1. Nursing Care of Patients with Skin Disorders
Chapter 54
Nursing Care of Patients with Skin Disorders

2. Pressure Ulcers Pathophysiology Etiology Pressure Against Skin
Tissue Anoxia
Etiology
Pressure
Friction
Shear

3. Risk Factors Immobility Impaired Circulation
Impaired Sensory Perception
Elderly
Very Thin or Obese

4. Prevention Assess Daily Cleanse and Dry Daily and PRN Lubricate Daily
Clean Incontinence Promptly
Use Moisture Barrier PRN
Do Not Massage Reddened Areas
Shift every Weight every 15 min

5. Prevention (cont’d) Turn/Reposition at Least every 2 hr
Keep Heels Off Bed
Pad/Protect Bony Prominences
Use Pressure-Reducing Mattress
Use Lift Sheet to Move
Provide Nutrition and Hydration

6. Braden Scale Page 1306 Sensory Perception Moisture Activity Mobility
Nutrition
Friction and Shear

7. Signs and Symptoms Pain Open Ulcerated Area Color Tip Black: Necroses
Yellow: Infection
Red: Healing

8. Diagnosis Physical Examination Culture and Sensitivity
Blood Supply Studies
Wound Biopsy

9. Therapeutic Interventions
Remove All Pressure
Debride
Mechanical- Scissors and forceps are used to selectively remove non-viable tissue, wet to dry dressings, and whirlpool bath
Enzymatic- topical debriding agent, agents selectively digest necrotic tissue.
Autolytic- synthetic dressing over the wound , eschar is self digested via the action of the enzymes that are present in the fluid environment of the wound
Surgical – Removal of devitalized tissue
Cleanse
4 – 15 PSI- Irrigation system- shower head, 30ml syringe

10. Dressings Types Moist Environment Caution with Tape Hydrogel
Polyurethane Film
Hydrocolloid Wafer
Biological
Alginate
Gauze
Moist Environment
Caution with Tape

11. Negative Pressure Wound Therapy

12. Stages Deep Tissue Injury I – Skin Intact, Red, Does Not Blanch
II – Partial Thickness Skin Loss
III – Full Thickness Skin Loss, May Have Eschar
IV – Damage to Muscle, Bone, or Support Structures
Unstageable

13. Stages (cont’d)

14. Nursing Diagnoses Page 1312 Impaired Skin Integrity Risk for Infection
Pain

15. Disorders of the Skin

16. Pruritus Etiology and risk factors
Triggered by touch, temperature changes, emotional stress, and chemical, mechanical, and electrical stimuli
Prominent symptom of psoriasis, dermatitis, eczema, insect bites

17. Pruritus Medical treatment
Stress management and avoidance of known irritants, sudden temperature changes, and alcohol, tea, and coffee
Lubricants in the bathwater and emollients applied after bathing also may help
Medications include corticosteroids, antihistamines, and local anesthetics

18. Pruritus
Assessment
Collect data about symptoms that may help determine the cause
The history of the current illness is important because pruritus may be just one symptom of a condition that requires attention

19. Pruritus Interventions Lubricants/emollients; adding oils to bathwater
Advise to avoid bathing in very hot water
Administer medications or instruct patient in their use
Inspect skin daily to determine effects of treatment
Explain possible causes of pruritus and encourage the patient to avoid them

20. Atopic Dermatitis (Eczema)
Pathophysiology
Acute stage: red, oozing, crusty rash and intense pruritus
Subacute stage: redness, excoriations, and scaling plaques or pustules. Fine scales may give skin a silvery appearance
Chronic stage: the skin becomes dry, thickened, scaly, and brownish gray

21. Types of Dermatitis
Contact
Irritant
Allergic
Atopic
Seborrheic

22. Signs and Symptoms Rash, Itching Lesions Scales Crusts Fissures
Macules
Papules
Pustules

23. Atopic Dermatitis (Eczema)
Etiology and risk factors
Personal or family history of asthma, hay fever, eczema, or food allergies
People with atopic dermatitis have an immune dysfunction, but it is not known whether that dysfunction is a cause or an effect of the disorder

25. Complications
Infection
Sepsis

26. Atopic Dermatitis (Eczema)
Medical diagnosis
Health history and physical examination
Skin biopsy, serum immunoglobulin E levels, and cultures; allergy tests

