Management of Clients with Integumentary Problems

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Management of Clients with Integumentary Problems
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Brief Review of Integumentary System

• Comprised of skin, hair and nails
• First line of defense
• Barrier between internal and external environment
• Largest organ of the body

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Brief Review of Integumentary System

• Physiologic Functions
• Protection
• Water balance
• Temperature regulation
• Sensory organ
• Vitamin synthesis
• Immune Response Function
• Psychologic Function
• Psychosocial

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Aging

• Identify physiologic skin changes associated with
  aging.
• What are the implications for care related to the
  associated changes?

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Integumentary Assessment History

• An accurate history is needed before physical
  examination
• Demographic data
• Personal and family history
• Medication history
• Diet history
• Socioeconomic background
• Current health problems

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Integumentary Assessment Exam

• Inspection
• Observe all areas
• Systematic assessment
• obvious changes in color or vascularity
• Presence of absence of moisture
• Edema
• Skin lesions
• Skin integrity
• Palpation

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Integumentary AssessmentPsychosocial

• Psychosocial
• Assess for altered perceptions in body image or
  disturbances in self concept
• Assess for social isolation

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Integumentary AssessmentDiagnostic Evaluation

• Skin Biopsy
• Immunofluorescence
• Patch testing
• Skin scrapings
• Tzanck Smear
• Woods Light Examination
• Clinical photographs

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Skin Care for Patients with Skin Conditons

• What are the three main objectives of skin care
  in patients with skin conditions?
• How will these objectives be achieved?

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Wound Care for Skin Conditions

• Three types of wound dressings
• Passive
• Interactive
• Active
• Compare and contrast autolytic debridement and
  surgical debridement.

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Categories of Wound Dressings

• Occlusive
• Wet
• Moisture-retentive
• Hydrogels
• Hydrocolloids
• Foam dressings
• Calcium alginates

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Wound Treatment Advances

• Cytokines
• Bioengineered skin substitutes
• Oral medications
• Under investigation

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Medical Therapy

• Therapeutic baths
• Pharmacologic therapy
• Lotions, powders, creams, gels, pastes,
  ointments, sprays and aerosols, corticosteroids,
  intralesional therapy, and systemic medications

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Pruritis

• Itching caused by stimulation of itch-specific
  nerve fibers at the dermal-epidermal junction
• Scratching brings relief, but causes the
  itch-scratch cycle
• Associated with local (skin lesions) or systemic
  (liver, venous) disorders
• Care goal promote comfort and prevent
  alterations in skin integrity
• Therapeutic baths
• Antihistamines /or topical steroids

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Urticaria

• White or red edematous papules or plaques of
  varying sizes
• Usually caused by exposure to a specific noxious
  stimulus which causes release of histamines
• Exact cause not always identified, possible
  factors
• Drug -- Foods -- Infections --
  Autoimmune disease
• Malignancies -- Physical stimuli --
  Psychogenic reactions
• Treatment aimed at removal of potential stimulus
  and relief of symptoms
• Antihistamines
• Avoidance of overexertion, alcohol consumption,
  and warm environments

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Skin Infections Assessment

• History clinical manifestations provide
  direction for data collection
• Physical exam many skin lesions are contagious,
  precautions to prevent spread must be taken
• Lab swab culture, blood culture, viral culture

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Skin Infections

• Bacterial Infections
• Usually start at the hair follicle
• Folliculitis superficial infection of upper
  portion of follicle caused by staph
• Furuncles infection caused by staph is deeper in
  hair follicle (boil)
• Cellulitis is a generalized non-follicular
  infection of the deeper tissues caused by either
  staph or strep
• Can spread infection to other parts by scratching

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Viral Skin Infections

• Herpes Simplex
• Type I cold sore
• Type II genital lesions
• After primary infection virus remains dormant in
  the nerve ganglia
• Physical or psychological stressors can
  reactivate the infection
• Time between episodes and the severity of
  individual attacks will vary

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Viral Skin Infections

• Herpes Zoster
• Reactivation of latent varicella zoster virus
• Resides in dorsal root ganglia of the sensory
  cranial and spinal nerves
• Multiple lesions, segmentally distributed on skin
  area innervated by infected nerve
• Discomfort is experienced before eruptions and
  can persist after lesions are healed
  (postherpetic neuralgia)
• Herpes Zoster is contagious to those who have
  never had chickenpox

