Integumentary SystemIntegumentary System

RESPONSE TO ALTERED INTEGUMENTARY FUNCTION

Unit Outcomes: Upon completion of this unit of studyUpon completion of this unit of study, , the student will be able the student will be able to: to: •   Safe Effective Care Environment: Safe Effective Care Environment:

• 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental 1. Identify factors that influence injury and disease prevention ( sun exposure, environmental toxins, etc.).toxins, etc.).

• 2 . Perform thorough dermatological assessment throughout the life span. 2 . Perform thorough dermatological assessment throughout the life span.

• Health Promotion and Maintenance: Health Promotion and Maintenance:

• 3. Identify healthy behaviors by the client and family ( screening exams, limiting risk taking 3. Identify healthy behaviors by the client and family ( screening exams, limiting risk taking behaviors). behaviors).

• Psychosocial Integrity: Psychosocial Integrity:

• 4. Discuss psychosocial impact of client’s altered dermatological condition ( acne, burns, rashes, 4. Discuss psychosocial impact of client’s altered dermatological condition ( acne, burns, rashes, tumors). tumors).

• Physiologic Integrity: Physiologic Integrity:

• 5. Discuss nursing implications for medications prescribed for clients with dermatologic 5. Discuss nursing implications for medications prescribed for clients with dermatologic disorders. disorders.

• 6. Develop plan of care for client with impaired skin integrity. 6. Develop plan of care for client with impaired skin integrity.

• 7. Explain the eight parameters of assessing a lesion. 7. Explain the eight parameters of assessing a lesion.

• 8. Describe common lesions and rashes utilizing proper terminology. 8. Describe common lesions and rashes utilizing proper terminology.

• 9. Describe pre-op and post care of clients receiving dermatological surgical procedures. 9. Describe pre-op and post care of clients receiving dermatological surgical procedures.

• 10. Select nursing diagnoses most likely to be utilized with clients with integumentary problems. 10. Select nursing diagnoses most likely to be utilized with clients with integumentary problems.

• 11. Discuss etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and 11. Discuss etiology, clinical manifestations, and interventions for viral, bacterial, fungal, and parasitic skin disorders. parasitic skin disorders.

Introduction: Skin in our Introduction: Skin in our CultureCulture• Defining ‘beauty’Defining ‘beauty’

• LanguageLanguage

• CostsCosts

Functions:Functions:

• Protective BarrierProtective Barrier– InjuryInjury– Microbial InvasionMicrobial Invasion– Fluid & Electrolyte BalanceFluid & Electrolyte Balance– Temperature controlTemperature control

•ExcretionExcretion

•SensationSensation

•Vitamin D Vitamin D

• IdentityIdentity

Topics:Topics:• AssessmentAssessment

• Safety and preventive measures Safety and preventive measures

• Nursing Implications for Pharmacologic Nursing Implications for Pharmacologic Management Management

• Nursing Implications for Nonpharmacologic Nursing Implications for Nonpharmacologic Management Management

• Nursing Implications for Surgical Nursing Implications for Surgical ManagementManagement

• Nursing Management of Clients with Nursing Management of Clients with Alterations - IntegumentAlterations - Integument

KP’sKP’s

•AssessmentAssessment• A. Parameters of General Skin A. Parameters of General Skin

Assessment Assessment

• B. Lesions B. Lesions

• C. Cultural/Ethnic variations C. Cultural/Ethnic variations

• D. Diagnostic Testing D. Diagnostic Testing

Thorough HistoryThorough History

•Dx & Tx – realm of practice– Difficult due to similarities in lesions and

sx

•Differential dx requires clues

Assessment: Assessment: Subjective Subjective DataData

– Past Medical Past Medical HistoryHistory•TraumaTrauma

•SurgerySurgery

•Prior skin diseasePrior skin disease

• JaundiceJaundice

•Delayed wound healingDelayed wound healing

•Allergies Allergies

•Sun exposure Sun exposure

•Radiation treatmentsRadiation treatments

Assessment: Assessment: HistoryHistory

MedicationsMedications– PrescriptionPrescription– OTCOTC– HerbalsHerbals– NameName– Length of usageLength of usage

Assessment: Assessment: HistoryHistory• SurgerySurgery

– CosmeticCosmetic– BiopsyBiopsy

• DietDiet

• Health PracticesHealth Practices– Hygiene, productsHygiene, products– Sunscreen, SPFSunscreen, SPF– Complementary & Complementary &

alternative alternative medicinemedicine

• C/O symptomsC/O symptoms

• Known Known exposureexposure to to carcinogens, carcinogens, chemical irritants, chemical irritants, allergensallergens

• FamilyFamily– Alopecia (bald)Alopecia (bald)– PsoriasisPsoriasis– Skin cancerSkin cancer

Assessment: Assessment: HistoryHistory

• ChangesChanges

– Skin conditionSkin condition– Hair conditionHair condition– Nail conditionNail condition– Mucous membranesMucous membranes

• PrivacyPrivacy

• Carefully describe:Carefully describe:– Obvious Obvious changeschanges in color and in color and

vascularityvascularity– Presence or absence of moisturePresence or absence of moisture– EdemaEdema– Skin LesionsSkin Lesions– Skin integritySkin integrity

• Document properlyDocument properly

AssessmentAssessment

Parameters of General Skin Parameters of General Skin Assessment Assessment

• color, temperature, moisture, color, temperature, moisture, elasticity, turgor, texture, and odor. elasticity, turgor, texture, and odor.

Assessment: Assessment: InspectionInspection

• Consider Cultural and Ethnic Consider Cultural and Ethnic variationsvariations– Dark skinDark skin

• rates - skin cancerrates - skin cancer

•Difficult to assess flushing; cyanosis; jaundiceDifficult to assess flushing; cyanosis; jaundice

•Rashes difficult to observeRashes difficult to observe

• PseudofolliculitisPseudofolliculitis

• Keloids Keloids

• Mongolian spotsMongolian spots

• Inspection of hairInspection of hair– DistributionDistribution– TextureTexture– QuantityQuantity

• Inspection of nailsInspection of nails• Iggy page 474-475; Wilkinson 370Iggy page 474-475; Wilkinson 370

– GroovesGrooves– PittingPitting– RidgesRidges– CurvatureCurvature– ShapeShape

MalnutritionAnorexia nervosaAnxietyHygiene DepressionHormonesLiving conditionsCirculatory statusChronic disease

Assessment: InspectionAssessment: Inspection

Lesion DescriptionLesion Description• SizeSize

– MetricMetric• ShapeShape

– CircumscribedCircumscribed– IrregularIrregular– RoundRound

• TextureTexture– RoughRough– smoothsmooth

• ConfigurationConfiguration– AnnularAnnular

•““relating to, or relating to, or forming a ring”forming a ring”

– LinearLinear– Concentric ringsConcentric rings– ClusteredClustered– DiffuseDiffuse

• Effect of pressureEffect of pressure

Lesion Description Lesion Description • DistributionDistribution

– Asymmetric vs. SymmetricAsymmetric vs. Symmetric– ConfluentConfluent

•““flowing or coming together; flowing or coming together; alsoalso :: run together” run together”

– DiffuseDiffuse– LocalizedLocalized– SolitarySolitary– ZosteriformZosteriform

•““resembling shingles”resembling shingles”

– SatelliteSatellite

Assessment: Assessment: PalpationPalpation

– EdemaEdema– MoistureMoisture– TemperatureTemperature– TurgorTurgor– TextureTexture

FeverC-V statusRespiratory statusHormonesHydrationRash/ LesionNutritional status

Skin cancer - most common Skin cancer - most common cancer!cancer!

