INTEGUMENTARY DISORDERS

By Habtamu A.(RN, BSc, MSc in Adult Health Nursing, PhD student)

HA(MSN) 1

Anatomy of the skin

• The skin consists of 3 layers:

– Epidermis- non vascular outermost layer, continuously dividing cells

–Dermis- takes the largest portion of the skin and provides strength and structure. It consists of glands (sebaceous, sweat), hair follicle, blood vessels, and nerve endings

– Subcutaneous tissue (hypodermis)- the inner most layer. contains major vascular networks, fat, nerves, and lymphatics

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Function of the skin • Protection- protection of underlying structures from

invasion by bacteria, noxious chemicals and foreign matter.

• Sensory perception- transmits pain, touch, pressure, temperature, itching, etc

• Fluid balance (excretion)- absorption of fluids and evaporation of excess.

• Temperature regulation- produced heat released through skin by radiation, conduction, and convection

• Vitamin synthesis- skin exposed to ultra violet light can convert substances necessary for synthesizing vitamin D3 (cholecalciferol).

• Aesthetic- provides beautiness and appearance

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Factors influencing skin integrity

• Immoblity is the major factor leading to pressure sore development .

• The pt who is confined to bed & unable to change position is at greatest risk .

• Trauma most likely occur

– over the prominent areas

– weight bearing areas

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• Prolonged pressure impairs blood flow to tissue & resulfs in ischemia & inferction

• The extent of pressure necessary to cause tisue damage depnds on the tolerance of the pt's skin & supporting stuctures .

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• Tolerance to pressurs trauma is influenced by the following factors:

– Duration of pressure

– Magnitude of pressure

– Body position

– Friction

– Impaired moblity

– Malnutrition

– Dehy dration

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COMMON DERMATOLOGIC TERMS

• Lichenification: distinictive thickening of skin

• Crust: dried exudate of body fliuds

• Erusion: epithelial deficiet

• Ulcer: epithelial deficiet (disruption of deep skin integrity)

• Atrophy: an acquired loss of substance

• Scar:change in the skin secondery to trumas or inflammation

HA(MSN) 9

Description of skin lesion(primary lession)

I. circumscribed , flat , nonpalpable changes in skin color

• Macule = small upto 1 cm, eg. petechia

• Patch = larger than 1 cm , eg vitilligo

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Description of skin lesion...

II. Palpable elevated solid masses

– Papule: up to 0.5cm eg. elevated nevus

– Plaque: elevated surface > 0.5 cm

– Nodule: deeper & firmer than papule

=> 0.5 -1-2cm eg tumor

– Wheal: irregular, superficial area of localized

skin edema

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Description of skin lesion...

III. Superficial elevation of skin formed by free fluid in a cavity in the skin layer.

• Vesicle: up to 0.5 cm

=> filled c serous fluid,eg herps simplex

• Bulla: > 0.5 cm, Filled of serous fluid, eg 2nd degree burn ( blister)

• Pustule: filled pus, eg impetiao, acne

HA(MSN) 12

Secondery lesion

IV. Loss of skin surface

• Erusion => loss of superficial epidermis

• Ulcer => deep loss of skin surface

=> May bleed & scar, eg. sphilic chancre

• Fissure => linear creak in the skin

eg.A thlet's foot

HA(MSN) 13

Secondery lesion....

On skin surface:

• curst = dried residue of serum ,pus or blood, eg Impetigo

• Scale = a thin flake of exfoliative epiderms eg.dandruff, Dry skin, Psoriasis

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Vascular skin lesions

• a lesion that originated from a blood vessel

– Petechia/Purpura

– Ecchymosis

– venous star

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Skin lesion configuration

• Linear- in line

• Annular and arciform –circular or arcing

• Zosteriform- linear along a nerve route.

• Grouped -clustered lesion

• Discrete -separate and distinict

• Confluent- lesions that run together or join

• Generalized- widespread eruption

• Localized- lesions on distinct area

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Assessing the skin

• Assessment includes a thorough

- history taking,

-inspection and

-palpation of the skin.

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Herpes vircilla virus

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Tinea pedis

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acne

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Adverse effect of topical corticosteriods

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pso

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Assessing the general appearance of the skin

• The general appearance of the skin is assessed by observing (Inspection) color, skin lesions, and vascularity.

• On palpation skin turgor and mobility, possible edema, temperature, moisture, dryness, oiliness, tenderness, and skin texture (rough and smooth).

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Color change: can be hyperpigmentation, hypopigmentation or depigmentation

1. Redness- fever, alcohol intake, local inflammation due to increased blood flow to the skin.

2. Bluish color (cyanosis) - decreased oxygen supply due to chronic heart and lung disease, exposure to cold, and anxiety

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Cont’ed…

3. Yellowish color (jaundice) - increased serum bilirubinconcentration due to liver disease or red blood cell haemolysis- Uremia- renal failure

4. Brown-tan- Addison’s disease: cortisol deficiency stimulates increased melanin production

- Birth mark, chloasma of pregnancy (face patches), and sun exposure

5. Pale: Albunism- total absence of pigment melanin• Vitiligo- destruction of the melanocytes in

circumscribed areas of the skin

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Benign skin condition-vitiligo

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Diagnostics test

• Skin biopsy: removal of a piece of skin by shave, punch, or excision technique for a microscopic study of the skin to determine the histology of cells to rule out malignancy and to establish an exact diagnosis.

• Patch testing: performed to identify substances to which the patient has developed an allergy.

• Potassium hydroxide test (KOH): helps to identify fungal skin infection

HA(MSN) 33

Diagnostics test…

• Gram stain and culture with sensitivity test:

helps to identify the organism responsible for

an underlying infection with the effective drug

identification

• Slit Skin Smear (SSS): to identify the

causative agent of leprosy (mycobacterium

leprea)

HA(MSN) 34

Disorder of the skin

I . Inflammatory and allargic skin disorders

– Acne

– Psoriasis

– Atopic dermatitis (eczema)

– Contact dermatitis

II. Bacterial infections

– Impetigo

– Boil (furuncle)

– Carbancle

– Cellilitis

HA(MSN) 35

Disorder of the skin…

III. fungal infections

– Candidiasis

– Tinea captis

– Tinea corporis

– Tinea pedis (atlet's foot)

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Disorder of the skin…

IV. Viral infections

– Herpes simplex (cold - sore)

– Herpes zoster (shingles)

– Warts

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Inflammatory and allergic condition

A. Eczema/Dermatitis

- It is a chronic pruritic inflammatory disorder affecting the epidermis, and dermis commencing in infancy, often persisting throughout child hood but eventually remitting and some times recurring in adult life.

