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Chapter 27 Care of Patients with Skin Problems

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Page 1: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Chapter 27

Care of Patients with Skin Problems

Page 2: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Xerosis (Dryness)

• A common problem among older patients• Fine flaking of the stratum corneum• Generalized pruritus• Scratching may result in secondary skin

lesions, excoriations, lichenification, and infection

Page 3: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Collaborative Management

• Nursing interventions aim to rehydrate the skin and relieve itching.

• Bathing with moisturizing soaps, oils, and lotions may reduce dryness.

• Water softens the outer skin layers; creams and lotions seal in the moisture provided by water.

Page 4: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Pruritus (Itching)

• Pruritus is caused by stimulation of itch-specific nerve fibers at the dermal-epidermal junction.

• Itching is a subjective symptom similar to pain.• “Itch-scratch-itch” cycle.• Cool sleeping environment is helpful.• Fingernails should be trimmed short.• Antihistamines.• Topical steroids.

Page 5: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Sunburn

• First-degree, superficial burn• Cool baths• Soothing lotions• Antibiotic ointments for blistering and

infected skin• Topical corticosteroids for pain

Page 6: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Urticaria (Hives)

• Urticaria—presence of white or red edematous papules or plaques of varying sizes

• Removal of triggering substances• Antihistamines helpful• Avoidance of overexertion, alcohol

consumption, and warm environments, which can worsen symptoms

Page 7: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Trauma

• Phases of wound healing:– Inflammatory phase– Fibroblastic or connected tissue repair phase– Maturation or remodeling phase

Page 8: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Process of Wound Healing

Page 9: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Process of Wound Healing (Cont’d)

• First intention resulting in a thin scar• Second intention (granulation) and

contraction—a deeper tissue injury or wound• Third intention (delayed closure)—high risk

for infection with a resultant scar

Page 10: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Partial-Thickness Wounds

• Involve damage to the epidermis and upper layers of the dermis

• Heal by re-epithelialization within 5 to 7 days • Skin injury immediately followed by local

inflammation

Page 11: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Re-epithelialization

Page 12: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Full-Thickness Wounds

• Damage extends into the lower layers of the dermis and underlying subcutaneous tissue.

• Removal of the damaged tissue results in a defect that must be filled with granulation tissue to heal.

• Contraction develops in healing process.

Page 13: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Pressure Ulcer

• Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period.

• Mechanical forces that create ulcers: – Pressure– Friction– Shear

Page 14: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Shearing Force

Page 15: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Identification of High-Risk Patients

• Mental status changes• Independent mobility• Nutritional status• Incontinence

Page 16: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Pressure-Relieving Techniques

• Adequate pressure relief key to prevention of pressure ulcers

• Capillary closing pressure• Pressure-relief products and devices• Positioning

Page 17: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Wound Assessment

• Pressure ulcers and their features are classified and assessed in four stages:– Stage I– Stage II– Stage III– Stage IV

Page 18: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Four Stages of Pressure Ulceration

Page 19: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Wound Assessment

• Location• Size• Color• Extent of tissue involvement• Cell types in the wound base and margins• Exudate• Condition of surrounding tissue• Presence of foreign bodies

Page 20: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Wound Contamination/Wound Infection

• A wound that is exposed is always contaminated but not always infected. Contamination is the presence of organisms without any manifestations of infection.

• Wound infection is contamination with pathogenic organisms to the degree that growth and spread cannot be controlled by the body’s immune defenses.

Page 21: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Nonsurgical Management

• Dressings:– Mechanical débridement– Natural chemical débridement– Hydrophobic material– Hydrophilic material

Page 22: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Nonsurgical Therapy

• Physical therapy• Drug therapy• Nutrition therapy• New technologies:– Electrical stimulation– Vacuum-assisted wound closure (VAC) – Hyperbaric oxygen (HBO) – Topical growth factors– Skin substitutes

Page 23: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Hyperbaric Oxygen Therapy

Page 24: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Surgical Management

• Surgical débridement• Skin grafting

Page 25: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Community-Based Care

• Home care management• Health teaching• Health care resources

Page 26: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Bacterial Infections

• Folliculitis—superficial infection involving only the upper portion of the follicle

• Furuncle (boil)—much deeper infection in the follicle

• Cellulitis—generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue

Page 27: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Furuncle

Page 28: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Cellulitis

Page 29: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Herpes Simplex Virus

• Type 1 herpes simplex virus (HSV-1)—classic recurring cold sore

• Type 2 herpes simplex virus (HSV-2)—genital herpes

• Herpes zoster (shingles)

Page 30: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Herpes Simplex Virus (Cont’d)

• Herpetic whitlow—a form of herpes simplex infection occurring on the fingertips of medical personnel who have come in contact with viral secretions

Page 31: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Herpes Zoster/Shingles

• Caused by reactivation of the dormant varicella-zoster virus in patients who have previously had chickenpox.