• Risk factorsRisk factors– Fair skinFair skin– Blue/green eyesBlue/green eyes– Blond/red hairBlond/red hair– History chronic sun exposureHistory chronic sun exposure– Family historyFamily history– Living near the equatorLiving near the equator– Very high/low altitudesVery high/low altitudes– Working outdoorsWorking outdoors– Age > 60 (damage is cumulative)Age > 60 (damage is cumulative)

Non-melanoma Skin Non-melanoma Skin CancersCancers• Basal Cell CarcinomaBasal Cell Carcinoma

– Most common type of skin Most common type of skin cancercancer

– Easily treatedEasily treated– Doesn’t metastasizeDoesn’t metastasize– Middle age to older adultsMiddle age to older adults– SymptomsSymptoms

• Small slow growing papuleSmall slow growing papule• Semi translucent or “pearly”Semi translucent or “pearly”• Erosion/ulceration of centerErosion/ulceration of center

Basal Cell CarcinomaBasal Cell Carcinoma

Medical TxMedical Tx

• ExcisionExcision• CryosurgeryCryosurgery• RadiationRadiation• Topical Topical

chemotherapychemotherapy

Non-Melanoma Skin CancerNon-Melanoma Skin Cancer• Squamous cellSquamous cell

– Less common than BCCLess common than BCC– High cure rate with High cure rate with early detectionearly detection– Can be aggressive, metastasize & be Can be aggressive, metastasize & be

fatalfatal– Common on lips, mouth, face and Common on lips, mouth, face and

handshands• Pipe, cigar, & cigarette smokingPipe, cigar, & cigarette smoking

– SymptomsSymptoms• Firm noduleFirm nodule• Scaling/ulcerationScaling/ulceration• OpaqueOpaque

Squamous cell carcinomaSquamous cell carcinoma

Medical TxMedical Tx

•ExcisionExcision•RadiationRadiation•Moh’s surgeryMoh’s surgery

(see slide #33)(see slide #33)

•5 FU or methotrexate 5 FU or methotrexate intralesional intralesional

– (see slide #34)(see slide #34)

Diagnostic & Surgical Diagnostic & Surgical TherapyTherapy• Simple ExcisionSimple Excision

• ExcisionExcision– Moh’s micrographic surgeryMoh’s micrographic surgery

•Microscopically controlled removal of lesionMicroscopically controlled removal of lesion

•Removes tissue in thin layersRemoves tissue in thin layers

•Can see all margins of specimenCan see all margins of specimen

•Preserves normal tissuePreserves normal tissue

•Produces smallest woundProduces smallest wound

Drug Therapy: Drug Therapy: Topical Fluorouracil Topical Fluorouracil (5-FU)(5-FU)

– Selective toxicity for sun damaged cells Selective toxicity for sun damaged cells (cytotoxic)(cytotoxic)

– IndicationsIndications•Premalignant skin disease (esp. actinic keratosis)Premalignant skin disease (esp. actinic keratosis)•Systemic absorption minimalSystemic absorption minimal

It causes painful eroded area within 4 days and It causes painful eroded area within 4 days and must use 1-2 times daily 2-4 weeks.must use 1-2 times daily 2-4 weeks.

Healing up to 3 weeks after med stoppedHealing up to 3 weeks after med stoppedIs photosensitizing - avoid sunlight during Is photosensitizing - avoid sunlight during

treatmenttreatmentWill look worse before it gets betterWill look worse before it gets better

Non-Melanoma Skin CancersNon-Melanoma Skin Cancers• Actinic Keratosis (AKA Solar keratosis)Actinic Keratosis (AKA Solar keratosis)

– Most common Most common preprecancerous lesioncancerous lesion– Premalignant form of squamous cell Premalignant form of squamous cell

carcinomacarcinoma– SymptomsSymptoms

• Hyperkeratotoc papules/plaques on sun exposed Hyperkeratotoc papules/plaques on sun exposed areasareas

• Varied appearanceVaried appearance– Irregular shapeIrregular shape– FlatFlat– Indistinct bordersIndistinct borders– Overlying scaleOverlying scale

Actinic Keratosis Actinic Keratosis (AKA Solar keratosis(AKA Solar keratosis))Medical Tx:Medical Tx:

•CryosurgeryCryosurgery (see slide #37)(see slide #37)

•5 FU5 FU•Surgical Surgical

removalremoval•Retin ARetin A•Chemical peelChemical peelss

CryosurgeryCryosurgery– Subfreezing temps for surgery (liquid nitrogen)Subfreezing temps for surgery (liquid nitrogen)

• Lesion becomes red & swollen, blisters, then scabs; Lesion becomes red & swollen, blisters, then scabs; falls off in 1-3 weeksfalls off in 1-3 weeks

• Minimal scarringMinimal scarring

– IndicationsIndications• Genital wartsGenital warts

• Seborrheic keratosisSeborrheic keratosis

• Actinic keratosisActinic keratosis

Malignant MelanomaMalignant Melanoma• 1/3 of all melanoma occur in 1/3 of all melanoma occur in existing existing

nevi nevi or molesor moles– Any sudden or progressive Any sudden or progressive changechange in in

size, color or shape of a mole should be size, color or shape of a mole should be checkedchecked

Malignant MelanomaMalignant Melanoma• Can metastasize Can metastasize anywhereanywhere• Most deadly of skin cancersMost deadly of skin cancers• CausesCauses

– UV radiationUV radiation– Skin sensitivitySkin sensitivity– GeneticGenetic– HormonalHormonal– Sun exposureSun exposure– Mutation of gene (B-RAF) 70%Mutation of gene (B-RAF) 70%

A B C D’s of Melanoma

AAsymmetrysymmetry

BBorder irregular, edges raggedorder irregular, edges ragged

CColor varied pigmentationolor varied pigmentation•Tan, brown, black, redTan, brown, black, red

DDiameter > 6mmiameter > 6mm

MelanomaMelanomaMedical TxMedical Tx

Depends on site, stage, age and general health of client

– Surgery– Chemotherapy – Biologic Therapy

• Interferon, interleukin

– Radiation therapy

Prevention/EducationPrevention/Education

• SunscreenSunscreen

• Limit exposureLimit exposure

• Hat/clothes/sunglassesHat/clothes/sunglasses

• ShadeShade

• Inspect skin regularlyInspect skin regularly

Sunburn: EducationSunburn: Education(Protect, Protect, Protect)(Protect, Protect, Protect)

• Same precautions as for skin cancer.Same precautions as for skin cancer.

• Don’t let clouds or cool air fool you – Don’t let clouds or cool air fool you – Florida sun is damaging then too.Florida sun is damaging then too.

• Get out of the sun Get out of the sun beforebefore you turn you turn red!red!

• Cool skin off. Immediately!Cool skin off. Immediately!

• Hydrate!Hydrate!

SunburnSunburn

• Superficial burnSuperficial burn

• Excessive exposure to ultraviolet rays Excessive exposure to ultraviolet rays injures dermis.injures dermis.

• Dilated capillaries = red, tender, edema, Dilated capillaries = red, tender, edema, blistersblisters

• Large area = nausea, feverLarge area = nausea, fever

SunburnSunburn• Redness & pain begin within a few Redness & pain begin within a few

HoursHours. .