• They are a non-infectious inflammation of the skin and it can be acute, sub-acute or chronic.

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Con’ted….

• Causes

– The exact cause is unknown

– Imbalance of the immune system with an increase in the immunoglobulin “E” activity and deficient of cell mediated delayed hypersensitivity.

• Can be exacerbated by infection, bites, pollen, wool, silk, fur, ointments, detergents, perfume, certain foods, temperature extremes, humidity, sweating and stress

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Hypersensitivity reactions

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Sign and symptom

• An acute stage eczema shows redness, swelling, papules, blisters, oozing and crusts.

• In the sub-acute stage the skin is still red but becomes drier and scalier and may show pigment change.

• In the chronic stage

-lichenification,

-excoriation,

-scaling and cracks are seenHA(MSN) 42

Types of eczemaAtopic eczema

- is a chronic relapsing skin disorder that usually begins in infancy and is characterized principally by dry skin and pruritis, consequent rubbing and scratching lead to lichenification

• This patient has a genetic predisposition for hypersensitivity reactions such as asthma, allergic rhinitis, and chronic urticaria. – The eczema comes and goes

– The eczema triggered by dryness of the skin, infections, heat, sweating, contact with allergens or irritants and emotional stress.

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Atopic eczema…

• Mostly affected sites are elbow and knee folds, wrists, ankles, face, and neck; in some cases it can be generalized

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Atopic dermatitis

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Atopic dermatitis

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Seborrhoic eczema

- is a very common chronic dermatitis characterized by redness and scaling that occurs in regions where the sebaceous glands are most active, such as:– Scalp, border of forehead/scalp–Behind ears, above and in between

eyebrows– In nasolabial folds, Sternum– In between the shoulder blades, in axillae–Groin , Perianal area

HA(MSN) 47

Seborrhoic eczema…

–Under the breast , umbilicus and in body folds

–Pts often complains of oily skin– The eczema comes and goes – In HIV patients, the eczema can become very

widespread and easily super infected

HA(MSN) 48

Infective eczema• which occurs as a response to an oozing skin

infection.

• Common sites are the foot, and ankle region

• Causative organisms are usually staphylococci/ streptococci

• Vaseline use aggravates this condition

HA(MSN) 49

Contact eczema:

• is caused by contact of the skin with an irritant or an allergen.

• Vaseline commonly causes: Vaseline dermatitis.

• Common causes of irritant contact eczema on hands, arms and legs are excessive use of H2O, soap (especially if not washed off properly) detergents, chemicals, sunlight, jewellery, dyes, bleaches, perfume, nail polish/remover, etc

HA(MSN) 50

Contact dermatitis

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Sign and symptom of eczema/ dermatitis

(general)

• Itching

• Redness, dry skin, lichenification, excoriation, scaling skin

• Papules, blisters, oozing and crusts

• Color change

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Management (general)

• Stop the use of irritants (contact eczema)

• Mild topical steroid such as hydrocortisone 1% cream twice daily until lesions clear.

• In severe itching use antihistamines

E.g.: promethazine 25mg at night, chlorphenaramine 4mg at day time/night

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Mgt cont…• In bacterial super infection use KMNO4

solution, Betadine solution, antibiotics

• Explain to the Patient, and Parents that not serious and will disappear in time.

• Keep finger nails short and covered at night

• Use non greasy or non moisturizers (seborrhoic eczema)

HA(MSN) 54

Mgt cont…

• An imidazole cream twice daily/ketaconazole200 mg/d 1-3 weeks (seborrhoic eczema)

• The vicious circle of itch – scratch –lichenification – itch needs to be broken , (atopic eczema)- conscious effort to stop scratching

• In photo allergies – sun protection by wide rim sun hat, long sleeves, high collar, sunglasses, stay indoor, sunscreen, umbrella, etc

• Keep the site clean

HA(MSN) 55

Acne- Is a common disorder of the sebaceous gland

associated with excess production of sebumand blockage of the duct resulting in a variety of inflammatory manifestations.

• Common in puberty and usually regresses in early adult hood

• Patient complain of oiliness of the skin.

- Occurs on the face, upper trunk and shoulders

- Appears to be multiple inflammatory papules, pustules and nodules

HA(MSN) 56

Acne…

• It can be very mild to be very severe: - they blend together to form large inflammatory areas with cysts and scar formation.

Cause-genetic, hormone and bacteria play a role

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Cont..Sign and symptom

• Red nodules, cyst , red papules, scars, pustules, keloids

• There may be mild soreness, pain or itching

• Inflammatory papules, pustules, pores acne cyst, scarring

Diagnosis

• Clinical – Cyst formation, slow resolution, scarring

– Common at puberty and common of all skin conditions

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Management

• Stop the use of vaseline, oil, ointment, greasy cosmetics which further blocks sebaceous ducts.

• Benzoyl per oxide 5-10% gel or tretinoin 0.01-0.1% cream or gel apply at night.

• Salicylic acid 1-10% in alcoholic solution for removal of excess sebum.

• For pustular/inflammatory lesions use topical clindamycin 1% solution, erythromycin 2% lotion

HA(MSN) 60

Management …

• In severe cases use systemic long term antibiotics like doxycycline 100mg twice daily until substantial improvement followed by 100mg once daily until acceptable.

• Surgical treatment – extraction of comedones, incision and drainage of large fluctuant, nodulocystic lesions

HA(MSN) 61

Psoriasis

• Is a chronic recurrent, hereditary, non infectious

disease of the skin caused by abnormally fast

turn over of the epidermis

• The turn over may be up to 40 times than

normal and as a result the epidermis is not able

to develop normally, therefore it doesn’t allow

formation of the normal protective layer of the

skin.

HA(MSN) 62

Psoriasis…

• Skin become red, inflamed, and the scales are

thicker than normal

• It produces a so called candle-wax

phenomenon, when you scratch such a patch it

becomes silvery white.