27. Therapeutic Interventions
Antihistamines
Analgesics
Antipruritics
Steroids
Colloidal Oatmeal Baths
Wet Dressings

28. Nursing Diagnoses Impaired Skin Integrity Disturbed Body Image
Deficient Knowledge

29. Seborrheic Dermatitis
Pathophysiology
Chronic inflammatory disease of the skin
Affects scalp, eyebrows, eyelids, lips, ears, sternal area, axillae, umbilicus, groin, gluteal crease, and under the breasts
Areas affected by this condition may have fine, powdery scales, thick crusts, or oily patches
Scales may be white, yellowish, or reddish
Pruritus is common

30. Seborrheic Dermatitis
Etiology and risk factors
The cause is unknown
May be an inflammatory reaction to infection with the yeast Malassezia

31. Seborrheic Dermatitis
Medical diagnosis
Health history and physical examination
Medical treatment
Topical ketoconazole (Nizoral), sometimes with topical corticosteroids
Shampoos that contain selenium sulfide (Selsun), ketoconazole, tar, zinc pyrithionate, salicylic acid, or resorcin

32. Seborrheic Dermatitis

33. Seborrheic Dermatitis
Assessment
Inspect and describe the affected areas
Interventions
Explain the condition and reinforce the physician’s instructions for treatment

34. Psoriasis Pathophysiology Etiology and risk factors
Abnormal proliferation of skin cells
Classic sign: bright red lesions that may be covered with silvery scales
Etiology and risk factors
Caused by rapid proliferation of epidermal cells
Usually chronic with cycles of exacerbations and remissions. No cure.

35. Aggravating Factors Stress Strep Pharyngitis Hormone Changes
Cold Weather
Skin Trauma
Some Drugs

36. Signs and Symptoms
Papules, Plaques
Silvery Scales
Itching

37. Complications Infection, Fever, Chills Arthritis Nail Changes
Lymphadenopathy

38. Psoriasis Assessment diagnosis Describe symptoms and treatments
Inspect affected areas for lesions and scales
Document joint pain or stiffness because the condition may cause arthritis
diagnosis
Ineffective Therapeutic Regimen Management
Disturbed Body Image
Social Isolation

39. Therapeutic Interventions
Tub Baths
Corticosteroids
Salicylic Acid
Keratolytics
Vitamin D Creams
Retinoids
Coal Tar, Anthralin
UV Light
Chemotherapy
Occlusive Dressings
Fish Oil Supplements

40. Intertrigo Pathophysiology Etiology and risk factors
Inflammation where two skin surfaces touch: axillae, abdominal skinfolds, and under the breasts
The affected area is usually red and “weeping” with clear margins; may be surrounded by vesicles and pustules
Etiology and risk factors
Results from heat, friction, and moisture between touching surfaces

41. Intertrigo Medical diagnosis and treatment
Based on site/appearance of inflamed skin
If the skin not broken, wash with water twice daily; rinse and pat dry; soft gauze used to separate layer of tissue and absorb moisture
For severe inflammation or fungal infection: topical corticosteroid or antifungal agent

42. Intertrigo Assessment
Complaints of pain, irritation, or redness in body folds
Inspect susceptible areas daily

43. Intertrigo Interventions
Areas where skin surfaces are in contact must be kept clean and dry
Apply topical medications as ordered
Report increasing redness and tenderness, fever, and broken skin to the physician
Encourage women with pendulous breasts to wear a soft, supportive bra
If incontinence has contributed to perineal intertrigo, position patient with legs apart to allow moisture to evaporate

44. Intertrigo

45. Fungal Infections Pathophysiology/Etiology Direct Contact with Fungus
Overgrowth with Antibiotic Therapy
Grows in Warm Moist Environment

46. Fungal Infections Pathophysiology Tinea pedis (athlete’s foot)
Tinea manus (hand)
Tinea cruris (groin)
Tinea capitis (scalp)
Tinea corporis (body)
Tinea barbae (beard)
Candidiasis: affects skin, mouth, vagina, gastrointestinal tract, and lungs

47. Fungal Infections
Etiology and risk factors
Spread through direct contact or by inanimate objects
Lesions may be scaly patches with raised borders
Pruritus common symptom
Medical diagnosis
Confirmed by microscopic examination of skin scrapings
Medical treatment
Fungal: treated with antifungal powders and creams
Oral candidiasis: treated with clotrimazole troches, nystatin mouthwash or lozenges, oral amphotericin B

48. Figure 50-8

49. Fungal Infections Assessment Interventions
Conditions that might make a person susceptible to fungal infections
Inspect the skin and mucous membranes for lesions
Interventions
Disturbed Body Image
Altered Oral Mucous Membrane
Risk for Injury

