Today we will be discussing Chapter 52, the Nursing Management of Patients with Dermatologic Problems. The objective of this chapter is to describe the manifestations and management of patients with abnormal skin conditions. Let's discuss some broad introductory statements regarding dermatologic problems. When dealing with dermatologic problems, Our goal for therapy is always to control the disorder and allow the skin to repair itself. When there are alterations in the skin, we lose one of our barriers.
This can put a patient at risk for things like infection. Another statement to consider is that isolation is required when the condition is contagious. The last statement to discuss are relevant nursing diagnosis.
Things like impaired skin integrity or disturbed body image, apply to most of these conditions. Let's discuss our first condition, contact dermatitis. Contact dermatitis is an inflammatory response of the skin to a physical, chemical, or biologic agent.
Common causes include soaps, detergents, scouring compounds, or industrial chemicals. Contact dermatitis often presents with pruritus, severe itching, burning, erythema, edema, papules, vesicles, oozing, or even weeping. The key treatment is to identify and remove that irritant. We can also apply cool compresses, try unmedicated and unscented lotions, or apply corticosteroids if necessary.
Next, let's look at scaboric dermatitis. Scaboric dermatitis is a chronic inflammatory disease of the skin. within areas of the body that are well supplied with sebaceous glands or in skin folds.
Common sites for this are the face, the scalp, eyebrows, eyelids, sides of the nose, upper lip, cheeks, ears, axilla, under the breasts, groin, or gluteal crease of the buttocks. Oftentimes they may present asymptomatically or have pruritus. Remember, pruritus can lead to excoriation of the skin, and even cause secondary infections.
Scaboric dermatitis presents as either an oily form or a dry form. Those with the oily form often may have a greasy or moist appearance. They may have a yellowish-red or even gray-white greasy skin. You might see white dry scaling to your dermacules and or your papules with slight redness. Dry scaboric dermatitis.
is often presented on the scalp with fine powdery scales, commonly called as dandruff. Treatment for oily scaboric dermatitis involves topical glucocorticoid cream. You should avoid the eyelids as it can cause glaucoma or even cataracts in predisposed patients. Another treatment option is ultraviolet radiation therapy for dry scaboric dermatitis. we often look at different types of shampooing.
An antiscorporic shampoo should be used about three to five times weekly. The shampoo should be left on for about five to ten minutes. To avoid resistance, the shampoo should be alternated. Examples include selenium sulfide suspension, sasilic acid, sulfur compounds, or even tar shampoo.
In either case, you should avoid external irritants, excessive heat, perspiration, rubbing, or scratching. Common complications involve a secondary candida or yeast infection. Keep the areas clean and dry and treat with topical antifungals if it occurs.
A key nursing diagnosis is a disturbed body image with scleroderma dermatitis. Next, let's look at viral skin infections, including herpes zoster, commonly known as shingles. Shingles is a painful vesicular eruption along the area of the distribution of the sensory nerves from one or more posterior ganglia. Shingles is caused from Bursell's zoster virus, commonly known as chickenpox.
Here, that virus lays dormant after that chickenpox outbreak inside the nerve cells by the brain and spinal cord, and then they travel by way of the peripheral nerves. to the skin. Key manifestations include a red rash with small fluid-filled vesicles and a band-like cluster.
There's usually significant pain and burning along the sensory nerve pathway. Patients that you suspect or have verified cases of shingles should remain on precautions. Shingles is contagious and can even harm an unborn child. Healthcare providers that are pregnant should stay away from patients with shingles. Due to the fact that shingles will spread the Furcella zoster virus, it is the chicken pox.
virus that is actually most harmful to the unborn child. Key treatment are antivirals such as acyclovir, valacyclovir, or femlicyclovir. Complications include a post-therapeutic neuralgia where the patient will experience persistent pain to the affected nerve after healing.
Treatment can include systemic corticosteroids. Other complications involve eye complications when the virus affects the face. These patients should be sent to an ophthalmologist for further treatment to prevent secondary complications up to and including blindness. The patients may also experience infection or scarring from the rash itself.
Next, let's look at tinea. Tinea is a fungal infection of the skin commonly known as ringworm. Common areas affect the generalized body up to and including the groin, feet, and nails. Based on the location of the infection, you'll see different presentations.