• Intensity may increase before Intensity may increase before subsiding.subsiding.

• 3-5 days to heal3-5 days to heal

• Tx: cool bath; soothing lotions; Tx: cool bath; soothing lotions; topical corticosteroids; fluidstopical corticosteroids; fluids

Insects/Pests/ParasitesInsects/Pests/Parasites

• SpidersSpiders

• Fire AntsFire Ants

• Lice/ScabiesLice/Scabies

• MosquitoesMosquitoes

• ScorpionsScorpions

• ““Sand fleas”Sand fleas”

Infestations: Infestations: PediculosisPediculosis

– Head, body or pubic lice (“crabs”)Head, body or pubic lice (“crabs”)– Parasite excrement and eggs on skinParasite excrement and eggs on skin– Nits in hair Nits in hair

•Waxy, don’t fall off easilyWaxy, don’t fall off easily

• SymptomsSymptoms•Tiny red points to papular wheal-like lesionsTiny red points to papular wheal-like lesions

•Pruritis – check hairlinePruritis – check hairline

•Secondary excoriationSecondary excoriation

PediculosisPediculosis

Medical txMedical tx

•Pyrethrins (Rid), Permethrin (Nix) or if all Pyrethrins (Rid), Permethrin (Nix) or if all other agents fail…Benzene hexachloride other agents fail…Benzene hexachloride (Kwell)(Kwell)

•Contact screeningContact screening

• ll

Infestations: Infestations: ScabiesScabies– Skin reactions due to eggs, feces, & mite partsSkin reactions due to eggs, feces, & mite parts– Transmitted by direct contactTransmitted by direct contact

• SymptomsSymptoms– Severe itching especially at HSSevere itching especially at HS– Usually not on faceUsually not on face– Presence of burrows esp. interdigital webs & Presence of burrows esp. interdigital webs &

flexor surface of wristsflexor surface of wrists– Redness, swelling, vesiculationRedness, swelling, vesiculation

ScabiesScabies

Medical txMedical tx

– Topical ScabicideTopical Scabicide– Antibiotics for 2ndary Antibiotics for 2ndary

infectioninfection– Treat those in close Treat those in close

proximityproximity– Clothing & linens – Clothing & linens –

hot water and hot water and detergentdetergent

Drug Therapy: Drug Therapy: AntiparasiticsAntiparasitics– PediculicidesPediculicides

•Pyrethrins (RID)Pyrethrins (RID)•Permethrin (NIX)Permethrin (NIX)

– Scabicide & PediculicideScabicide & Pediculicide•Lindane (Kwell, Scabene)Lindane (Kwell, Scabene)

– Cream, lotionCream, lotion– ShampooShampoo

nit combnit comb– Adverse effectsAdverse effects

Rash, rare CNS toxicityRash, rare CNS toxicity

PlantsPlants in FL that irritate skin in FL that irritate skin

• Poinsettia, CrotonPoinsettia, Croton• Milky sap can cause skin irritationMilky sap can cause skin irritation

• Oleander Oleander – Touching the plant is not dangerous, but prolonged contact Touching the plant is not dangerous, but prolonged contact

can irritate the skin.can irritate the skin.

• Poison Ivy , Brazilian PepperPoison Ivy , Brazilian Pepper– Touching the leaves or oil from the plant can cause an itchy Touching the leaves or oil from the plant can cause an itchy

rash with blisters.rash with blisters.

Brazilian Pepper

Poison Ivy:

Virginia Creeper

Drug TherapyDrug Therapy

• Topical CorticosteroidsTopical Corticosteroids– Anti-inflammatory, antipruriticAnti-inflammatory, antipruritic

•Low potency (hydrocortisone)Low potency (hydrocortisone)– Slower actingSlower acting– Can be used longer without serious side effectsCan be used longer without serious side effects– Ointment most efficientOintment most efficient

– Higher potency, long term, systemic use is Higher potency, long term, systemic use is different txdifferent tx

– IntralesionalIntralesional•Reservoir of med effects lasts several weeks to Reservoir of med effects lasts several weeks to

monthsmonths• IndicationsIndications

– PsoriasisPsoriasis– AlopeciaAlopecia– Cystic acneCystic acne– Hypertrophic scars and keloidsHypertrophic scars and keloids

– SystemicSystemic•Undesirable adverse effects – Undesirable adverse effects – Lilley 6Lilley 6thth ed. Page 869 ed. Page 869

•Short term therapy – poison ivyShort term therapy – poison ivy•Long term therapy – chronic bullous diseasesLong term therapy – chronic bullous diseases

CorticosteroidsCorticosteroidsTriamcinolone (Kenalog)Triamcinolone (Kenalog)

Bases for Topical Bases for Topical MedicationsMedications• PowderPowder

– Promotes drynessPromotes dryness– Good for antifungalsGood for antifungals

• LotionLotion– Cooling and drying with residual powder filmCooling and drying with residual powder film– Good for pruritic eruptionsGood for pruritic eruptions

• CreamCream– Emulsion of oil and waterEmulsion of oil and water– Lubrication and protectionsLubrication and protections

• OintmentOintment– Oil with water in suspensionOil with water in suspension– LubricationLubrication– Most efficient delivery systemMost efficient delivery system

• PastePaste– Mixture of powder and ointmentMixture of powder and ointment– Drying Drying – Moisture absorptionMoisture absorption

NursingNursing Management: Management:RN as skin “symptomologist”RN as skin “symptomologist”• Dry skinDry skin

– Elderly; InfantsElderly; Infants• Itchy skinItchy skin• Broken skinBroken skin• Prevention of secondary infectionsPrevention of secondary infections

Nursing Management: Dry Nursing Management: Dry skinskin

• ManifestationsManifestations

• Interventions:Interventions:– Elder – Elder –

•Fewer total bathsFewer total baths

•Lotions & Mild soapsLotions & Mild soaps

•Hydrate!Hydrate!

NursingNursing Management: Itchy Management: Itchy skinskin

• Control of pruritisControl of pruritis– Keep coolKeep cool– No rubbingNo rubbing– MoisturizeMoisturize– Systemic antihistaminesSystemic antihistamines– Wet dressingWet dressing– Topical steroidsTopical steroids– Menthol, Camphor, Phenol numb itch receptorsMenthol, Camphor, Phenol numb itch receptors– Oatmeal bathsOatmeal baths

NursingNursing Management: itch Management: itch• BathsBaths

– For large body areasFor large body areas– Has sedating and antipruritic effectHas sedating and antipruritic effect– Oilated oatmeal (Aveeno), potassium Oilated oatmeal (Aveeno), potassium

permangenate, sodium bicarbpermangenate, sodium bicarb– Temp comfortable to clientTemp comfortable to client– Soak 15-20 mins 3-4 times dailySoak 15-20 mins 3-4 times daily– Pat dry, no rubbingPat dry, no rubbing– apply moisturizers or meds after bathsapply moisturizers or meds after baths

NursingNursing Management Management•Wet dressingsWet dressings

– IndicationsIndications•Skin weepy from infection/inflammationSkin weepy from infection/inflammation•Relieves itchingRelieves itching•Debrides woundDebrides wound• Increases penetration of topical medsIncreases penetration of topical meds•Relieves discomfortRelieves discomfort•Enhances removal of scabs, crusts, and Enhances removal of scabs, crusts, and

exudateexudate

Wet dressingsWet dressingsProcedureProcedure

•Clean solution and gauzeClean solution and gauze•Squeeze until not drippingSqueeze until not dripping•Apply to affected area, avoid normal Apply to affected area, avoid normal

tissuetissue•Leave in place 10-30 minutes 2-4 times a Leave in place 10-30 minutes 2-4 times a

dayday•Discontinue if skin macerates (“to Discontinue if skin macerates (“to

soften”)soften”)

Nursing Management: Nursing Management: ProtectProtect• Protect intact skin!Protect intact skin!