• Sites can be extensor areas of extremities

especially elbow, knees, buttocks, shoulder and

scalp

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Generalized psoriasis

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• Cure is there but it reoccurs

• Occurs at any age but 10-35 years is common mostly.

• Periods of emotional stress and anxiety aggravate the condition.

Sign and symptom.

• May itch severely in body folds covered with silvery scales

• Finger and toenails may show pitting and thickening

• Associated arthritis

HA(MSN) 67

Management

• Explain to the Pt the recurrent nature of the disease.

• Salicylic acid 2-10% ointment twice daily to reduce scaling

• Moisturizers (Vaseline, paraffin oil, or cream)

• Treat any super infection with KMNO4 , or antibiotics if necessary

• Psoriatic arthritis NSAIDS E.g.: Ibuprofen, Indomethacin, and ASA

• Methotrexates as a last option in sever cases. HA(MSN) 68

Infection of the skin 1. Cellulitis• Is a diffuse, acute streptococcal or staphylococcal

infection of the skin and subcutaneous tissue

Cause• Caused by bacteria’s like streptococcus/staphylococcus

aureus• Results from break in skin• Infection rapidly spread through lymphatic system

Sign and symptom• Tender, red, hot, indurated and swollen area that is well

demarcated• Possible fluctuant abscess or purulent drainage• Fever, chills, and malaise

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Features:

Red

Swollen

Warm to touch

No areas of pus

Painful

Tender

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The result of “skin popping” -

Multiple injection site abscesses

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Cellulitis with abscess

If rapid spreading beyond this line occurs, this may be necrotizing , and requires surgery

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Necrotizing fasciitis

HA(MSN) 78

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Management

• Oral antibiotics

• Parentral/systemic antibiotics for hands, face, or lymphatic spread

• Surgical drainage and debridement

HA(MSN) 80

2. Furunclosis

• Is an acute painful infection of perifollicularabscess (boils)

• Is an acute, localized, deep seated, red, hot, very tender, inflammatory perifollicular abscess.

• Common microorganism: staphylococcusaureus

• Most common on persons who are carriers of staphylococcus, contact with oils or grease, diabetes, poor habits of personal hygiene, immunosuppression, alcoholism, obese, malnutrited, etc

HA(MSN) 81

Furunclosis…

• The lesion begins in the opening of hair follicle or sebaceous gland

• Sites can be back of the neck, face, buttocks,

thighs, perineum, breasts, axilla, nose, genitallia, etc

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Sign and symptom

• Hard nodule initially then fluctuant abscess with centrally yellow pustule, then ruptures in to an ulcer.

• It can be isolated single lesion or few multiple lesion

• Hotness and pain at the site.

Diagnosis

• Gram stain of the pus

• Culture and sensitivity test of blood/pus

HA(MSN) 84

Cont..Treatment

• Warm compresses -

• Warn patient not to squeeze or incise the lesion

• Incision and drainage when it is fluctuance.

• Systemic antibiotics (cloxacillin, erythromycin)

• Rest especially for genital areas.

• For the sever pain codien, morphine

HA(MSN) 85

3. Carbuncles(multiple furuncles)

- Is an aggregation of interconnected furuncles that drain through multiple openings in the skin.

• Exposure to grease and oil increase the risk.

• Occurs mostly where the skin is thick

• Microorganism mostly: staph. aureus

Sign and symptom

• Sites are back of the neck, shoulder, buttock, outer aspect of the thigh and over the hip joints.

HA(MSN) 86

Carbuncles ….

• Develop slowly than furuncle

• They can reach the size of an egg/small orange.

• Fever, chills, extreme pain, malaise.

• Because of the large size of the lesion and its delayed drainage the patient is much sicker

HA(MSN) 87

HA(MSN) 88

Cont…Diagnosis

• Gramstain of the pus

• Culture of pus/blood

• Leucocytosis (12,000-20,000 mm3) normal 4,000-10,000mm3

Treatment

• The same as furuncle, plus

• Avoid friction and irritation from tight clothing.

HA(MSN) 89

4. Folliculitis

• Is inflammation of the hair follicle

Sign and symptom– Single or multiple papules or pustules

– Commonly seen in the beard area of men and women’s legs from shaving

Management

• Warm compress to relieve pain

• Clean with antibacterial soap

• Topical antibiotic ointment

• Systemic antibiotics for recurrent casesHA(MSN) 90

HA(MSN) 91

5. Impetigo• Is an acute, contagious, rapidly spreading

cutaneous infection and is a very common bacterial infection of the superficial skin

• Causative agents are stap. aureus or a B-hemolyticstreptococcus or both

Sign and Symptom• Superficial pustules or blisters which becomes

oozing with yellow crusts • Contagious • Blisters break easily and form golden crusts

Diagnosis-Clinical- Culture and sensitivity

HA(MSN) 92

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Management

• KMNO4 bath or wet dressing-in mild forms • Prevent spreading by not sharing towels and

ointment, change clothes, towels and sheets frequently.

• In sever forms give cloxacillin 250-500mg QID daily for 7-10 days in adults, and 50-100mg/kg/24 hours divided in to 4 doses for children.

• Erythromycin 250-500mg 4 times daily for 7-10 days in adults, and 25-50mg/kg/24hrs divided in to 4 doses for children

• Cut finger nails short to minimize damage to lesion and to prevent autoinoculation from scratching

HA(MSN) 95

Fungal skin disorder1. Dermatophytoses (Mycoses)

• Is a fungal infection of the skin, hair and nails

Types

a. Tinea pedis (Athlete’s foot)

• Is itchy, whitish scaling lesions and inflammation of the superficial skin of the feet and interdigitalspaces of the toes

• Common between the 4th and 5th toe.

• Often seen in people wearing rubber boots/shoes

HA(MSN) 96

HA(MSN) 97

Cont..Management

• Keep the space in between the toes dry

• wear cotton socks

• Avoid shoe that are too tight/hot

• changing socks daily prevents reinfection.