Common infections to the body will present with a red macule that spreads in a ring or rounded tunnel-like appearance with a clear center, much like the image on the top. Infections to the groin present with small red scaling patches in the form of circular elevated plaques. Infections to the feet involve a scaling or mild redness with maceration to the toe webs.
Infections to the nail often show a thickening and crumbling of the nails. Diagnostics involve cleaning the lesion and then scraping with a scalpel or a glass side to remove scales from the margins of the lesion. They'll add potassium hydroxide and use a microscope to look for spores or hyphae. Another diagnostic option is to use a woodslight.
Under the woodslight, infected hair will appear fluorescent. Treatment for ringworm involves the use of topical antifungal creams. In severe conditions, grisonoflovin or Turbofine may also be used.
The feet can also be soaked in a vinegar and water solution. With nails, we can use Sporanex in pulses of one week for a month and then for three months we'll repeat this same treatment. Next let's discuss scabies, an infestation of the skin by the itch mite.
Common affected areas involved between the fingers, elbows, knees, edges of the feet, axillary folds, around nipples, under pendulous breasts, within the groin or gluteal folds. Key presentation is usually severe itching anywhere from contact to four weeks later. Using a light and a magnifying glass you may even have small raised burrows created by the mites.
Eventually red, parotid eruptions will appear between the adjacent skin areas. To diagnose, a scrape of the affected areas will be used under a microscope to look for the presence of the actual itch mite. Key treatment involves the use of a scapeicide.
A scapeicide should be applied after a warm soapy bath or shower. The skin is allowed to dry and cool. The scapeicide will then be applied in a very thin layer to the entire body but sparingly to the face and the scalp. After about 12 to 24 hours, the scapeicide can be removed.
Oftentimes, a repeat treatment will be done in one week. Consider long-term care facilities and the easy spread of scabies throughout a facility. When dealing with scabies, all parties need to be treated, as contact will spread the scabies from one person to the next to the next. So again, it is key to understand that anybody living within the same area should be treated with escapicide.
Next, we have psoriasis. Psoriasis is a chronic, non-infectious inflammatory disease that stems from the hereditary defect that causes the overproduction of keratin. This condition can worsen or improve over time.
Triggers to worsen the condition are emotional stress, anxiety, trauma, infection, seasonal or hormonal changes. Clinical manifestations involve a red raised patch of skin covered with silvery scales. Common sites are the scalp, the extensor surface of the elbow, knees, lower back, genitalia, and even nails.
Diagnosis is reliant on a skin assessment. Biopsy of the skin and blood tests often offer no results. Management involves multiple things. Stress management or key treatment being baths, whether it's oils or cold tar preparation baths, photo chemotherapy where UV lights are utilized, topical pharmacological therapy such as corticosteroids, intraliazonal agents for thick plaque nails, or even systemic agents can be prescribed and utilized based on the extent of the psoriasis.
Common complications involve asymmetric rheumatoid factor negative arthritis to multiple joints. Next we have exfoliative dermatitis. Exfoliative dermatitis is a progressive inflammatory response that causes generalized erythema and scaling to occur to the skin.
There's a loss of the stratum corneum or over layer of the skin. This can lead to capillary leaks, hypoproteinemia, negative nitrogen balance, and even lead to body heat loss. This is often associated as a secondary or reactive process to an underlying skin or systemic disease. This typically presents in an acute phase.
with patchy or generalized erythematous eruptions accompanied by fever, malaise, and GI symptoms. The skin then changes from a pink to a very dark red color. You'll want to assess for firmness or even bogginess.
The patients may have pain, swelling, warmth, or even a cooler temperature. Approximately one week later, the scaling will occur. That new underlying skin will come in as smooth and red in color. Management for exfoliative dermatitis is to maintain your fluid and electrolyte balance and prevent infection. The patients may even require plasma volume expanders during this time period.
Next we're going to look at two blistering disorders, femphigus and voluus femphigoid. Femphigus is a blistering of the normal skin and mucous membranes. It's an autoimmune condition that involves immunoglobulin G.
The blisters are a result of an antigen and antibody reaction. Diagnosis involves serum antibody testing. Clinical manifestations involve oral lesions or lesions on the body that are irregularly shaped, painful, and often bleed easily. Drainage is odorous when those bulbula erupt. Voluosemphagoid is an acquired disease with flaccid blisters.