– Turn at least q2hTurn at least q2h– Reposition frequentlyReposition frequently– Alleviate pressureAlleviate pressure– HydrationHydration– Mechanical intervention Mechanical intervention – Rx Rx

NursingNursing Management: Management: Psychological supportPsychological support• Chronic skin conditionsChronic skin conditions

– Emotional stressEmotional stress– Self concept alterationsSelf concept alterations– Body image changesBody image changes

Nursing Nursing Interventions:Interventions:Psychological support:Psychological support:– Support clientSupport client– Allow verbalizations of frustrationsAllow verbalizations of frustrations– Reinforce treatmentReinforce treatment– Support groupsSupport groups– Help with camouflageHelp with camouflage

Diagnostic TestingDiagnostic Testing

BiopsyBiopsy

– PunchPunch– IncisionalIncisional– ExcisionalExcisional– ShaveShave

RNRN Responsibilities Responsibilities

– Informed ConsentInformed Consent– Prep sitePrep site– Assist with Assist with

procedureprocedure– Apply dressingApply dressing– Post-op instructionsPost-op instructions– Properly ID Properly ID

specimenspecimen

Diagnostic TestingDiagnostic Testing

• CulturesCultures– Diagnose fungal, bacteria, viral infectionsDiagnose fungal, bacteria, viral infections

– KOH (Potassium Hydroxide)KOH (Potassium Hydroxide)• FungusFungus

• Sample collectionSample collection– Skin scrapingSkin scraping– SwabbingSwabbing– Meticulous labelingMeticulous labeling

Diagnostic Testing Diagnostic Testing

• Woods LightWoods Light– Organisms fluoresceOrganisms fluoresce

• PseudomonasPseudomonas

• FungusFungus

• VitiligoVitiligo

• Mineral oil slidesMineral oil slides– InfestationsInfestations

• Patch testPatch test– Allergen testingAllergen testing

Dermatological Dermatological InterventionsInterventions• PhototherapyPhototherapy

– UVA & UVB (UVL)UVA & UVB (UVL)– Ultraviolet wavelengths cause erythema, Ultraviolet wavelengths cause erythema,

desquamation, and pigmentationdesquamation, and pigmentation– Enhance with psoralem (photosensitizing)Enhance with psoralem (photosensitizing)

• Treatment forTreatment for• PsoriasisPsoriasis• Atopic dermatitisAtopic dermatitis• VitiligoVitiligo

PhototherapyPhototherapy• Adverse effectsAdverse effects

– Basal or squamous cell CaBasal or squamous cell Ca– Burns Burns – ErythemaErythema– Teach patients to avoid further sun exposure & Teach patients to avoid further sun exposure &

photosensitizing drugsphotosensitizing drugs– Wear eye protections as psoralem absorbed by lens of Wear eye protections as psoralem absorbed by lens of

eyeeye

Dermatological Dermatological InterventionsInterventions• Radiation TherapyRadiation Therapy

– IndicationsIndications•Cutaneous malignanciesCutaneous malignancies

– AdvantagesAdvantages•Produces minimal damage to surrounding tissuesProduces minimal damage to surrounding tissues

– Adverse effectsAdverse effects•Permanent hair loss (alopecia) to irradiated Permanent hair loss (alopecia) to irradiated

areasareas•TelangiectasiaTelangiectasia•AtrophyAtrophy•Hyperpigmentation / depigmentationHyperpigmentation / depigmentation•UlcerationUlceration

• BCC and SCC BCC and SCC y. y.

Dermatological Dermatological InterventionsInterventions• Laser Therapy Laser Therapy (CO2, Argon)(CO2, Argon)

– Cuts, coagulates, & vaporizes tissueCuts, coagulates, & vaporizes tissue– No cumulative tissue damageNo cumulative tissue damage

• IndicationsIndications– Coagulation of vascular lesionsCoagulation of vascular lesions– Skin resurfacingSkin resurfacing– Removal birthmarksRemoval birthmarks– BCCBCC– KeloidsKeloids– Plantar wartsPlantar warts

Diagnostic & Surgical Diagnostic & Surgical TherapyTherapy• Skin ScrapingSkin Scraping

– ScalpelScalpel– Surface cells for microscopic inspectionSurface cells for microscopic inspection

• Electrodesication & Electrodesication & electrocoagulationelectrocoagulation– Electrical energy converted to heatElectrical energy converted to heat– Destroys tissue by burningDestroys tissue by burning

•Coagulates bleeding vesselsCoagulates bleeding vessels

• CurettageCurettage– Remove tissue with circular cutting edgeRemove tissue with circular cutting edge– Small skin tumors Small skin tumors

•warts, seborrheic keratosis, BCC, SCCwarts, seborrheic keratosis, BCC, SCC

Allergic ConditionsAllergic Conditions• Contact DermatitisContact Dermatitis

– Delayed hypersensitivity Delayed hypersensitivity – Lesions 2-7 days after antigen exposureLesions 2-7 days after antigen exposure

• ManifestationsManifestations– Red, hive-like papules and plaquesRed, hive-like papules and plaques– Sharply circumscribedSharply circumscribed– VesiclesVesicles– PruriticPruritic

Contact DermatitisContact DermatitisMedical TxMedical Tx

– Topical Topical corticosteroidscorticosteroids

– AntihistaminesAntihistamines– Skin lubricationSkin lubrication– Elimination of Elimination of

allergenallergen– Systemic steroids if Systemic steroids if

severesevere

http://dermatology.cdlib.org/DOJvol7num1/NYUcases/contact/joe.html

Drug Therapy: Drug Therapy: Antihistamines Antihistamines • Compete with histamine receptor siteCompete with histamine receptor site

– Oral or TopicalOral or Topical• Cetitizine (Zyrtec)Cetitizine (Zyrtec)

– PO tabs, syrup QDPO tabs, syrup QD– Non-sedatingNon-sedating

• Diphenahydramine (Benadryl)Diphenahydramine (Benadryl)– PO, IM, topicalPO, IM, topical

• IndicationsIndications– UrticariaUrticaria– PruritisPruritis– Allergic reactionsAllergic reactions

Drug Therapy: Drug Therapy: Antihistamines Antihistamines

• Adverse effectsAdverse effects– AnticholinergicAnticholinergic– Sedation (Benadryl)Sedation (Benadryl)– Use with caution in older adultsUse with caution in older adults

• IndicationsIndications– UrticariaUrticaria– PruritisPruritis– Allergic reactionsAllergic reactions

• Adverse effectsAdverse effects– AnticholinergicAnticholinergic– Sedation (Benadryl)Sedation (Benadryl)– Use with caution in older adultsUse with caution in older adults

Allergic Conditions: Allergic Conditions: Drug Drug ReactionReaction • ManifestationsManifestations