• Imidazole cream/ whitfield’s ointment twice daily until symptoms disappear for a total of 4 weeks

• Treat secondary bacterial infection if present

HA(MSN) 98

b. Tinea corporis (Tinea circinata)

• A fungal infection that affects the trunk, legs, arms/neck, excluding the beard area, feet, hands and groin

– Is fungal infection of the skin most common on the exposed surfaces of the body.

– Sites are face, arms and shoulders.

– Intensive itching is there

• Frequent causes of tinea corporis is the prescence of an infected pet in the home

HA(MSN) 99

Cont..Management

• Imidazole cream/whitfield’s ointment twice daily for aminimum of 4 weeks

• Multiple, widespread lesions may be treated systematically

• Griseofulvin 500mg once daily for 2-6wks (10-15mg/kg)

• Ketaconazole 200mg once/twice daily

• When there is sever itching antihistamines /mild steroids can be added

HA(MSN) 100

HA(MSN) 101

c. Tinea capitis (ring worm)

• Is a contagious fungal disease of the scalp and hair shaft

Sign and symptom

• One or more round patches with scaling

• Hair loss (temporarly), alopecia

• Lymphnodes in the neck swell and the patient may have fever and headache

Diagnosis– Clinical

– Microscopy of affected hairs and skin(KOH)

HA(MSN) 102

HA(MSN) 103

Cont..Management

• Greseofulvin 500mg once daily for 8-12 weeks. (10-15mg/kg for children)

• Add whitfield’s ointment/miconazole twice daily topically for 4 weeks

• In case of bacterial super infection antiseptics and /antibiotics are needed

HA(MSN) 104

d. Tinea unguium- Is a chronic fungal and some times mixed

yeast infection of the toe/finger nails

• Is commonly occurs in people who frequently wet the hands such as domestic workers, cleaners, kitchen and laundary staff

Sign and Symptom

• Nail become thickened, friable (easily crumbled), lusterless

• Accumulation of debris under the free edge of the nail

• The nail may be destroyed

HA(MSN) 105

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Cont..Management

• Griseofulvin 500gm once daily until the affected nails have grown out completely (year/longer) even though it recurres.

• If there is no improvement by griseofulvin in 2-4 monthsmixed yeast infection

- use ketaconazole 200mg/d until symptoms clear. (Itraconazole 200mg/d x 3 months, or Itraconazole 200mg bid x 1week per month during 3 months)

• Keep the site dry HA(MSN) 107

e. Tinea versicolor (pityriasisversicolor)

• Is a common chronic superficial fungal infection which is caused by the unicellular yeast pityrosporum ovale or orbiculare which is normally present on the trunk as a commensal.

• Often there is cosmetic complaints

HA(MSN) 108

HA(MSN) 109

Cont..Sign and Symptom

• Appears commonly when there is warm and humid air, pregnancy, and serious underlying disease

• Hypopigmented macule on the trunk

• Disturbance of the pigment of the skin (versicolor)

• Recurrences are common especially after in adequate treatment or re-infection.

Diagnose

– Clinical

– Microscopy

HA(MSN) 110

Cont…Management

• Scrubbing the skin with a brush takes away a lot of the infected scales.

• Imidazole cream twice daily on affected areas for 4 weeks.

• Add selenium sulphide suspension /ketaconazole2% shampoo twice weekly.

• Selsun shampoo to affected areas overnights as a lotion or to affected areas and the scalp for 10 minutes daily for 2-4 weeks.

HA(MSN) 111

f. Tinea cruris (Jack itch)• A fungal infection of the groin, pubic region and thighs

Sign and symptom• Scaling at the periphery• A patch that may spread to buttocks• Starts from groin and advancing down to inner thigh• Itching and irritation

Diagnosis• Clinical,KOH

Management• Treat with topical antifungal or systemic antifungal for

sever cases• Reduction of moisture in groin• Wash contaminated under wear in hot water

HA(MSN) 112

g. Tinea barbae

• Is a fungal infection involving the beard

• Affects males only

• More common in farmers

Sign and symptom

• Pruritis

• Tenderness and pain

• Pustular folliculitis around the hair follicle

• Involved hairs are loose and easily removed

Management:Systemic antifungalHA(MSN) 113

HA(MSN) 114

h. Candidiasis /moniliasis/

• Candida albicans is a resident of the mucus membranes, it becomes pathogenic under favourable host condition these are:

– When host immunity is decreased, such as HIV, cancer, steroid use, cytotoxic drugs, radiotherapy, chronic disease, pregnancy and contraceptive pill use

– Warm and moisture (groins, under breasts, b/n toes)

– Use of broad spectrum antibiotics which kills resident non pathogenic bacteria

HA(MSN) 115

HA(MSN) 116

Sign and Symptom

• On the oral (oral candidiasis/thrush)- white cheesy adherent plaque that can be painful

• When oral lesions extend to the throat and esophagus they can cause anorexia, nausea, dysphagia, and vomiting

• On the vulvovagina (candidia vulvovaginitis)-vaginal irritation, soreness and a thick creamy discharge

HA(MSN) 117

Management • Keep lesions of the skin dry • Paint mucosal /smaller wet lesions with

Gentian violet daily • Nystatin cream, oral suspension twice daily for

skin/ oral / miconazol oral gel 4 x /d x 1week• Imidazole pessaries nightly for 2 weeks for

vaginal candldiasis• Imidazole cream twice daily for skin infections• Ketaconazole 200mg twice daily for 1-2weeks

for oesophageal candidiasis• Itraconazole 100mg/d x 2weeks • Fluconazole 50-200mg /d x 1-2weeks

HA(MSN) 118

Parasitic skin disordera. Scabies• Is an infection of the skin caused by a parasite

called mite sarcoptes scabiei, a mite which lays its eggs in burrow in the stratum and induces an intensively itchy allergic response

Sign and Symptom• Small blisters and papules • Sever itching, when warm particularly at night• Scratch marks and very common secondary

infection with pustules• Common sites are between fingers, sides of the

hands, sides of the wrists, buttocks

HA(MSN) 119

HA(MSN) 120

Cont…Management

• Treat all close contacts of the patient and family

• Benzyl benzoate 25% emulsion for adult, dilute with one part water (1:1) for children, dilute with 3 parts water (1:3) for infants. Apply for 3 consecutive nights. Wash off each morning.