50. Therapeutic Interventions
Keep Skin Clean and Dry
Topical Antifungals
Oral Antifungals
Corticosteroids
Teach to Avoid Spread

51. Acne Pathophysiology Etiology and risk factors Medical diagnosis
Affects the hair follicles and sebaceous glands
Comedones (whiteheads, blackheads), pustules, cysts
Often develop on the face, neck, and upper trunk
Etiology and risk factors
Androgenic hormones cause increased sebum production; bacteria proliferate, causing sebaceous follicles to become blocked and inflamed
Medical diagnosis
Health history and physical examination findings

52. Acne Medical treatment
Topical medications: antibiotics, keratolytics such as benzoyl peroxide, topical vitamin A preparations
Oral antibiotics given over several months
Nonpharmacologic treatment: comedo extraction or cryotherapy
Dermabrasion to reduce scarring

53. Acne Assessment Interventions Document any treatments being used
Inspect skin to determine extent and severity
Interventions
Disturbed Body Image
Ineffective Therapeutic Regimen Management

54. Herpes Simplex Etiology and risk factors Medical diagnosis
Viral infection begins with itching and burning and progresses to vesicles that rupture and form crusts
Nose, lips, cheeks, ears, genitalia most often affected
Oral lesions called cold sores or fever blisters
Infections on the face and upper body usually caused by HSV-1; genital infections by HSV-2
Medical diagnosis
Laboratory studies of exudate from a lesion and blood studies to detect specific antibodies

55. Figure 50-9

56. Herpes Simplex Pathophysiology Viral Infection HSV1 – Above Waist
HSV2 – Below Waist

57. Herpes Simplex (cont’d)
Primary Infection
Direct Contact
Respiratory Droplet
Fluid Exposure
Lies Dormant
Recurs with Stress

58. Herpes Zoster Etiology and risk factors Commonly called shingles
Varicella-zoster virus; also causes chickenpox
Symptoms: pain, itching, and heightened sensitivity along a nerve pathway, followed by the formation of vesicles in the area
When the skin is affected, crusts form
Older adults especially susceptible to complications
Immunosuppressed at greater risk for herpes zoster infections; may have serious systemic complications

59. Figure 50-10

60. Signs and Symptoms Prodromal Phase Vesicles and Pustules
Burning, Tingling
Vesicles and Pustules
Burning, Itching, Pain
Contagious Until Scabs Form

61. Herpes Zoster
Assessment
Conditions or treatments that might cause the patient to have a reduced immune response
Distribution and appearance of the lesions
Interventions
Impaired Skin Integrity
Acute Pain
Ineffective Coping

62. Therapeutic Interventions
Antiviral Agents (Acyclovir/Zovirax)
Topical
Oral
Antibiotics for Secondary Infection
Avoid Triggers of Recurrence

63. Herpes Zoster (Shingles)
Pathophysiology
Acute Inflammation/Infection
Painful Vesicules
Follows Nerve Distribution
Usually One-sided

64. Etiology Reactivation of Varicella Zoster Virus (Chickenpox Virus)
Occurs with Reduced Immune Function
Elderly
AIDS
Immunosuppressed

65. Prevention Avoidance of Infected Persons Varicella Vaccine (Varivax)
Zostavax

66. Signs and Symptoms Vesicles, Plaques Irritation Itching Fever Malaise
Pain

67. Complications Postherpetic Neuralgia Persistent Dermatomal Pain
Hyperesthesia
Opthalmic Herpes Zoster
Sepsis

68. Diagnosis
History and Physical
Culture

69. Therapeutic Interventions
Acyclovir
IV, Oral, Topical
Analgesics
Anticonvulsants/Antidepressants
Antihistamines
Corticosteroids
Antibiotics for Secondary Bacterial Infection

70. Cellulitis Pathophysiology Etiology
Inflammation of Skin/Connective Tissue
Infection
Staphylococcus/MRSA
Streptococcus
Etiology
Open Wound/Trauma
May be Unknown

71. Signs and Symptoms Warmth Redness Edema Pain, Tenderness Fever
Lymphadenopathy

72. Diagnosis
Culture and Sensitivity
Blood Cultures

73. MRSA

74. Therapeutic Interventions
Antibiotics
Topical
Systemic
Debridement

75. Acne Vulgaris Increased Sebum Production
Obstruction of Pilosebaceous Ducts

76. Acne Vulgaris (cont’d)
Signs and Symptoms
Comedones
Open
Closed
Therapeutic Interventions
Benzoyl Peroxide
Vitamin A Acid
Antibiotics
Estrogen Therapy

