Medical-Surgical Nursing Care Third Edition CHAPTER Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third

Medical-Surgical Nursing CareThird Edition

CHAPTER

Copyright ©2011 by Pearson Education, Inc.All rights reserved.

Medical-Surgical Nursing Care, Third EditionBurke • Mohn-Brown • Eby

Caring for Clients With Skin Disorders

45



Skin Changes in Older Adults

• Decrease in activity of sebaceous and sweat glands leading to reduced lubrication and moisture retention

• Reduced fat in subcutaneous layers increases the risk for shearing, tearing, and pressure ulcers



Common Skin Disorders

• Pruritis• Dry Skin• Psoriasis• Dermatitis• Acne



Pruritis

• Itching sensation producing the urge to scratch

• Small or widespread with or without a rash• Triggered by heat and prostaglandins• Increased by release of histamine and

chemical mediators



Pruritis

• Caused by anything in the internal or external environment

• Stimulation or irritation of receptors in the junction between the epidermis and dermis– Itch–scratch–itch cycle



Dry Skin

• Decreased activity of sebaceous and sweat glands reducing skin lubrication

• More common in older adults• Exposure to environmental heat and low

humidity, sunlight, excessive bathing, and decreased intake of liquids

• Pruritis and flaking of skin



Psoriasis

• Chronic, noninfectious skin disorder• Raised, reddened, round circumscribed

plaques covered by silvery white scales• Appear anywhere in the body• Plaques shed gray scales



Psoriasis

• Cause unknown– May be an autoimmune disorder

• Sunlight, stress, hormone fluctuations, steroid withdrawal, seasonal changes, and drugs may make condition worse

• Family history• Pruritis, pain, discoloration of nails



Dermatitis

• Acute or chronic inflammation of the skin• Erythema and pain or pruritis• Vesicles, scales, and pruritis initially• Progresses to edema, serous discharge,

and crusting



Dermatitis

• Types– Contact– Atopic—eczema– Seborrheic– Exfoliative



Acne

• Disorder of sebaceous glands– Face, scalp, scrotum

• Sebum is produced in response to hormonal stimulation

• Lesions are called comedones• Acne vulgaris• Acne rosacea




• Most treated by self-care at home• Focus of treatment is identifying, modifying,

or eliminating precipitating factors• Diagnosis

– Culture– Skin scrapings– Biopsy– Ultrasound tests




• Pruritis - medications and treatments– Antihistamines– Tranquilizers—stress related to pruritis– Antibiotics– Topical steroids– Therapeutic baths




• Psoriasis - medications and treatments– Topical corticosteroids– Tar preparations– Retinoids to decrease inflammation– Photochemotherapy– Ultraviolet-B




• Acne - medications and treatments– Based on type and severity of lesions– Retinoic acid, Retin-A– Benzoyl peroxide– Azelaic acid– OTC medications– Accutane– Surgery—dermabrasion




• Complimentary therapy– Aloe– Goldenseal– Peppermint oil



Bacterial Infections

• Arise from the hair follicle where bacteria accumulate and grow

• Localized infection• Systemic if invade into deeper tissue



Folliculitis

• Staphylococcus aureus• Skin surface and extends into hair follicle• Inflammation• Scalp and extremities, face of bearded

men, legs of women who shave, eyelids (stye)

• Poor hygiene, nutrition, prolonged moisture, trauma



Furuncle

• Infection of the hair follicle• Carbuncle—group of infected hair follicles• Staphylococcus aureus• Deep red nodule that gets larger and

cystic• May cause fever, chills, or malaise



Cellulitis

• Localized infection of the dermis and subcutaneous layers

• Spreads as a result of spreading factor hyaluronidase

• Breakdown of fibrin network and other barriers



Cellulitis

• Red swollen, painful• Fever, chills, malaise, headache, swollen

lymph glands



Fungal Infections

• Plantlike organisms that live in soil, on animals, on humans

• Dermatotypes live on stratum corneum, hair, and nails

• Superficial infections– Ringworm or tinea

• Mycoses



Dermatophyte (Tinea)

• Tinea pedis– Athlete’s foot

• Tinea curis– Groin infection



Candidiasis

• Candida albicans• Yeastlike infections on skin, vagina,

gastrointestinal tact



Viral Infections

• RNA or DNA core surrounded by a protein coat

• Depend on live cells for reproduction• Increase cell growth or cause cellular

death



Warts

• Human papillomavirus• Skin and mucous membranes• Nongenital warts are benign lesions• Genital warts are precancerous• Transmitted through skin contact• Common• Plantar• Condylomata acuminate (venereal warts)



Herpes Simplex

• Herpes virus I and II• Fever blister or cold sore• HSV I—lips, face, and mouth• HSV I or II—genital herpes, sexually

transmitted• Begins with a tingling sensation followed

by erythema, vesicle formation, and pain• Lasts 10–14 days



Herpes Zoster

• Varicella zoster• Reactivation of dormant virus• Painful vesicles on the face, trunk, and

thorax• Prevalent in people who are

immunocompromised• Recovery 4–6 weeks• Postherpetic neuralgia



Parasitic Infestations

• Skin invaded by parasites or insects• Most common parasites are mites and lice



Pediculosis

• Infestation of lice• First stage is an unhatched egg (nit)• Three types live on humans• Pediculosis corporis—body lice• Pediculosis capitus—head lice• Pediculosis pubis—pubic lice (crabs)