• Sulphur 5-20% ointment twice daily for 1-2 Weeks

HA(MSN) 121

b. Pediculosis• Is an infestation with a louse which may be found

in the:

• Scalp- Pediculosis capitis

• Body- Pediculosis corporis

• Hair bearing region- Pediculosis pubis (phthiriasis)

Sign and symptom

• Itching (excoriation)

• The presence of lice and nits

• Over crowding, poor personal hygiene, prolonged wearing of the same cloth

HA(MSN) 122

HA(MSN) 123

Cont..Management

• Improve personal hygiene

• Improve living condition

• Change clothing

• Treat secondary bacterial infection if present

HA(MSN) 124

F. Viral skin disorder

• It is an acute contagious short lived (7-12 days) infection of the skin or mucus membrane caused by virus

Types:

a. Herpes simplex

• Is an infection which is caused by herpes simplex virus that causes vesicular eruption (cold sore or fever blister) on lip (herpes labialis), and on genitalia (herpes genitalia)

HA(MSN) 125

Cold sores

HA(MSN) 126

HA(MSN) 127

Cont….Sign and Symptom

- Few days of burning sensation at the site initially and tingling sensation

- Then a group of blisters appear which quickly break down to form superficial ulcer

- Highly contagious when the lesions are visible

Diagnose

• Clinical

• smearHA(MSN) 128

Cont…Management

• Primary infection-since they are painful: Analgesia

• Lips: Zinc oxide ointment to soothe and protect from sun light

• Zinc oxide ointment plus castor oil

• Antiseptic mouth wash: Chlorhexidine 3-4 times daily

HA(MSN) 129

Cont….• TTC skin ointment 3 times daily for secondary

bacterial infection

• Genital: KmNo4 (Betadine) sitz bath 3 times a day

• TTC ointment application 3 times a day

• Zinc oxide and castor oil to soothe

• For severe infections or infections in immunocompromised patients Acyclovir 200-400 mg five times daily for 5-10 days either topically or systematically

• Recurrence can be triggered by:

- Exposure to sun light (herpes labialis)

-Oral sex, fever, stress, etcHA(MSN) 130

b. Herpes zoster (shingles)• Is an acute unilateral and segmental

inflammation of the dorsal root ganglia of a nerve by a latent varicella zoster infection in the partially immune host.

Sign and symptom

• A localized vesicles in cluster form on one side of the body/unilateral/

• Itching, tenderness and severe pain on the site

**The thoracic, cervical and ophthalmic nerves are frequently affected

HA(MSN) 131

b. Herpes zoster…

• After 1-2 weeks crusts begin to fall off with residual scaring

• Over 10% of patients develop a persistent burning sensation

• Much more common in HIV patients, old patients, and malignancy cases

HA(MSN) 132

HA(MSN) 133

Management

• Analgesia with NSAIDs

• Antibiotics for secondary infections

• If the eye is involved immediately refer to ophthalmologist

• For immunocompromised patients Acyclovir 800mg 5 times daily for 1 week

• Amitryptline 75mg at night

• Night/Carbamazepine 600-800mg/day

HA(MSN) 134

c. Verrucae /Warts/• Are common benign skin tumors caused by infection

with the Human Papilloma Virus.

Types:

1. Plantar warts- warts on the sole of the foot

2. Plane (flat/Juvenile) warts- warts on the face of children

3. Genital warts/condylomata acuminate/- warts that appear on genital organs

4. Molluscum contagiosum- a wart which appear on small children which has typical characteristics of central dimple and dome shaped papules

HA(MSN) 135

HA(MSN) 136

Sublingeal warts

HA(MSN) 137

Sign and symptom• Found at any age but most common in children and

teenagers• They can spread by contact• The infected person immune system clears the warts

with in 2 years in 2/3 casesManagement

• Freeze with liquid nitrogen- Molluscum contagiosum• Salicylic acid 50% twice daily followed by scraping the

warts –Plantar warts• Salicylic acid 2-5% ointement twice daily for 4-8 weeks –

Plane warts• Silver nitrate pencil touch- daily - Plane warts• Podophyllin 10-25% solution apply weekly by using

match sticks and wash off after 4-6 hours- Genital warts• Threat partners - Genital warts

HA(MSN) 138

G. Skin cancer• Cancer is a disease of the cell in which the

normal mechanism of control of growth and proliferation are disturbed. The malignant cell is able to invade the surrounding tissue and regional lymph nodes.

• Metastasis is the secondary growth of the primary cancer in another organ.

• Skin assessment-20-39 age-every 3 years

• >40 age-annually

HA(MSN) 139

Plastic surgery (Cosmetic surgery)

• Are a type of reconstructive surgery performed to reconstruct or to alter congenital or acquired defects or to restore or improve the body’s appearance

HA(MSN) 140

Purpose of plastic surgery

– To repair defect (reconstruction)

– To restore function (restoration)

– To replace lost part

– For better appearance

– To install prosthetic implants

– For complete change of identity

HA(MSN) 141

Possible complications of plastic surgery

• Pigment change- chemical peeling

• Infection-surgery

• Milia- chemical peeling

• Scarring- surgery

• Atrophy- surgery

• Sensitivity change- chemical peeling

• Long term (4 to 5 months) erythema or pruritis-chemical peeling

• Hematoma- surgery

HA(MSN) 142

Skin graft

• Is the technique in which a section of skin is detached from its own blood supply from the donor site and transferred as free tissue to a distant (recipient)

Purpose

• To enhance wound healing

• To repair defects

• To cover wounds in which insufficient skin is available

• To improve appearance

HA(MSN) 143

Sources of skin graft can be:

• Autograft- use of tissue from self

• Allograft- use of tissue from the same species

• Xenograft- use of tissue from different species

• Isograft- use of tissue from genetically identical persons

• Engineered- graft sources from combined biological and synthetic materials

• Synthetic graft- substance from non-biological source

HA(MSN) 144

BURN

HA(MSN) 145

HA(MSN) 146

Pathophysiology of burn

• Tissue destruction results from:- coagulation- protein denaturation, or -ionization of cellular contents.

• Disruption of the skin can lead to:- increased fluid loss, -infection, hypothermia, scarring, -compromised immunity, and

-changes in function, appearance, and body image.• The depth of the injury depends on:

- the temperature of the burning agent and -the duration of contact with the agent.