– Rash of any morphologyRash of any morphology– Red, macular, papularRed, macular, papular– Generalized rash with sudden onsetGeneralized rash with sudden onset– Pruritic Pruritic – Can occur as late as 14 days after drug is Can occur as late as 14 days after drug is

stoppedstopped

Drug ReactionDrug ReactionMedical TreatmentMedical Treatment

– Discontinue drugDiscontinue drug– Antihistamines, local Antihistamines, local

or systemicor systemic– Corticosteroids if Corticosteroids if

neededneeded

Allergic Conditions: Allergic Conditions: Atopic Atopic DermatitisDermatitis

– Cause unknownCause unknown– Begins in infancy and declines with ageBegins in infancy and declines with age

• ManifestationsManifestations– Scaly, red to re-brown, circumscribed lesionsScaly, red to re-brown, circumscribed lesions– PruriticPruritic– Symmetric eruptionsSymmetric eruptions

Atopic DermatitisAtopic Dermatitis– Topical corticosteroidsTopical corticosteroids– PhototherapyPhototherapy– Coal tarCoal tarcorticosteroidscorticosteroids– Lubrication of dry skinLubrication of dry skin– Antibiotics for secondary infectionsAntibiotics for secondary infections

Medical TreatmentMedical Treatment

Dysplastic Nevus SyndromeDysplastic Nevus Syndrome

• AbnormalAbnormal mole pattern mole pattern

• Increased risk for melanomaIncreased risk for melanoma– Doubles with dysplastic neviDoubles with dysplastic nevi

• Atypical moles larger than usual (>5mm)Atypical moles larger than usual (>5mm)

• Irregular borders, possibly notchedIrregular borders, possibly notched

• Various variegated colorsVarious variegated colors

• Most common on backMost common on back

Infections of the skinInfections of the skin• Risk factorsRisk factors

– Imbalance between host and Imbalance between host and microorganismmicroorganism

– Broken or damaged skin; TraumaBroken or damaged skin; Trauma– Systemic disease such as DiabetesSystemic disease such as Diabetes– MoistureMoisture– ObesityObesity– Systemic corticosteroids, antibioticsSystemic corticosteroids, antibiotics

• PreventionPrevention– Proper hygieneProper hygiene– Good healthGood health

Infections: Infections: Herpes Simplex Virus, Herpes Simplex Virus, Type IType I (AKA “cold sores/fever blisters”) (AKA “cold sores/fever blisters”)

• ContagiousContagious• Dormant – ExacerbationDormant – Exacerbation

• Triggers Triggers

• Symptoms -- Symptoms -- 11stst episode 3-7 days after exposure episode 3-7 days after exposure– Painful local reactionPainful local reaction– Vesicles on erythematous baseVesicles on erythematous base– Fever, malaiseFever, malaise

Herpes Simplex Virus, Type Herpes Simplex Virus, Type II

Medical TxMedical Tx

– Symptom management

– Moist compresses– PetrolatumPetrolatum to lesions– Antiviral agents

(Zovirax, Famvir, Valtrex)

www.treatmentsforhealth.com/.../cold-sores/

Infections: Infections: Herpes Simplex Virus, Herpes Simplex Virus, Type IIType II

– Genital Genital ““Most genital herpes is caused by HSV-2.” Most genital herpes is caused by HSV-2.” (n.l.m.-n.i.h./ (n.l.m.-n.i.h./

Medline plus)Medline plus)

– RecurrenceRecurrence more common than oral more common than oral•Does not mean re-infectionDoes not mean re-infection

• SymptomsSymptoms– Same as Type ISame as Type I

• TreatmentTreatment– Same as Type ISame as Type I

Iggy page 1742-1743

Infections: Infections: Herpes Varicella Herpes Varicella VirusVirus(chicken pox)(chicken pox)

** Highly contagious• No chicken pox or vaccinationNo chicken pox or vaccination

• Keep those w/active lesions separated until crustedKeep those w/active lesions separated until crusted

• SymptomsSymptoms– Vesicular lesions in successive cropsVesicular lesions in successive crops

• Face , scalp, spreading to trunk and extremitiesFace , scalp, spreading to trunk and extremities Protect eyesProtect eyes Do not squeeze pustules or crustsDo not squeeze pustules or crusts

• Vesicles > pustules > crusts > scarsVesicles > pustules > crusts > scars

• Postherpetic neuralgiaPostherpetic neuralgia

• Self limiting in childrenSelf limiting in children

Herpes Varicella VirusHerpes Varicella Virus

Medical TxMedical Tx

– AntiviralsAntivirals– Symptomatic reliefSymptomatic relief

Infections: Infections: Herpes ZosterHerpes Zoster(shingles)(shingles)

– Activation of varicella zoster virusActivation of varicella zoster virus– Frequent occurrence in immunocompromisedFrequent occurrence in immunocompromised– Potentially contagious to immunocompromisedPotentially contagious to immunocompromised

• SymptomsSymptoms– Linear patches along dermatomeLinear patches along dermatome– Grouped vesicles on erythematous baseGrouped vesicles on erythematous base– Unilateral on trunkUnilateral on trunk– Burning pain and neuralgiaBurning pain and neuralgia

Herpes ZosterHerpes Zoster

Medical TxMedical Tx

– SymptomaticSymptomatic• Wet compressesWet compresses• White petrolatum to lesionsWhite petrolatum to lesions

– Antiviral agents Antiviral agents

Drug Therapy: Drug Therapy: AntiviralsAntivirals– Acyclovir (Zovirax)Acyclovir (Zovirax)

•Suppresses chicken pox, herpes simplex 1 & 2, Suppresses chicken pox, herpes simplex 1 & 2, shinglesshingles

•Po, IV, topicalPo, IV, topical

– Valacyclovir (Valtrex)Valacyclovir (Valtrex)•Herpes zoster (shingles) & genital herpesHerpes zoster (shingles) & genital herpes

– Vaccines Vaccines •Varivax Varivax

– Prevention of chicken poxPrevention of chicken pox– Given to children > 12 mo.Given to children > 12 mo.

•ZostivaxZostivax– HZU vaccine for adults > 60 y/oHZU vaccine for adults > 60 y/o

Infections: Infections: Verruca VulgarisVerruca Vulgaris– Human papillomavirusHuman papillomavirus– Mildly contagiousMildly contagious

• SymptomsSymptoms– Circumscribed hypertrophic flesh colored Circumscribed hypertrophic flesh colored

papulepapule

• TreatmentTreatment– Scoop removalScoop removal– Liquid nitrogen therapyLiquid nitrogen therapy– Keratolytic agentsKeratolytic agents– CO2 laser therapyCO2 laser therapy

Infections: Infections: Plantar WartsPlantar Warts(Human papillomavirus)(Human papillomavirus)

• SymptomsSymptoms– Wart on “Plantar” surface (bottom) of Wart on “Plantar” surface (bottom) of

foot – foot – – Cone shaped with black dots (“seeds”)Cone shaped with black dots (“seeds”)

Plantar WartsPlantar WartsMedical TxMedical Tx

– Liquid nitrogen Liquid nitrogen – Frequent paring with chemical patchesFrequent paring with chemical patches– Duct tape??????Duct tape??????