The lesions often affect the flexor surface of the arms, legs, axilla, groin. Oral lesions are very rare. Typically, volvulosemphagoid presents with blisters on the skin that are shallow erosions and heal fast. Both disorders are often treated very similarly. The treatment involves corticosteroids, immunosuppressive agents like azithriropine, or even plasmapheresis.
The plasmapheresis will lessen the antigen and antibody reaction and allow for a quicker healing process, also associated with lower needs for corticosteroids. Complications to both are bacterial infection or even sepsis. The skin should be cleaned and debris should be removed.
There should be close monitoring for signs and symptoms of infection. Remember corticosteroids can mask those signs and symptoms. The patients will also need protective isolation.
You'll also want to monitor and assess for fluid and electrolyte imbalances due to that fluid and protein loss when the bulbula erupt. Hypoalbuminia is one key finding. Treatment with IV fluids or even blood components may be required based on lab results.
In both disorders, key nursing diagnoses involve risk for infection, impaired skin integrity, and disturbed body image. Next, we're going to look at toxic epidermal necrolysis and Steven-Johnson syndrome. Both are potentially fatal disorders triggered by reaction to medication. Typically, these triggering agents are new medications.
Examples include antibiotics such as sulfas, anti-seizure agents, or even NSAIDs. Clinical manifestations include conjunctival burning or itching, cutaneous tenderness, fever, cough, sore throat, headache, extreme malaise, or even muscle pain. Next you'll develop a rapid onset of urethema involving much of the skin and mucous membranes.
This does include the oral mucosa, conjunctiva, and even genitalia. It can even lead to ulceration of the larynx, bronchi, or esophagus. Next you'll see large flaccid bulbula develop and large sheets of epidermis can be shed. This leaves the underlying skin weepy and tender, similar to that of partial thickness burns.
You may even have hair and nail loss. Key treatment is to stop the triggering agent. Control pain, monitor for fluid and electrolyte imbalances.
Ultimately an NG tube may be required to assist in this. We'll want to prevent sepsis and worsening infection with good hand hygiene, reverse isolation. Topical agents such as antibacterial agents or antibiotics will be used with extreme caution. They may choose temporary biologic dressings such as pigskin or amniotic membranes or even plastic semipermanent dressings. We'll also want to look at ophthalmic complications and use.
good eye care, and even oropharyngeal care. Eye lubricants and damp, cool cloths should be used. Supportive care like family education on infection process, dressing change, is also key.
The patients may require PT and OT assistance with mobility after the condition progresses. Patients will also require strict follow-up to ensure good wound healing. Next, let's talk about skin cancer. The book breaks down nicely risk factors preventing skin cancer, periodic self-examinations, and assessing the A, B, C, D, and E of moles nicely within boxes. Let's discuss each further.
Risk factors to skin cancer do involve insufficient skin pigmentation, so light skin, hair, blue eyes, those whom sunburn, chronic sun exposure, exposure to chemical pollutants, History of x-ray therapy for acne or benign lesions, scars from severe burns, chronic skin irritations, immunosuppression, or genetic factors. Prevention for skin cancer really lies with avoiding sun exposure. Things like sunscreen education should be expressed. This does require daily sunscreen use. Using SPF 15 or higher, reapply applying water-resistant sunscreen after swimming or heavy sweating, and every two to three hours within the sun.
Avoid oils before and during sun exposure, and using SPF lip balm, wearing protective clothing like a large brim hat, avoiding sun lamps, indoor tanning, or commercial tanning beds. Remember that 50% of UV rays can still penetrate loose clothing, and UV rays can even penetrate cloud covering. Self-exams do involve looking at the entire body, using mirrors to see behind you, and include looking under the underarms and gluteal folds. Assessing the ABCD of moles looks at A, asymmetry, B, irregular borders, C, variegated color, D, E. Elevation, enlargement, and or evolution of the pre-existing moles. All of these should be teaching points for each patient regarding potential skin cancer.
To help understand this chapter, we will be reviewing some of these concepts in class briefly, utilizing the matching activity found on Canvas. The matching activity has three areas of focus, the previously discussed dermatologic conditions, benign skin tumors, and malignant melanomas. Please be prepared to discuss each of these using that matching activity in class next week.