HA(MSN) 147

Assessment of burn injury depends on:

1. cause and temperature of the burning agent.

2. location

3. duration of contact with the agent

HA(MSN) 148

Classification of burn

• Burn injuries are described according to:

- the depth of the injury,

-extent of body surface area injured,

-location and age..

A. By depth

1. First degree burn (superficial burn)

• epidermis is involved

• Redness and pain on the area

• Healing takes place rapidly within a week.HA(MSN) 149

HA(MSN) 150

CONT…2. Second degree burn (partial thickness burn)

• epidermis and part of the dermis

• Blister formation, pain, moist, mottled appearance of skin, and swelling.

• Hair follicles and sebaceous glands may be partly destroyed.

• Superimposed infection can interfere with healing

• Small burns (1-2% BSA) of this type can be treated through self care

HA(MSN) 151

HA(MSN) 152

Deep partial thickness

HA(MSN) 153

HA(MSN) 154

Cont’d..• infection by gram +ve bacteria

(staphylococcus, streptococcus) occurs during the first day.

• After the third day, gram –ve bacteria (mainly pseudomonas) predominate and can convert a second degree burn to third degree.

• Topical therapy with silver sulfadiazines, silver nitrate or antibiotics is essential

HA(MSN) 155

3. Third degree burn (full thickness burn)

• The skin, with all of its epithelial structures, hair follicle, sebaceous gland and subcutaneous tissue destroyed.

• Dry, pale white, leathery, or charred, broken skin with fat exposed is seen.

• Symptoms of shock and haematuria can be present.

• Scarring and loss of function is inevitable.

• Needs skin graft for healing

HA(MSN) 156

HA(MSN) 157

HA(MSN) 158

Fourth degree burn (as char burn)

• May damage bones, tendons, muscles, blood vessels and peripheral nerves.

• Necrosis of muscles and bones can happen.

*The following factors are considered in determining the depth of burn:– How the injury occurred

– Causative agent

– Temperature of the burning agent

– Duration of contact with the agent

– Thickness of the skin

HA(MSN) 159

extravasations

HA(MSN) 160

RXs1. Superficial burn treatment

• Skin is intact so there is a low chance of infection.

• Topical “exudates” as physical protection can be used.

• Dressings or films that are self adhesive, water proof and semi-permeable.

• Skin protectants

• Cold compresses, external anesthetics, topical corticosteroids and oral pain relievers.

HA(MSN) 161

2. Superficial partial thickness burn

• Unbroken skin

Do not disturb blisters!!! They are protective of the skin below the blister.

• If broken/debrided: May become infected so cleanse 1-2x’s/day to remove dead skin. Do not pull on skin!

• Cleanse with bland soaps or surfactants and water 1-2xs/day

• First aid antiseptics or antibiotics sufficient

• Dressing and skin protectant should be used

HA(MSN) 162

B. By extent• TBSA

-Rule of nine,

- Lund and Browder method, and

- Palm method.

1. Estimate of body surface area using rule of nine

• It assigns percentages in multiples of nine to major body surfaces

• It is the most common, simple, and quick method

HA(MSN) 163

Adult Infant (child)

• Head 9% 18%

• Abdomen and Thorax

- Front 18% 18%

- Back 18% 18%

• Genitalia 1% -

• Hands

- Right 9% 9%

- Left 9% 9%

• Leg

-Right 18% 14%

-Left 18% 14%

Total 100% 100%

HA(MSN) 164

HA(MSN) 165

HA(MSN) 166

2. Estimate of body surface area using the Lund and Browder method

• Is the more precise method of estimating the extent of burn, because it recognizes the various anatomic parts, especially the head and legs

• Head----------------------- 7%

• Neck----------------------- 2%

• Anterior trunk---------- 13%

• Posterior trunk--------- 13%

• Right buttock------------ 2 ½ %

• Left buttock-------------- 2 ½ %HA(MSN) 167

• Genitalia------------------ 1%• Right upper arm--------- 4%• Left upper arm----------- 4%• Right lower arm---------- 3%• Left lower arm------------ 3%• Right hand----------------- 2 ½ %• Left hand------------------- 2 ½%• Right thigh---------------- 9 ½%• Left thigh------------------ 9 ½%• Right leg------------------- 7%• Left leg--------------------- 7%• Right foot----------------- 3 ½%• Left foot------------------- 3 ½%

100%

HA(MSN)

168

3. Palm method

• Used in patients with scattered burns

• The size of the patient’s palm is approximately 1% of TBSA

• In general an adult who suffered burns of 25% and an infant (child) of 15% wherever the location requires Hospitalization

HA(MSN) 169

C. By location• Burns of the

-face,

-neck and

-circumferential burns of the chest may inhibit respiration

• Burns of the hands, feet, joints, and eyes are of concern because they make self care impossible and jeopardize later function

• Hands and feet are difficult to manage medically because of superficial vascular and nerve supply systems

HA(MSN) 170

Cont…• The ears and nose, composed mainly of

cartilage, are susceptible to infection because of poor blood supply to the cartilage

• Burns of the buttock or genitalia are susceptible to infection

• circumferential burns of the extremities can cause circulatory compromise distal to the burn with subsequent neurologic impairment of the affected extremity

HA(MSN) 171

D. By age

• an infant is less able to cope with burn injuries

because of:

- an immature immune system and

- generally poor host defense mechanisms,

• The older adult heals more slowly and has more difficulty with rehabilitation than a child or younger adult

• Infection of the burn wound and pneumonia are common complications in the older patient

HA(MSN) 172

Fluid type and fluid replacement formulas for burn patients

Fluids can be:• Colloids are whole blood, plasma, plasma

expanders, and dextran, etc• Crystalloid (Electrolytes) are sodium chloride,

ringers lactate, etcFluid replacement formulas are:• Consensus formula• Evans formula• Brooke Army formula• Parkland/Baxter formula

HA(MSN) 173

1. Consensus formula (In the first 24 hours)- the most commonly used method

2-4ml X kg X % TBSA burned for 24 hours

• E.g.: Ato Chane, 38 years old factory worker, 60kg body weight, sustained a burn injury with a 30% body surface burn came to surgical emergency OPD where you are working.