Scabies

• Female mite• Infestation between fingers and inner

surfaces of wrist, elbow, axillae, nipple, penis, belt line, and gluteal crease

• Occur up to 4 weeks after contact• Small red mite burrows into skin



Infections/Infestations

• Treatment focused on identifying causative agent

• Administer medication to kill bacteria or eradicate the organism

• Prevent secondary infection• Environmental surveillance and control




• Diagnosis– Culture and sensitivity– Scrapings and microscopic examination– Ultraviolet light inspection– Lab studies



Infections/Infestations - Treatment

• Bacterial infections– Antiobiotics—topically or systemically

• Fungal infections– Antifungal agents—topically or systemically

• Viral infections– Antiviral agents– Medications to relieve pain and pruritis




• Parasitic infestations– Topical agents to kill the parasite

• Complementary therapy– Tea tree oil



Skin Cancer

• Most common of all cancers• Result of long-term exposure to the sun or

environment• Exposure to chemicals, ultraviolet light• Skin pigmentation

– The more melanin, the more you are protected



Nonmelanoma Skin Cancer

• Basal cell carcinoma– Epidermis– Sun-exposed areas of the head and neck– Slow growing and rarely metastasize



Nonmelanoma Skin Cancer

• Squamous cell carcinoma– Squamous epithelium of the skin or mucous

membranes– UV ray exposure– Forehead, helix of ear, top of nose, lower lip,

back of hands– Firm flesh-colored or erythematous papule– Can be recurring and invasive increasing risk

of metastasis



Melanoma

• Cutaneous or malignant • Arises from the melanocytes that produce

melanin• Lesions can be benign until they infiltrate

the dermis and mingle with blood and lymph

• Increases the risk of metastasis



Melanoma

• Precursor lesion is a dysplastic nevi (mole)• Change in the color or size of a nevus

occurs in 70% of people diagnosed with melanoma– A asymmetry– B border irregularity– C color variation– D diameter greater than 6 mm



Skin Cancer

• Treatment focuses on removal of malignant tissue

• Surgery• Chemotherapy• Immunotherapy• Radiation therapy• Biological therapies



Skin Cancer

• Diagnosis– Microscopic exam and tissue biopsies– Liver function tests– Chest x-rays– Microstaging



Skin Cancer

• Assessment– Present health status

Change in mole, wart, birthmark, scar Exposure Other

– Past medical history Skin cancer or family history Geographic residence Serious sunburn



Pressure Ulcers

• High risk for the older adult– Limited mobility with aging

• Illnesses that result in paralysis



Skin Breakdown

• Altered nutrition less than body requirements

• Incontinence• Chronic illness



Pressure Ulcers

• Pressure develops over bony prominences• Shearing forces, friction, external pressure

cause damage• Impairment of flow of blood and lymph

causing ischemia from distortion of capillaries

• If pressure continues, platelets clump and form microthrombi



Pressure Ulcers

• Microthrombi impede blood flow, resulting in ischemia and hypoxia

• Cells and tissue die and become necrotic• Superficial

– Red or blister

• Deep– Deeper structures where tissue becomes

necrotic and dies



Pressure Ulcer

• Shearing forces– Result when one tissue layer slides over

another– Stretching and bending of blood vessels– Head of bed elevated and torso slides down

toward foot of bed– Pulling client up in bed– Increased risk with immobility



Pressure Ulcers

• Goal is prevention• Laboratory tests to determine infection• Topical and systemic antibiotics• Surgical debridement• Specialty dressings and beds



Common Skin Disorders – Nursing Care

• Assessment– Present health status– Past medical history– Inspection of the entire skin for color and

lesions– Palpate skin for temperature, texture,

moisture, and turgor




• Impaired Skin Integrity– Strategies to relieve itching– Therapeutic baths

• Disturbed Body Image– Trusting relationship– Self-perception– Involvement of family




• Deficient Knowledge– Medication administration



Infections/Infestations – Nursing Care

• Assessment– History of contact– Living conditions– Chronic illnesses– Inspect skin, hair, mucous membranes

Note location, appearance, and size of lesions



Infections/Infestations – Nursing Care

• Acute pain• Disturbed of sleep pattern• Risk for infection



Skin Cancer – Nursing Care

• Assessment– Inspection and palpation of skin lesions– Measure and document location– Monitor report results



Skin Cancer – Nursing Care

• Anxiety• Impaired Skin Integrity• Hopelessness



Pressure Ulcers – Nursing Care

• Assessment– Identify patients at risk– Describe appearance– Measure size and depth




• Risk for Impaired Skin Integrity and Impaired Skin Integrity– Minimize risk– Conduct systematic inspection– Keep skin clean and manage incontinence– Minimize environmental factors– Minimize friction and shearing forces




• Risk for Impaired Skin Integrity and Impaired Skin Integrity– Maintain adequate nutritional intake– Maintain activity level– Teach client to shift weight– Use positioning devices, pillows– Keep head of bed at lowest position– Use specialty devices



Skin Disorders – Client Teaching

• Supportive role• Report complications of treatments• Proper medication administration• Care to facilitate healing and eliminate

spread of infection



Skin Disorders - Client Teaching

• Dressing changes and direct care of skin lesions

• Nutrition• Environmental control



Skin Disorders - Client Teaching

• Early detection and care of skin cancers• Prevention of skin cancer• Prevention of pressure ulcers in clients

cared for at home

Documents

Medical-Surgical Nursing Care Third Edition CHAPTER Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medical-Surgical Nursing Care, Third