spreads Small papule on scalp;spreads

237 Griseofulvin drug of choice. Compliance difficult due to tx of 3mos Griseofulvin drug of choice. Compliance difficult due to tx of 3mos Corporis lesions on body Corporis lesions on body Usually from infected dog or cat Usually from infected dog or cat Miconazole, clotrimazole Miconazole, clotrimazole T. pedis, hygiene, meds, white socks T. pedis, hygiene, meds, white socks T. cruris T. cruris

238 Fungal infections (pg 406) Tinea, fungal infection living in outer layers of hair, skin, nails Tinea, fungal infection living in outer layers of hair, skin, nails Ringworm of scalp, tinea capitis/tonsurans Ringworm of scalp, tinea capitis/tonsurans Transmitted person to person Transmitted person to person Microsporum canis/animal to child Microsporum canis/animal to child Hair brittle and breaks off easily Hair brittle and breaks off easily

239 Parasitic infections Pediculosis and scabies Pediculosis and scabies Suck blood of hosts Suck blood of hosts Capitis, corporis, pubis Capitis, corporis, pubis Human to human Human to human Severe itching Severe itching Kwell shampoo for at least 4min, rinse, dry, dip comb in warm white vinegar Kwell shampoo for at least 4min, rinse, dry, dip comb in warm white vinegar Wash all in hot wter and dry in hot dryer Wash all in hot wter and dry in hot dryer

240 Dryclean non-washables Dryclean non-washables Seal in plastic bags for 2 weeks to break cycle Seal in plastic bags for 2 weeks to break cycle All in contact days, treat All in contact days, treat

241 Drugs affecting skin TERMS TERMS Antiseptic: chemicals applied to living tissue to kill pathogens that may harm the host Antiseptic: chemicals applied to living tissue to kill pathogens that may harm the host Disinfectants: chemicals used to kill organisms present on objects Disinfectants: chemicals used to kill organisms present on objects Bacteriostatic: halts or slows growth without killing off entire population Bacteriostatic: halts or slows growth without killing off entire population Bactericidal: will kill bacteria, not fungus, spores or viruses Bactericidal: will kill bacteria, not fungus, spores or viruses

242 Types of drugs I. Topical anti-infectives I. Topical anti-infectives Topical antibiotics Topical antibiotics Topical antifungals Topical antifungals Topical antivirals Topical antivirals II.Topical antiseptics and germicides II.Topical antiseptics and germicides III.Topical corticosteroids III.Topical corticosteroids IV.Topical antipsoriatics IV.Topical antipsoriatics V.Topical enzymes V.Topical enzymes VI.Keratolytics VI.Keratolytics VII.Topical local anesthetics VII.Topical local anesthetics

243 Topical antibiotics Exert direct local effect on specific organisms Exert direct local effect on specific organisms Can be bacteriostatic/bactericidal Can be bacteriostatic/bactericidal Used to prevent superficial infections in minor breaks in skin integrity Used to prevent superficial infections in minor breaks in skin integrity

244 Bacitracin; 1-5x day Bacitracin; 1-5x day G-myticin; 1-5xday G-myticin; 1-5xday Emgel; 2x day Emgel; 2x day Neomycin; 1-3x day Neomycin; 1-3x day Thin layers Thin layers All have significant side effects All have significant side effects

245 antifungals Interrupts the continued growth of a fungus after long period of use Interrupts the continued growth of a fungus after long period of use Used for jock itch, athletes foot, ringworm, candidal infections of skin, vagina and mucus membranes Used for jock itch, athletes foot, ringworm, candidal infections of skin, vagina and mucus membranes Fungizone (amphetericin B), Miconozole (Micatin), ciclopirox olamine (Loprox) Econazole(spectazole) Fungizone (amphetericin B), Miconozole (Micatin), ciclopirox olamine (Loprox) Econazole(spectazole)