Infections: Infections: Candidiasis Candidiasis ((moniliasis)moniliasis)

– Candida albicans Candida albicans (Fungus)(Fungus)– 50% are symptom free carriers50% are symptom free carriers– Immunocompromised >> pathogenicImmunocompromised >> pathogenic– Likes warm moist areasLikes warm moist areas

•Mouth, vagina, skinMouth, vagina, skin

An opportunistic infection

Infections: Infections: CandidiasisCandidiasis– SymptomsSymptoms

•MouthMouth– White, cheesy plaque (milk curds)White, cheesy plaque (milk curds)

•VaginaVagina– VaginitisVaginitis– Red edematous painful vaginal wall Red edematous painful vaginal wall – White patchesWhite patches– Vaginal dischargeVaginal discharge– PruritisPruritis– Painful urination & intercoursePainful urination & intercourse

•SkinSkin– Diffuse papular erythematous rashDiffuse papular erythematous rash– Pinpoint satellite lesions around edgesPinpoint satellite lesions around edges

Physiologic Integrity: Physiologic Integrity: 5. Discuss nursing implications for medications prescribed for clients with dermatologic disorders. 6. Develop plan of care for client with impaired skin integrity. 5. Discuss nursing implications for medications prescribed for clients with dermatologic disorders. 6. Develop plan of care for client with impaired skin integrity.

CandidiasisCandidiasisMedical Tx: Anti-fungalsMedical Tx: Anti-fungals

•NystatinNystatin– Vaginal suppositoryVaginal suppository– Oral lozengeOral lozenge

•Mycostatin powder, creamMycostatin powder, cream

•Keep skin clean dryKeep skin clean dry

• DiagnosisDiagnosiscultureculture

Microscopic exam (KOH)Microscopic exam (KOH)

Infections: FungalInfections: Fungal• Tinea CorporisTinea Corporis

– AKA ringwormAKA ringworm

– SymptomsSymptoms•AnnularAnnular

• well defined marginswell defined margins

• erythematouserythematous

Tinea CorporisTinea CorporisAKA ringwormAKA ringworm

Medical TxMedical Tx

•Cool compressesCool compresses

•Topical antifungalsTopical antifungals– Miconazole, clotrimazole, Miconazole, clotrimazole,

butenafinebutenafine

Infections: FungalInfections: Fungal• Tinea CrurisTinea Cruris

– AKA jock itchAKA jock itch– SymptomsSymptoms

•Self-defined borderSelf-defined border

• In groinIn groin

– Treatment topical antifungal cream or Treatment topical antifungal cream or solutionsolution

Infections: FungalInfections: Fungal• Tinea PedisTinea Pedis

– AKA athletes footAKA athletes foot

– SymptomsSymptoms• Interdigital scalingInterdigital scaling

•ErythemaErythema

•BlisteringBlistering

•PruritisPruritis

•PainPain

Medical TxMedical Tx• Topical antifungalsTopical antifungals

• Keep dryKeep dry

Tinea PedisAKA athletes foot

Infections: FungalInfections: Fungal• Tinea UnguiumTinea Unguium

– SymptomsSymptoms•Brittle thickened nails Brittle thickened nails

•White/yellow discolorationWhite/yellow discoloration

Tinea UnguiumTinea UnguiumMedical TxMedical Tx

•Topical antifungal Topical antifungal cream or solutionscream or solutions

•Griseofulvin Griseofulvin (fingernails)(fingernails)

•LamisilLamisil

•Debride toenailsDebride toenails

Drug Therapy: AntifungalsDrug Therapy: Antifungals– Clotrimazole (Mycelex, Lotrimin)Clotrimazole (Mycelex, Lotrimin)

•Lozenges- thrushLozenges- thrush•Cream, solution, lotion- athletes footCream, solution, lotion- athletes foot• Intravaginal creams, tabletsIntravaginal creams, tablets

– Miconazole (Monistat, Micotin)Miconazole (Monistat, Micotin)•Athletes footAthletes foot• Jock itchJock itch•RingwormRingworm•Yeast infectionsYeast infections

Drug Therapy: AntifungalsDrug Therapy: Antifungals– Fluconazole (Diflucan)Fluconazole (Diflucan)

•PO & IVPO & IV•Excellent bioavailabilityExcellent bioavailability•Vaginal or systemic candidiasisVaginal or systemic candidiasis

– Ketaconazole (Nizoral)Ketaconazole (Nizoral)– Nystatin (Mycostatin)Nystatin (Mycostatin)– Tervinafine (Lamisil) for onychomycosisTervinafine (Lamisil) for onychomycosis– Tolnaftate (Tinactin)Tolnaftate (Tinactin)

Infections, BacterialInfections, Bacterial• ImpetigoImpetigo

– Group A beta hemolytic strept or staphGroup A beta hemolytic strept or staph– Associated with poor hygiene and low socioeconomic Associated with poor hygiene and low socioeconomic

statusstatus

• SymptomsSymptoms– Vesiculopustular lesionsVesiculopustular lesions– Thick honey colored crustThick honey colored crust– Surrounded by erythemaSurrounded by erythema– PruriticPruritic– ContagiousContagious

• TreatmentTreatment– Systemic antibioticsSystemic antibiotics– Saline or aluminum acetate soaksSaline or aluminum acetate soaks– Soap & water Soap & water – Removal of crustsRemoval of crusts– Topical antibiotic creamTopical antibiotic cream

• Strept can cause glonerulonephritis if untreatedStrept can cause glonerulonephritis if untreated

Infections: BacterialInfections: Bacterial• CellulitisCellulitis

– Staph aureus or streptStaph aureus or strept– Can be primary or secondary infectionCan be primary or secondary infection– SymptomsSymptoms

• HotHot• TenderTender• ErythematousErythematous• EdematousEdematous• Diffuse borders maybe malaise and feverDiffuse borders maybe malaise and fever

– TreatmentTreatment• Moist heatMoist heat• ImmobilizationImmobilization• ElevationElevation• Systemic antibioticsSystemic antibiotics• Hospitalize if severeHospitalize if severe

– Can progress to gangrene if untreatedCan progress to gangrene if untreated

Drug Therapy: Drug Therapy: AntibioticsAntibiotics– Topical - apply lightlyTopical - apply lightly

• OTCOTC– bacitracinbacitracin– Polymixin BPolymixin B

• PrescriptionPrescription– Mupirocin (staph)Mupirocin (staph)– gentamycin (staph),gentamycin (staph),– erythromycin (staph & strept)erythromycin (staph & strept)– clindamycin (Cleocin) (acne)clindamycin (Cleocin) (acne)

– Systemic - culture & sensitivity guides Systemic - culture & sensitivity guides selectionselection• PenicillinPenicillin• ErythromycinErythromycin• TetracyclineTetracycline

Benign Skin Conditions: Benign Skin Conditions: AcneAcne Inflammatory disorder of sebaceous glandsInflammatory disorder of sebaceous glands

• SymptomsSymptomscomedones, inflammatory lesions, papules, comedones, inflammatory lesions, papules, pustules face, neck, upper backpustules face, neck, upper back

• TreatmentTreatment– Comedo extractionComedo extraction– Topical Benzoyl PeroxideTopical Benzoyl Peroxide– Peeling and irritating agents (retinoic acid)Peeling and irritating agents (retinoic acid)– Antibiotic therapy - long termAntibiotic therapy - long term– PhototherapyPhototherapy– Sun exposureSun exposure– If severe - isotretinoin (Accutane) If severe - isotretinoin (Accutane) CAUTION! CAUTION!