77. Nursing Diagnoses: Skin Infections
Risk for Spread of Infection
Acute Pain

78. Pediculosis Pathophysiology/Etiology Infestation by Lice
Transmission by Direct Contact

79. Types
Pediculosis Capitis
Pediculosis Corporis
Pediculosis Pubis

80. Signs and Symptoms Itching Papular Rash
Presence of Lice, Nits, and Excreta

81. Diagnosis
History and Physical
Test for STD if Pediculosis Pubis

83. Figure 50-12

84. Therapeutic Interventions
Pediculosides
Permethrin, Pyrethrin, Lindane
Mechanical Removal
Antipruritics
Topical Corticosteroids

85. Patient Education Self Medication Removal of Nits
Cleaning of Clothing and Objects
Inspection of Family and Friends

86. Scabies Pathophysiology Etiology Sarcoptes Scabiei Mites
Burrow into Skin
Etiology
Contact with Infected Clothing or Animals

87. Signs and Symptoms
Itching
Rash
Burrows

88. Diagnosis
Shaving of Lesion
Microscopic Evaluation

89. Therapeutic Interventions
Topical Scabicides
Permethrin
Crotamiton
Antipruritics

90. Patient Education Self Medication Treat Family Members
Wash Clothing and Linens
Itching May Continue 2 Weeks Following Treatment

91. Pemphigus Pathophysiology/Etiology Triggers Autoimmune Disorder
Bullae on Skin and Mucous Membranes
Triggers
Sun
Some Drugs or Foods

92. Signs and Symptoms Bullae Pain Burning Itching Mucous Membranes
Spread to Skin
Rupture
Raw Wounds
Pain
Burning
Itching

93. Pemphigus

94. Diagnosis
Positive Nikolsky’s Sign- Sloughing or blistering of normal skin, when minimal pressure is applied
Biopsy- Biopsy of blister reveals acantholysis ( separating of the epidermal cells from each other)

95. Therapeutic Interventions
Corticosteroids
Cytotoxic Agents
Antibiotics
Analgesics
Antipruritics
Fluid Replacement
High Protein, High Calorie Diet

96. Nursing Care Monitor Fluid Balance Monitor Diet
Administer Wet Dressings or Baths
Control Pain
Maintain Oral Hygiene
Provide Psychosocial Support

97. Malignant Skin Lesions
Cancer Arising From
Basal Cell Layer
Basal Cell Carcinoma
Epidermis
Squamous Cell Carcinoma
Menalocytes
Malignant Melanoma

98. M
Malignant Melanoma
Basal Cell Carcinoma
Figure 50-13D

99. Squamous cell carcinoma

100. Nonmelanoma Skin Cancer
Basal cell carcinoma
Painless, nodular lesions; pearly appearance
Related to sun exposure
Grow slowly and rarely metastasize
Treated with surgical excision, Mohs’ micrographic excision, electrodesiccation and curettage, cryotherapy, radiation, or drugs that are applied topically or injected into the lesion

101. Nonmelanoma Skin Cancer
Squamous cell carcinoma
Scaly ulcers or raised lesions
Develop on sun-exposed areas including the lips, and in the mouth
Caused by overuse of tobacco and alcohol
Grow rapidly and metastasize
Treatment may include surgical excision, cryotherapy, and radiation therapy

102. Basal Cell Carcinoma

103. Squamous Cell Carcinoma

104. Melanoma Arises from pigment-producing cells in the skin
Most serious form of skin cancer; fatal if it metastasizes
Found anywhere on the body
Irregular borders and uneven coloration; many are dark, but some are light. Begin as tan macule that enlarges
Removed surgically; a wide area around a melanoma is usually excised
Chemotherapy and immunotherapy also may be employed

105. Malignant Melanoma

106. Lentigo Maligna Melanoma
Slow growing dark macula on exposed skin surfaces, especially on the face of elderly patients

107. Risk Factors Ultraviolet Rays Fair Skin Genetic Tendency X-Ray Therapy
Chemicals
Immunosuppressive Therapy

108. Prevention Limit Exposure to UV Rays Report Changes in Moles
Use Sunscreen
Wear Protective Clothing
Report Changes in Moles

109. Diagnosis
Examination
Biopsy

110. Therapeutic Interventions
Surgical Excision
Chemotherapy
Radiation Therapy

111. Dermatological Surgery
Rhinoplasty- Nasal reconstruction
Blepharoplasty- Eyelids
Rhytidoplasty- Face lift
Otoplasty- correction of ear