Due to the activity, I am going to jump ahead to malignant skin tumors and focus on basal cell carcinoma here and squamous cell carcinoma. Basal cell carcinoma Manifests as small waxy nodules with rolled translucent pearly borders as it grows. Central ulceration and crusting can even occur. In squamous cell carcinoma, typically you'll have a pre-existing lesion that's now metastasized to the blood and lymphatic system.
They present with a rough, thickened, scaly tumor. When we deal with malignant cancer, we often look at excursion of the tumor. We will as previously mentioned in our previous chapters, also look at the size and the extent of the tumors and determine if lymph node involvement has occurred. Surgical treatment options do include MAAS micrographic surgery. It is a very accurate and precise procedure that preserves as much normal tissue as possible while also removing the tumor by shaving it down layer by layer.
Electrosurgery looks at the destruction and removal of the tissue by electrical energy after an initial curating or scraping of the tumor. Cryosurgery involves a deep freezing of the tissue using liquid nitrogen. Radiation therapy is used for areas of vital structures like the eyelids or the tips of the nose. Due to changes with the radiation and chances of malignancy in the future, these procedures are often reserved for the the elderly population only. Please be aware that nursing management is key when dealing with the surgical removal of skin cancer.
There should be a high focus on teaching self-care such as wound care, dressing changes, educations on bleeding and suture removal, and follow-up examinations. There should also be a high emphasis on teaching the prevention of skin care itself. At this point, we've talked about corticosteroids often. Corticosteroids are used to treat many dermatologic conditions due to their anti-inflammatory, antipyretic, and vasoconstrictive effects. Corticosteroids do require being applied sparingly to the affected area and rubbed in thoroughly to well-hydrated skin.
Local side effects can include skin atrophy, thinning of the skin, stria, and telangieostasia. Systemic side effects do include hyperglycemia. Another long-term complication is that corticosteroid use can cause immunosuppression.
Patients should be frequently checked for masked signs of infection. As we discuss dermatologic conditions, it's important to also note that not only medical conditions can affect skin integrity, but so can physical alterations like body jewelry. This includes piercings and implants.
Please keep in mind that those with body jewelry, implants, and etc. all run the risk of impaired skin integrity, risk for infection, and should be monitored for such. Body jewelry can also affect the ability to allow imaging during medical emergencies. Body jewelry may need to be removed to complete such imaging and or tests or procedures. Let's review.
A 20-year-old patient is being seen in the dermatology clinic for basal cell carcinoma on her eye. The nurse would expect the physician to complete which intervention? A. Electrosurgery, B. Maws Micrographic Surgery, C. Cryosurgery, or D. Radiation.
The correct answer is B. Maws Micrographic Surgery. This treatment is the most precise and effective for tumors around the eyes, nose, upper lip, auricular, or periocular areas. Next question.
Topical corticosteroid therapy has been ordered for a patient with pruritus. Which of the following should be incorporated into the plan of care for this patient? A, apply liberally to prescribed areas. B, absorption is enhanced when skin is dry.
C, local side effects may include skin atrophy and thinning. Or D. Absorption is decreased when covered with an occlusive dressing. The correct answer is C.
Local side effects may include skin atrophy and thinning. Additional side effects like strea or telangieostasia can also occur. The patient should be taught to apply the medication sparingly and rub it into the prescribed area thoroughly.
Absorption of topical corticosteroids is enhanced when the skin is hydrated or when the affected area is covered by an occlusive or moisture-retentive dressing. Last question. A 55-year-old patient with leukemia is being seen in the clinic for complaints of burning pain on her back.
She's been diagnosed with shingles. The nurse would expect which medication classification to be ordered for her to reduce pain and halt the progression of the disease? A. Anti-inflammatory, B. Antiviral, C. Antibiotic, or D. Antifungal?
The correct answer is B. Antivirals, such as acyclovir. When started early enough, it is effective in significantly reducing pain and halting the progression of the disease. Remember, shingles is a reactivated, for cell is zoster's virus.
Therefore, there is an increased frequency of the herpes zoster infection among patients with a weakened immune system and cancers such as leukemia and lymphomas. This completes our discussion on Chapter 52. Please remember to complete the matching activity found on Canvas so we may discuss it further in class and review these concepts briefly.