• How are you going to calculate the fluid to be replaced for Ato Chane? – Using the Consensus formula

– 2ml X 60kg X 30%=3600ml/24 hours

HA(MSN) 174

Plan of fluid administration

• Half of the calculated fluid in the above case 1800ml should be given over the first 8 hours and the remaining half that is 1800ml over the next 16 hours.

For example

• Our casualty has a burn to his legs approximating 18% of body surface: 18

• He weighs approximately 100 Kilograms: 100

• Therefore 100 x 4 = 400, 400 x 18 = 7200

• 7200 CCs of fluid are needed.

HA(MSN) 175

cont’d

• Standard IV drip sets for Prehospital cases are usually called Macrodrip sets...they deliver

1ml Q 10 drop, 1ML= 1CC• In order to deliver 3600 CCs of fluid in eight

hours we would set the drip rate at 75 drops per minute, or 7.5 CCs per minute.

• 7.5 CCs x 480 minutes (8 hours) = 3600 CCs or 3.6 Litres (1000 CCs per Litre)

HA(MSN) 176

2. Evans formula

• Colloids-

1ml X Kg X % TBSA burned

• Electrolyte(normal saline)-

1ml X Kg X % TBSA burned

Plan of fluid administration

• Day 1: Half to be given in first 8 hours; remaining half over the next 16 hours

• Day 2: Half of previous day’s colloids and electrolytes

HA(MSN) 177

3. Brooke Army formula

• Colloids

0.5 ml X Kg X % TBSA burned

• Electrolyte(Ringer’s lactate)-

1.5 ml X Kg X % TBSA burned

Plan of fluid administration

• Day 1: Half to be given in first 8 hours; remaining half over the next 16 hours

• Day 2: Half of colloids; half of electrolytes

HA(MSN) 178

4. Porkland/Baxter formula

• Ringer’s lactate-

4 ml X Kg X % TBSA burned

Plan of fluid administration

• Day 1: Half to be given in first 8 hours; remaining half over the next 16 hours

• Day 2: Varies. Colloid is added

HA(MSN) 179

Systemic effects of burn• Metabolic - client is in a hypermetabolic stage

• Endocrine– increased catecholamines, ADH, aldosterone, and

cortisol increase metabolism

– O2 and calorie needs are increased

– the body is under stress response catabolism increases

calorie requirements may be double or triple the usual amount needed

HA(MSN) 180

RespiratoryMajor cause of morbidity/ mortality– inhalation injury r/t contact to steam, toxic

fumes, or smoke– may be r/t treatmentlarge amount of fluid

volume infused may cause edema– increase in alveolar capillary permeability– constriction of chest r/t circumferential burn– injury can occur from edema from irritants

which cause edema and blockage of trachea

HA(MSN) 181

Respiratory…

– decreased movement of the normal cilia in the trachea may allow foreign bacteria and particles to enter into the lungs

– lining of the trachea may slough off and become lodged in the bronchus

– damage to the alveoli and the capillary membrane may lead to infection and respiratory failure

HA(MSN) 182

Cardiac• cardiac output is the most effected by the

loss of fluid• early the rate increases to compensate

for the loss of volume• cardiac output remains decreased in spite

of the increase rate– may be decreased for 36 hrs– when fluid is replaced goes back to normal

function

HA(MSN) 183

GASTROINTESTIONAL- Effects occur due to the shift of blood volume

to vital organs- Epinephrine and NE inhibit gastric motility

and decrease blood flow to the GI tract- Decreased periostalis occurs- H+ ion production increases- Develop ulcers (Curling’s ulcer within 24

hours) - Use H2 blockers

HA(MSN) 184

Immune response

• Widespread impairment of the immune system

• Skin is barrier to invading organisms

• Changes in the WBC’s occur,

• Susceptibility to infection increases

HA(MSN) 185

Renal response• Blood flow to the kidneys is decreased and

renal ischemia occurs• Unless flow is improved renal failure occurs• With full thickness electrical burns myoglobin

and hemoglobin are released in the blood and can occlude the renal tublesWith adequate diuretics and fluid the

problem can be corrected

HA(MSN) 186

• Renal function may be altered as a result of decreased blood volume.

– Destruction of RBC at the injury site results in free haemoglobin in the urine.

– If muscle damage occurs, myoglobin is released from the muscle cells and excreted by the kidney.

– If there is in adequate blood flow through the kidneys, the hemoglobin and myoglobinocclude the renal tubules resulting in acute tubular necrosis and renal failure.

HA(MSN) 187

Etiologies of burn• Many causes cause affects the outcome

Dry heat-open flame house fire and explosionsŸ

Moist heat=scald older adults most common=spills and splatters

Contact burns hot metal/tar/grease (industrial, home and restaurants)usually deep because liquid is extremely hot

Chemical injury-occurs in home and industry (drain cleaner, acids used in industry or chemicals in industry )**Severity depends on the length of contact and amount of tissue exposed

HA(MSN) 188

Management of the patient with a burn injury

• Burn care must be planned according to the burn depth, local response, the extent of the injury, and the presence of a systematic response.

• Burn care then proceeds through 3 phases

HA(MSN) 189

Emergent/ resuscitative phase• Duration is from onset of injury to completion

of fluid resuscitation.

• The priorities are ABC of first aid

– Prevention of shock

– Prevention of respiratory distress

– Detection and treatment of concomitant injuries

– Wound assessment and initial care

HA(MSN) 190

Emergent/ resuscitative phase…

• The goal of fluid replacement therapy should be out put totals of 30 to 50ml/ hour, in addition systolic blood pressure exceeding 100 mmHg and pulse rate less than 110/minute.

• Oral resuscitation can be successful in adults with less than 20% TBSA and children with less than 10% to 15 % TBSA

HA(MSN) 191

2. Acute/ intermediate phase

• Duration is from the beginning of diuresis to near completion of wound closure.

• The priorities are- wound care and closure

–Prevention and treatment of complications, including infection.

–Nutritional support

HA(MSN) 192

3. Rehabilitation phase

»Duration is from major wound closure to return to individual’s optimal level of physical and psychosocial adjustment.

»The priorities are- Prevention of scars and contractures.