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Fungal Skin Infections

• Dermatophytoses (superficial)
• Term tinea plus the term for the location is used
  to describe
• Infection occurs when infecting organism come in
  contact with impaired skin surface of a
  susceptible host
• Most infections spread by direct contact
• Tinea capitus and tinea corporus can be spread by
  inanimate objects

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Skin Infections Interventions

• Non-surgical
• Meticulous skin care
• Antibacterial soaps or baths
• Astringent compresses
• Isolation precautions
• Minimize spread of microorganisms
• handwashing
• Drug therapy
• Topical medications (antibacterial, antifungal)
• Acyclovir for viral infections (topical or oral)
• Surgical Management
• Not indicated except for ID of furuncles or when
  lesion progresses to full-thickness in
  immunocompromised person

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Fungal Skin Infections

• What is the most common fungal infection?
• What body areas are most often affected?
• What is the mainstay of medical management?
• Discuss key aspects of nursing management.

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Parasitic Disorders

• Pediculosis
• Lice infestation
• Transmitted by contact or sharing of combs, hats,
  etc.
• Pruritis- most prominent symptom
• Can result in secondary infection
• Lindane
• Wash clothing and linens
• Environment clean-up

• Scabies
• Contagious mite infestation which causes a
  hypersensitivity reaction
• Transmitted by close and prolonged contact
• Epidermal ridges skin between fingers, palms and
  volmar aspect of wrists
• Confirmed by skin scraping
• Lindane/topical sulfur
• Launder clothes and bed linens

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Contact Dermatitis

• What is it?
• Describe lesion progression.
• What are common causes?
• What are predisposing factors?
• Identify complications of repeated outbreaks.
• Describe medical management.
• What are key aspects of nursing care?

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Non-Infectious Inflammatory Dermatoses

• Psoriasis
• Chronic
• Hereditary defect
• Exfoliative Dermatitis
• Serious condition
• Profound loss of stratum corneum
• Considerable water and protein loss from skin

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Blistering Diseases

• Identify origins or skin blisters.
• Severity
• Diagnosis
• Based upon histologic examination of biopsy
  specimen
• Acantholysis
• Immunofluorescent studies may identify
  circulating antibiodies

• Disorders
• Pemphigus
• Bullous Pemphigoid
• Dermatitis Herpetiformis
• Toxic Epidermal Necrolysis
• Stevens-Johnson Syndrome

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Toxic Epidermal Necrolysis and Stevens-Johnson
Syndrome

• Potentially fatal skin disorders
• Mucocutaneous reactions
• Triggered by reaction to medications
• Clinical manifestations
• Initially conjunctival burning or itching,
  cutaneous tenderness, fever, cough, sorethroat,
  headache, malaise, myalgia
• Followed by rapid onset of erythema, flaccid
  bullae and shedding of sheets of epidermis

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TEN and SJS Care

• What normal body functions are altered?
• What complications would you anticipate?
• What is the mainstay of care?
• The care of TEN or SJS will be similar to what
  other condition?

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Skin Tumors (Benign)

• Cysts
• Seborrheic and actinic keratoses
• Keloids
• Nevi (Moles)
• Verrucae (Warts)
• Angiomas
• Dermatofibroma
• Neurofibromatosis (Von Recklinghausess Disease)

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Skin Cancers

• Actinic/solar keratosis
• Premalignant
• May progress to squamous cell
• Squamous cell
• Cancer of epidermis
• Potentially metastatic
• Basal cell
• Metastasis is rare
• Underlying tissue destruction
• Melanoma
• Originate in melanin-producing cells of epidermis
• Highly metastatic

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Mole Assessment

• A
• B
• C
• D
• What should be done if patient experiences one or
  more of the above?

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Skin Cancers Interventions

• Non-surgical management
• Drug therapy
• Topical chemotherapy
• Systemic chemotherapy
• Interferon after OR for melanoma
• Radiation therapy
• Limited to older clients with large, deeply
  invasive basal cell tumors or poor surgical risks
• Immunotherapy
• Experimental, melanoma vaccine

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Skin Cancer Interventions

• Surgical Management
• Cryosurgery
• Local application of liquid nitrogen
• Curettage/electrodesiccation
• For small lesions with well defined borders
• Excision
• For large of poorly defined skin cancers,
  recurrent tumors and deeply invasive cancers

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Post-Surgical Wound Coverage

• Skin grafts
• Flaps
• What are the key aspects of nursing care for
  these?