• Multiple lesions occur in a segmental distribution on the skin area innervated by the infected nerve.

• Eruption lasts several weeks.• Postherpetic neuralgia occurs after lesions

have resolved.

Page 32: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Fungal Infections (Dermatophyte)

• Tinea pedis• Tinea manus• Tinea cruris• Tinea capitis• Tinea corporis• Candida albicans

Page 33: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Assessment

• History • Laboratory assessment:– Tzanck smear– Swab culture– Potassium hydroxide (KOH) test

Page 34: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Interventions

• Skin care with proper cleansing• Isolation Precautions• Drug therapy

Page 35: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Skin Care

• Bathe daily with an antibacterial soap.• Remove any pustules or crusts gently.• Apply warm compress twice a day to furuncles

or areas of cellulitis.• Apply Burow's solution to viral lesions.• Avoid excessive moisture.• Ensure optimal patient positioning.

Page 36: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Drug Therapy for Skin Disorders

• Antibacterial drugs• Antifungal drugs• Anti-inflammatory drugs

Page 37: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Cutaneous Anthrax

• Infection caused by the spores of the bacterium Bacillus anthracis

• Diagnosis based on appearance of the lesions and culture or anthrax antibodies in the blood

• Oral antibiotics for 60 days—ciprofloxacin or doxycycline

Page 38: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Cutaneous Anthrax

Page 39: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Pediculosis

• Pediculosis—infestation by human lice:– Head lice—pediculosis capitis– Body lice—pediculosis corporis– Pubic or crab lice—pediculosis pubis

• Pruritus most common symptom• Drugs• Laundering of clothing and bed linen

Page 40: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Scabies

• Scabies is a contagious skin disease caused by mite infestations.

• Scabies is transmitted by close and prolonged contact or infested bedding.

• Examine skin between fingers and on the palms.

• Infestation is confirmed by an examination of a scraping of a lesion under a microscope.

Page 41: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Common Inflammations

• Contact dermatitis, atopic dermatitis• Interventions include:– Steroids– Avoidance of oil-based products– Antihistamines– Compresses and baths

Page 42: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Psoriasis

• Lifelong disorder with exacerbations and remissions

• Scaling disorder with underlying dermal inflammation; possibly an autoimmune reaction

• Psoriasis vulgaris most often seen• Exfoliative psoriasis—an explosively eruptive

and inflammatory form of the disease

Page 43: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Psoriasis Vulgaris

Page 44: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Treatment of Psoriasis

• Corticosteroids • Tar preparations• Other topical therapies • Ultraviolet light therapy• Systemic therapy:– Biologic agents– Cytotoxic agents– Immunosuppressants

• Emotional support

Page 45: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Benign Tumors

• Cysts• Seborrheic keratoses • Keloids• Nevi (moles)

Page 46: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Skin Cancer

• Actinic keratoses• Squamous cell carcinomas• Basal cell carcinomas• Melanomas—highly metastatic; survival

depends on early diagnosis and treatment

Page 47: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Skin Cancer (Cont’d)

Page 48: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Surgical Management of Skin Cancer

Surgical management:– Cryosurgery – Curettage and electrodesiccation– Excision– Mohs’ surgery– Wide excision

Page 49: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Nonsurgical Management of Skin Cancer

• Drug therapy• Radiation therapy

Page 50: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Plastic Surgery

• Rhytidectomy (face-lift)• Rhinoplasty (reconstruction of the nose)

Page 51: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Acne

• Red pustular eruption affecting the sebaceous glands of the skin

• Progressive disorder that manifests as noninflammatory comedones, inflammatory papules, pustules, and cysts

• Topical agents• Systemic antibiotics and possibly isotretinoin

(Accutane) helpful

Page 52: Chapter 27 Care of Patients with Skin Problems. Xerosis (Dryness) A common problem among older patients Fine flaking of the stratum corneum Generalized

Other Skin Disorders

• Lichen planus with itchy papules• Pemphigus vulgaris with chronic blistering• Toxic epidermal necrolysis—a rare, acute drug

reaction• Stevens-Johnson syndrome• Leprosy