TeratogenicTeratogenic

Drug Therapy: Drug Therapy: AcneAcne PreparationsPreparations

– Benzoyl peroxide (Benzac, Desquam-X, PanOxyl, etc)•Apply 1-4x day•Effects seen 4-6 weeks•Adverse effects

– Erythema, tenderness, dryness, pruritis, burning

– Erythromycin (Eryderm, T-Stat, Erygel)•Macrolide antibiotic•Adverse effects

– Erythema, tenderness, pruritis, burning

Drug Therapy:Drug Therapy: Acne Acne PreparationsPreparations

– Isotretinoin (Accutane)•Pregnancy Category X

– Proven teratogen– 2 contraceptive methods

– Tretinoin (Retinoic acid, Vitamin A acid, Retin-A)•Stimulates epidermal cell turnover -> skin peeling•Adverse effects

– Red edematous blisters, crusted skin, altered skin pigmentation

•Avoid sun, use sunscreen•Apply to dry skin

Benign Skin Conditions: Benign Skin Conditions: MolesMoles

Grouping of normal cells Grouping of normal cells

• ManifestationsManifestations– Hyperpigmented areasHyperpigmented areas– Varying form and colorVarying form and color

• TreatmentTreatment– None necessaryNone necessary– CosmeticCosmetic– Biopsy for diagnosisBiopsy for diagnosis

Benign Skin ConditionsBenign Skin Conditions• PsoriasisPsoriasis

– Chronic dermatitis due to rapid turnover of epidermal Chronic dermatitis due to rapid turnover of epidermal cellscells

– Family predispositionFamily predisposition– ManifestationsManifestations– Sharply demarcated scaling plaques of Sharply demarcated scaling plaques of

• ScalpScalp• ElbowsElbows• KneesKnees• Palms, soles, and fingernails possiblePalms, soles, and fingernails possible

• TreatmentTreatment– Retard growth of epidermal cellsRetard growth of epidermal cells– Topical corticosteroidsTopical corticosteroids– TarTar– Anthralin topicalAnthralin topical– Sunlight, UV lightSunlight, UV light– Alefacept (Amevive) injectionAlefacept (Amevive) injection– Antimetabolites (methotrexate) or systemic retinoids for Antimetabolites (methotrexate) or systemic retinoids for

difficult casesdifficult cases

Benign Skin ConditionsBenign Skin Conditions• Seborrheic KeratosesSeborrheic Keratoses

– Irregularly shaped flat topped papules or Irregularly shaped flat topped papules or plaquesplaques

– Warty surfaceWarty surface– Appearance of being stuck onAppearance of being stuck on– Increase in pigmentationIncrease in pigmentation– No association with sun exposureNo association with sun exposure– TreatmentTreatment

•Removal Removal – CurettageCurettage– cryosurgerycryosurgery

Benign Skin Conditions: Benign Skin Conditions: LipomaLipoma

Encapsulated tumor of adipose tissueEncapsulated tumor of adipose tissue

Most common 40-60 years of ageMost common 40-60 years of age

• ManifestationsManifestations– Rubbery, compressible, round massRubbery, compressible, round mass– Variable in sizeVariable in size– Most common on trunk, back of neck, forearmsMost common on trunk, back of neck, forearms

• TreatmentTreatment– BiopsyBiopsy– Excision if indicatedExcision if indicated

Benign Skin Conditions: Benign Skin Conditions: VitiligoVitiligo

– Unknown causeUnknown cause– Genetic connectionGenetic connection– Complete absence of melanocytesComplete absence of melanocytes– Non-contagiousNon-contagious

• ManifestationsManifestations– Complete loss of pigmentComplete loss of pigment– Variation in size an locationVariation in size an location– Symmetric and permanentSymmetric and permanent

• TreatmentTreatment– Exposure to UVA and psoralensExposure to UVA and psoralens– Depigmentation of pigmented skin in extensive Depigmentation of pigmented skin in extensive

diseasedisease– Cosmetics and stainsCosmetics and stains

Benign Skin Conditions: Benign Skin Conditions: LentigoLentigo• (see fig. 26-7, Iggy page 465)(see fig. 26-7, Iggy page 465)

– AKA liver spotsAKA liver spots– Increased number of melanocytesIncreased number of melanocytes– Related to aging and sun exposureRelated to aging and sun exposure

• ManifestationsManifestations– Hyperpigmented brown to black flat Hyperpigmented brown to black flat

lesionlesion– Usually in sun exposed areasUsually in sun exposed areas

• TreatmentTreatment– Liquid nitrogenLiquid nitrogen

•Possible reoccurrence in 1-2 yearsPossible reoccurrence in 1-2 years

– CosmeticsCosmetics

Primary LesionsPrimary Lesions• MaculeMacule (freckles, petecchia, measles)(freckles, petecchia, measles)

– FlatFlat– Change in colorChange in color– < 1cm< 1cm

• Papule Papule (wart, mole) (wart, mole)– elevated,elevated,– SolidSolid– <1cm<1cm

• Vesicle Vesicle (chicken pox, herpes zoster, 2 (chicken pox, herpes zoster, 2ndnd burns) burns)– ElevatedElevated– Fluid filledFluid filled– <1cm<1cm

Primary LesionsPrimary Lesions• BullaBulla

– > 1cm> 1cm– ElevatedElevated– Serous fluid filledSerous fluid filled

• Plaque Plaque (psoriasis, keratosis)(psoriasis, keratosis)– ElevatedElevated– Solid lesionSolid lesion– >1cm>1cm

Primary LesionsPrimary Lesions• WhealWheal (insect bite) (insect bite)

– FirmFirm– EdematousEdematous– Irregular shapeIrregular shape– Diameter variableDiameter variable

• Pustule Pustule (acne, impetigo) (acne, impetigo)– ElevatedElevated– Purulent fluidPurulent fluid– Varied sizeVaried size

Secondary LesionsSecondary Lesions• FissureFissure (athletes foot) (athletes foot)

– Linear crack from epidermis to dermisLinear crack from epidermis to dermis

• Scale Scale (excess dead & flaking of skin) (excess dead & flaking of skin)– Drug eruptionDrug eruption– Scarlet feverScarlet fever

• ScarScar– Increased connective tissueIncreased connective tissue– Surgical incisionSurgical incision– Healed woundHealed wound

Secondary LesionsSecondary Lesions• UlcerUlcer

– CraterCrater– Loss of epidermis, dermisLoss of epidermis, dermis– Pressure ulcers, chancrePressure ulcers, chancre

• AtrophyAtrophy– Thinning of epidermis/dermisThinning of epidermis/dermis– Ages skin, striaeAges skin, striae

• ExcoriationExcoriation– Missing epidermisMissing epidermis– Scabies, abrasion, scratchScabies, abrasion, scratch

References:References:• Chickenpox in Pregnancy. (2009). March of Dimes Foundation. (2009). March of Dimes Foundation.