• Physical, occupational and vocational rehabilitation

• Functional and cosmetic reconstruction .

• Psycho-social counseling

HA(MSN) 193

Nursing management by using the

nursing process

1. Assessment

• Vital signs- especially respiration rate and pulse

• Respiratory functions

• Monitor fluid intake and out put

• Urine out put hourly

• Maximum requirements of fluid replacement

• Body weight

• History of allergy

HA(MSN) 194

• Tetanus immunization

• Past medical and surgical problems

• Current illness and use of medication

• Patient with facial burns- eye examination

• Depth of the wound

• Time of injury

• Burn occurrence in closed space

• Related trauma

• Level of consciousness

• Excessive fluid volume loss

HA(MSN) 195

2. Nursing diagnosis

3. Outcome identification

4. Planning

5. Implementation

6. Evaluation

Complication of Burn/Most severe ones are:

• Air way obstruction

• Hypovolemic shock

• Secondary infection

• Contracture

HA(MSN) 196

Wound I. Based on cleanness

• Clean wound- has a discharge that may be fresh blood/ serum.

• Septic wound- has discharge like pus, exudates, and dead tissues.

II. Based on opening

• 1. Closed wound- involves injury to the underlying tissues with out a break to the skin or mucus membrane

• 2. Open wound- is a break in the skin or mucus membrane

HA(MSN) 197

Cont’dIII. Based on tissue damage

1. Abrasion/Graze/wound– The outer layer/superficial layer of the protective skin is

scrapped off2. Incised wound/cut/

– When body tissue is cut by a sharp edged material3. Lacerated wound• It is an irregular tearing of soft tissue4. Puncture/stab/wound5. Avulsion wound6. Contusion wound/bruise/ wound• A closed wound that results in tissue damage and ruptured blood

vessels• If internal organs are contused serious effect may result

HA(MSN) 198

Types of wound healing1. Primary intention• The wound is clean and no tissue loss• The wound closes rapidly because there are no gaps in the tissue• Edges can be approximated with suture/staples (clip)/ wound closure

strips• Risk of infection is low• Fine scar will remain• E.g.: surgical incision

2. Secondary intention• Loss of tissue• Irregular edge, large wound with blood clot• Edge can not be approximated• Greater risk of infection• Longer healing time• Granulation tissue fills in wound• Visible scar formation• E.g.: wounds from trauma, ulceration and infection

HA(MSN) 199

Cont’d…

3. Tertiary intention

• Large area of tissue loss

• Contaminated wound

• Delayed closure even with suture that breaks down and re-sutured latter

• Results in deeper and wider scar

• E.g.: primary wound which was infected

HA(MSN) 200

Phases of wound healingInflammatory phase

• Occurs immediately after an injury and lasts 4-6 days

• Small blood vessels become more permeable

• Presence of edema

• Pain and tenderness occurs

• Phagocytosis occurs

• The client shows elevated temperature, leukocytosis and generalized malaise

HA(MSN) 201

2. Proliferative or granulation phase

– Begins between 1 and 4 days after the injury and ends 14-21 days later

– Rapid growth of epithelial cells

– Rebuilding of vascular capillary network and collagen tissue

– Collagen fibers fill in the gap and form the scar

– Wound scar tissue is very fragile and susceptible to re-injury

– The color is red because of increased blood flow

HA(MSN) 202

cont’d…

3. Maturation or wound remodeling phase

• Wound contraction begins between 14-21 days, after the injury and lasts up to 2 years

• Scar shrinks and become flat

• Less red as the capillary regress

HA(MSN) 203

Factors that delay wound healing Age

• Nutrition- adequate nutrition that includes essential amino acids, vitamin A, C, and zinc is essential for normal wound repairs

• Infection-• Hormonal influences- the therapeutic administration of adrenal

corticosteroids can make:• Impairs phagocytosis• Inhibit fibroblast proliferation and function• Depresses the formation of granulation tissue• Inhibit wound contraction• Mask presence of infection by impairing normal inflammatory

response• Blood supply-• Poor blood flow may occur as result of swelling, arterial and

venous pathology

HA(MSN) 204

• Wound separation

• Presence of foreign bodies-

• Smoking- vasoconstriction caused by smoking, decreases blood supply to the wound, the carbon in smoke binds with hemoglobin and further diminishes oxygenation

• Obesity- the bulk and weight of adipose tissue causes poor vascularity

• Fluid and electrolyte balance-

• Immuno-suppression-

• Radiation therapy- the blood supply in irradiated tissue is decreased

HA(MSN) 205

• Handling of tissue- rough handling causes injury and delayed healing

• Edema- reduces blood supply by exerting pressure on blood vessels

• Medications

-Anti-inflammatory- decrease epithelization and wound contraction

-Corticosteroids- may mask presence of infection by impairing normal inflammatory response

-Anticoagulants- may cause hemorrhage

• Patient over activity- prevents approximation of wound edges

HA(MSN) 206

Cont’d• Wound stressors- like vomiting, coughing heavily,

and straining produces tension on wounds and destroys granulation tissue that prevents apposition of wound edges

• Poor general health- alters cellular function

• Duration of surgical procedure- the longer the time the higher the delay of wound healing

• Drainage accumulation- accumulation of drainages favors bacterial growth

• Bleeding (hemorrhage)- bleeding sites becomes a growth media for microorganisms

HA(MSN) 207

Complications of wound healing • Hypertrophic scar and keloids- due to excess

production of collagen tissue

• Contracture- shortening of muscle or scar tissue

• Delviscence

• Separation and disruption of previously joined wound edge

• It can be due to infection, inflammation, weak granulation tissue.

• Evisceration- excess growth of tissue protrudes above the surface of the healing wound.

• Adhesions- binding two surfaces or structures that normally are separate

HA(MSN) 208

Cont’d…• Major organ dysfunction-

• Herination- the surface layer remains intact but the deep layers separate permitting the underlying muscles/organs bulge

• Fistula- draining tunnel may form between two organs

• Sinus tract- an abscess may form in deeper tissues and form a tunnel to the out side of the body

• Hematoma- collections of blood or serum in wound (seroma)

• Infection-

• Hemorrhage-

HA(MSN) 209

• Thanks but still to go!!!!!!

HA(MSN) 210