246 Tolnaftate (tinactin), Nystatin (Nilsat and Mycostatin) Tolnaftate (tinactin), Nystatin (Nilsat and Mycostatin)

247 antivirals 2 available are acyclovir (Zovirax) and penciclovir (Denavir) inhibit viral replication 2 available are acyclovir (Zovirax) and penciclovir (Denavir) inhibit viral replication Acyclovir for initial outbreaks of genital herpes and for Herpes simplex viral infections in immunocompromised clients Acyclovir for initial outbreaks of genital herpes and for Herpes simplex viral infections in immunocompromised clients Penciclovir only for HSV 1( Herpes labalis adults Penciclovir only for HSV 1( Herpes labalis adults

248 Adverse reactions of topicals Can cause hypersensitivity reaction Can cause hypersensitivity reaction Superinfection (overgrowth of organisms not affected by med) Superinfection (overgrowth of organisms not affected by med) Topical antibiotics are category C for pregnant women..used cautiously during pregnancy and lactation Topical antibiotics are category C for pregnant women..used cautiously during pregnancy and lactation Topical antivirals are Cat. B, still used with caution Topical antivirals are Cat. B, still used with caution Topical antifungals unknown except for Spectazole (cat. C) and ciclopirox (penlac)(cat. B) Topical antifungals unknown except for Spectazole (cat. C) and ciclopirox (penlac)(cat. B)

249 Topical antiseptics/germicides Exact action not known; affect a variety of organisms Exact action not known; affect a variety of organisms Efficacy may depend on strength, concentration and length of exposure with skin or mucus membrane Efficacy may depend on strength, concentration and length of exposure with skin or mucus membrane Used to reduce numbers of bacteria on skin surfaces Used to reduce numbers of bacteria on skin surfaces Benzalkonium,chlorhexidine, Iodine Benzalkonium,chlorhexidine, Iodine

250 Have few adverse reactions unless individual has an allergy Have few adverse reactions unless individual has an allergy Contraindicated if known hypersens otherwise, no significant reasons to avoid use Contraindicated if known hypersens otherwise, no significant reasons to avoid use

251 Topical corticosteroids Vary in potency, vehicle for delivery, and area of skin to which it is applied Vary in potency, vehicle for delivery, and area of skin to which it is applied Exert a local anti-inflammatory effect Exert a local anti-inflammatory effect Useful in relieving itching, redness and swelling from psoriasis, dermatitis, rashes, eczema, insect bites, first and second degree burns Useful in relieving itching, redness and swelling from psoriasis, dermatitis, rashes, eczema, insect bites, first and second degree burns May cause same symptoms supposed to relieve May cause same symptoms supposed to relieve

252 Dont give with known hypersensitivity Dont give with known hypersensitivity Not for use as monotherapy in bacterial skin infections or viral infections Not for use as monotherapy in bacterial skin infections or viral infections Limit or avoid use on face, eyes Limit or avoid use on face, eyes Preg. Category C Preg. Category C

253 Topical antipsoriatics Drugs help to remove plaques Drugs help to remove plaques Anthralin (Anthra-derm) and calcipotriene ( Dovonex) Anthralin (Anthra-derm) and calcipotriene ( Dovonex) Dont give with known hypers. Dont give with known hypers. Category C Category C

254 Topical enzymes Aids in removal of necrotic tissue by reducing proteins into simpler tissue (proteolytic action) Aids in removal of necrotic tissue by reducing proteins into simpler tissue (proteolytic action) Responders may be second/third degree burns, pressure ulcers and ulcers of PVD Responders may be second/third degree burns, pressure ulcers and ulcers of PVD Collagenase/Santyl Collagenase/Santyl Low incidence of adverse reactions Low incidence of adverse reactions Not for use in wounds where nerves are exposed or wounds connect with a body cavity. Cat. B, may be inactivated by detergents and antiseptics Not for use in wounds where nerves are exposed or wounds connect with a body cavity. Cat. B, may be inactivated by detergents and antiseptics