Retrieved 9/25/09 from Retrieved 9/25/09 from http://www.marchofdimes.com/professionals/14332_1185.asp://www.marchofdimes.com/professionals/14332_1185.asp

• Common Poisonous Plants of Florida (Florida Poison Information Common Poisonous Plants of Florida (Florida Poison Information Center/Tampa) @ http://www.poisoncentertampa.org/poisonous-Center/Tampa) @ http://www.poisoncentertampa.org/poisonous-plants.aspxplants.aspx

• Culbert, D. (April 14, 2005). Florida scorpions. UF/IFAS Okeechobee Culbert, D. (April 14, 2005). Florida scorpions. UF/IFAS Okeechobee County Extension Service. Retrieved 6/17/09 from County Extension Service. Retrieved 6/17/09 from http://okeechobee.ifas.ufl.edu/News%20columns/Florida.Scorpions.http://okeechobee.ifas.ufl.edu/News%20columns/Florida.Scorpions.htmhtm

• Groch, J. (August 23, 2006). Guidelines for Preventing Pressure Groch, J. (August 23, 2006). Guidelines for Preventing Pressure Ulcers Seen as Suboptimal. MedPage Today. Retrieved 6/12/09 Ulcers Seen as Suboptimal. MedPage Today. Retrieved 6/12/09 from from http://www.medpagetoday.com/Dermatology/GeneralDermatology/http://www.medpagetoday.com/Dermatology/GeneralDermatology/39823982

References:References:

• Hembree, D. (July 21, 2008) 10 Poisonous Plants in Florida Hembree, D. (July 21, 2008) 10 Poisonous Plants in Florida and Safety Precautions @ and Safety Precautions @ http://www.associatedcontent.com/article/875395/10_poisohttp://www.associatedcontent.com/article/875395/10_poisonous_plants_in_florida_and_pg2.html?cat=11nous_plants_in_florida_and_pg2.html?cat=11

• ““Herpes simplex” (May, 2009). Medline Plus Medical Herpes simplex” (May, 2009). Medline Plus Medical Encyclopedia. Retrieved 6/15/09 from Encyclopedia. Retrieved 6/15/09 from http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001324.http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001324.htmhtm

• Lilly, L.L., Harrington, S, & Snyder, J. (2005) Pharmacology Lilly, L.L., Harrington, S, & Snyder, J. (2005) Pharmacology and the Nursing Process. (4and the Nursing Process. (4thth ed.) Mosby Elsevier. St. Louis, ed.) Mosby Elsevier. St. Louis, MS. MS.

• Medical Dictionary (2009) Merrium – Webster Inc. Retrieved Medical Dictionary (2009) Merrium – Webster Inc. Retrieved 6/15/09 from 6/15/09 from http://www.nlm.nih.gov/medlineplus/mplusdictionary.htmlhttp://www.nlm.nih.gov/medlineplus/mplusdictionary.html

References:References:• The Medical News. Brain eating amoeba in lake kills sixth The Medical News. Brain eating amoeba in lake kills sixth

victim. (October 2007). Retrieved 6/16/09 from victim. (October 2007). Retrieved 6/16/09 from http://www.news-medical.net/news/2007/10/07/30863.aspxhttp://www.news-medical.net/news/2007/10/07/30863.aspx

• The US Market for Skin Care Products. (May, 2005). The US Market for Skin Care Products. (May, 2005). Retrieved 6/12/09 from Retrieved 6/12/09 from http://www.mindbranch.com/Skincare-Products-R567-0199/http://www.mindbranch.com/Skincare-Products-R567-0199/

• Scorpion Sting Treatments. (2008). Orkin. Retrieved Scorpion Sting Treatments. (2008). Orkin. Retrieved 6/17/09 from 6/17/09 from http://www.orkin.com/other/scorpions/scorpion-sting-http://www.orkin.com/other/scorpions/scorpion-sting-treatmentstreatments

BurnsBurns• Thermal burnsThermal burns

– Flame, flash, scaldFlame, flash, scald

• Chemical burnsChemical burns– Necrotizing substancesNecrotizing substances

• AcidsAcids

• AlkaliAlkali– Cleaning agents, drain cleaners, lyeCleaning agents, drain cleaners, lye

• Electrical burnsElectrical burns– Intense heat from electrical currentIntense heat from electrical current

The Following Content –

Burns –

will be covered in future classes!

Save this information for future use.

Classification: Depth of BurnClassification: Depth of Burn

See page 522 in Iggy textSee page 522 in Iggy text

• ABA by depth of destructionABA by depth of destruction– Partial thickness burnPartial thickness burn

• Epidermis and dermis involvedEpidermis and dermis involved

– Full thickness burnFull thickness burn• ““burns reach through the entire dermis and burns reach through the entire dermis and

sometimes into the subcutaneous fat.” sometimes into the subcutaneous fat.” (Iggy, page 522)(Iggy, page 522)

• Possibly involves muscles, tendons, and bonesPossibly involves muscles, tendons, and bones• *Skin cannot heal on its own.*Skin cannot heal on its own.

Classification: Extent of BurnClassification: Extent of Burn

• Total Body Surface Area (TBSF)Total Body Surface Area (TBSF)– (Iggy page 531)(Iggy page 531)

• Berkow method Berkow method – http://www.umobile.edu/main/notes/Burn.pdfhttp://www.umobile.edu/main/notes/Burn.pdf

• Rule of 9’s Rule of 9’s – (Iggy page 531)(Iggy page 531)

Classification: Location of BurnsClassification: Location of Burns

• Severity related to locationSeverity related to location• Complication risks related to locationComplication risks related to location• Face, neck, chestFace, neck, chest

– Respiratory complicationsRespiratory complications

• Hands, feet, joints, and eyesHands, feet, joints, and eyes– Compromise ADLs Compromise ADLs

• Circumferential burns of extremitiesCircumferential burns of extremities– Circulatory compromiseCirculatory compromise

Emergent CareEmergent Care• A,B,C’sA,B,C’s

• Fluid TherapyFluid Therapy

• Wound CareWound Care

• Pain managementPain management

• Prevention of infectionPrevention of infection

BurnsBurns

What happens….What happens….

Complications of Emergent Complications of Emergent PhasePhase• CardiovascularCardiovascular

– ArrhythmiasArrhythmias– Hypovolemic shockHypovolemic shock– Impaired circulationImpaired circulation

• RespiratoryRespiratory– Upper airway burnsUpper airway burns– Inhalation injuriesInhalation injuries

• UrinaryUrinary– Acute tubular necrosisAcute tubular necrosis

Acute PhaseAcute Phase• Fluid therapyFluid therapy

– Lactated Ringers per Parkland (Baxter) formulaLactated Ringers per Parkland (Baxter) formula

• Wound careWound care– Topical silvadene, sulfamylon, bacitracin, or bactrobanTopical silvadene, sulfamylon, bacitracin, or bactroban– PREVENT INFECTIONPREVENT INFECTION

• Excision and graftingExcision and grafting– Remove necrotic tissueRemove necrotic tissue– Apply split thickness auto graft skinApply split thickness auto graft skin

• Porcine skin, cadaver skin, clients own skin, skin culturePorcine skin, cadaver skin, clients own skin, skin culture

• Nutritional therapyNutritional therapy– Increased fluids, proteins, vitamins A, C, E.Increased fluids, proteins, vitamins A, C, E.– Zinc, iron, folateZinc, iron, folate

• Physical therapyPhysical therapy– Prevent contracturesPrevent contractures

• Physical and psychological comfortPhysical and psychological comfort

Drug Therapy: Drug Therapy: AntibioticsAntibiotics

• Silver Sulfadiazine (Slivadene)Silver Sulfadiazine (Slivadene)– Burn treatmentBurn treatment– QD or BIDQD or BID– ““frosting”frosting”

– Adverse effectsAdverse effects• PainPain• ItchingItching• BurningBurning

Rehabilitation PhaseRehabilitation Phase• Prevent and minimize contractures Prevent and minimize contractures

and scarring!and scarring!

• Cosmetic / reconstructive therapyCosmetic / reconstructive therapy

• Psychological support if neededPsychological support if needed