255 keratolytics Acts to remove excess growth of the epidermis Acts to remove excess growth of the epidermis Warts, calluses, corns, and seborrheic keratosis Warts, calluses, corns, and seborrheic keratosis Salicylic acid, diclofenac (solaraze) and Actinex, salicylic acid often in OTC preparations Salicylic acid, diclofenac (solaraze) and Actinex, salicylic acid often in OTC preparations Usually well tolerated Usually well tolerated

256 Dont give with known hypersen. Dont give with known hypersen. Not used on moles, warts with hair, genital or facial warts, warts on mucus membranes or infected skin Not used on moles, warts with hair, genital or facial warts, warts on mucus membranes or infected skin Not for longterm use in diabetics, clients with impaired circulation or infants Not for longterm use in diabetics, clients with impaired circulation or infants Cat. C Cat. C

257 Topical local anesthetics Temporarily inhibit conduction of impulses from sensory nerve fibers Temporarily inhibit conduction of impulses from sensory nerve fibers Relieve itching, burning and pain Relieve itching, burning and pain Can be used with caution on mucus membranes Can be used with caution on mucus membranes Lanacane, nupercainal, Xylocaine Lanacane, nupercainal, Xylocaine Occas. local irritation noted Occas. local irritation noted Contraind. With known hypers. And with certain class 1 antiarrhy meds Contraind. With known hypers. And with certain class 1 antiarrhy meds

258 Nursing process Pre-administration assessment consists of visual and palpation, describe using appropriate terminology Pre-administration assessment consists of visual and palpation, describe using appropriate terminology Ongoing assessment of site every application; checking for changes or adverse reactions Ongoing assessment of site every application; checking for changes or adverse reactions Apply nursing diagnoses Apply nursing diagnoses Planning for expected outcomes Planning for expected outcomes

259 Implementation to promote an optimal response to therapy Implementation to promote an optimal response to therapy Allow for time to verbalize concerns or ask questions Allow for time to verbalize concerns or ask questions Assure condition improves, if true Assure condition improves, if true

260 Topical antiinfectives Topical antiinfectives Cleanse skin with soap and warm water Cleanse skin with soap and warm water Apply medication thin layer, liberally Apply medication thin layer, liberally Either cover or leave exposed Either cover or leave exposed Avoid eye area Avoid eye area

261 Topical antiseptics and germicides Topical antiseptics and germicides Instill or apply as directed Instill or apply as directed Occlusive dressing only if ordered Occlusive dressing only if ordered All containers must be clearly labeled and dated, more advisable not to leave on bedside table, espec. With elderly or confused pt All containers must be clearly labeled and dated, more advisable not to leave on bedside table, espec. With elderly or confused pt Educate pt to any special effects of med, iodine may stain, etc Educate pt to any special effects of med, iodine may stain, etc

262 Topical corticosteroids Topical corticosteroids Wash site with soap/water unless otherwise directed Wash site with soap/water unless otherwise directed Applied sparingly. If to have occlusive drsg, apply while skin still moist, cover with plastic wrap Applied sparingly. If to have occlusive drsg, apply while skin still moist, cover with plastic wrap

263 Topical enzymes to remove dead tissue Topical enzymes to remove dead tissue Certain skin wounds may require special preparation, Certain skin wounds may require special preparation, Area is washed or cleansed Area is washed or cleansed Med applied as dir Med applied as dir If bleeding occurs, d/c and rept If bleeding occurs, d/c and rept Avoid application to healthy tissue Avoid application to healthy tissue

264 Topical antipsoriatics Topical antipsoriatics Apply only to prescribed areas Apply only to prescribed areas Assess for intensified irritation Assess for intensified irritation Educate pt on s/e and limitation to sunlight exposure Educate pt on s/e and limitation to sunlight exposure

265 Topical anesthetics Topical anesthetics Advise pt of numbness which can last an hour or so Advise pt of numbness which can last an hour or so If used on mucus membranes, advise no food for at least I hr, may have impaired swallow If used on mucus membranes, advise no food for at least I hr, may have impaired swallow

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