NURS 136: Skin Disorder Care Coordination

• Dyana Gallant, BSN, RN, CMSRN, presents a recorded lecture for NURS 136 on February 3, 2025, about coordinating care for patients with skin disorders, based on Hoffman Chapter 50, pages 1168-1189.

Objectives for the Lecture

• Discuss the epidemiology, pathophysiology, and clinical manifestations of common skin disorders such as bacterial infections, herpes simplex, fungal infections, and psoriasis.
• Describe diagnostic methods and results that confirm skin disorders.
• Explore collaborative management of bacterial infections, herpes simplex, fungal infections, and psoriasis involving multiple healthcare disciplines.
• Identify potential complications of skin disorders and prevention/management strategies.
• Develop comprehensive nursing care plans for skin disorder patients including pharmacological treatments, dietary modifications, and lifestyle interventions to promote optimal outcomes.

Functions of the Integumentary System

• Provides protection as a barrier from bacteria and viruses.
• Involved in insulation for temperature regulation.
• Facilitates sensory perception and movement.
• Important for Vitamin D metabolism.

Factors Influencing Skin

• Nutrition
• Hydration
• Age
• Hygiene
• Environment
• Mobility
• Lifestyle
• Medications

Skin Infections; Uncomplicated Infections vs Complicated Infections

• Uncomplicated infections lack systemic symptoms and present with localized signs, warmth, mild-moderate pain, and no changes in blood work.
• Complicated infections have systemic symptoms such as tachycardia, fever, lethargy, and disproportionate pain, as well as spreading cellulitis, edema, ischemia, tissue necrosis, moderate pain, and elevated WBC & CRP.

Bacterial Skin Infections: Epidemiology

• Bacterial skin infections can be acquired in the community or healthcare settings.
• Staphylococcus aureus and Streptococcus pyogenes are common causes of skin and soft tissue infections.
• Post-surgery, methicillin-resistant Staphylococcus aureus (MRSA) infections can affect up to 33% of patients.

Bacterial Skin Infections: Pathophysiology

• Non-necrotizing bacterial skin infections involve the entry through a breach in the skin integrity.
• Necrotizing bacterial skin infections spread rapidly and destroy tissue.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

• MRSA is resistant to many antibiotics.
• Factors such as overcrowded living conditions, skin-to-skin contact, sharing contaminated objects, previous MRSA infections, hospital professions, immunocompromise, and poor hygiene contribute to its spread
• MRSA can infect healthy/younger patients.

Impetigo

• Often caused by a combination of strep and staph.
• Typically affects the face.
• Presents with a honey-colored crust and surrounding redness.
• Treated with topical Rx antibiotics and is highly contagious.

Folliculitis

• Caused by staph.
• Tender to touch.
• Most common areas are the scalp, beard, and extremities.
• Advise patients to use soaps like Hibiclens or Dial.
• A topical antibiotic may be prescribed.
• Systemic antibiotics may be needed in extensive, deep lesions.

Cellulitis

• Caused by staph aureus or strep.
• Manifests as a hot, tender, red, and swollen area with diffuse borders.
• Can present with chills, malaise, and fever.
• Treated with systemic antibiotics and elevation.

Necrotizing Fasciitis

• Potentially life-threatening.
• Rapid spread.
• Fever, tachycardia, and hypotension can result.
• Pain is disproportionate.
• Can cause disorientation, edema, and loss of feeling due to vascular occlusion.
• Can result in sepsis.

Bacterial Skin Infections: Medical Management - Diagnosis

• Diagnosis involves laboratory data: culture and sensitivity tests, complete blood count (CBC), serum electrolytes, and C-reactive protein (CRP).
• Diagnosis may involve biopsies and a nasal swab.

Bacterial Skin Infections: Complications

• Complications can arise from the overuse and misuse of systemic antibiotics.
• Can result in necrotizing infection.

Bacterial Skin Infections: Nursing Management - Assessment and Analysis

• Clinical manifestations depend on the organism, tissues involved, and comorbidities.

Bacterial Skin Infections: Nursing Interventions - Assessments

• Monitor vital signs.
• Assess the wound and skin condition.
• Review complete blood count.
• Review culture results.
• Evaluate nutritional status.

Bacterial Skin Infections: Nursing Interventions - Actions

• Administer antibiotics based on culture results.
• Perform wound care.
• Surgical evaluation may be required.

Bacterial Skin Infections: Nursing Interventions - Teaching

• Educate on hand washing techniques.
• Instruct on wound care procedures.
• Describe the clinical manifestations of infection.

Bacterial Skin Infections: Nursing Management - Evaluating Care Outcomes

• Monitor recovery from infection.

Herpes Simplex Virus (HSV): Epidemiology

• 60-95% of adults have HSV-1.
• HSV-1 causes 71.2% of genital herpes cases.
• 16.2% of people aged 14-49 have HSV-2.

Herpes Simplex Virus (HSV): Pathophysiology

• Primary infection occurs through direct contact with an individual with HSV.
• Secondary infection occurs following an exogenous or endogenous trigger that reactivates the dormant virus.
• Examples of triggers: Ultraviolet (UV) light exposure, febrile illness, and stress.

Herpes Simplex Virus (HSV): Clinical Manifestations

• Fever
• Malaise
• Myalgia
• Anorexia
• Irritability
• Cervical or inguinal lymphadenopathy
• Lesions on lip, face, and mucous membranes.

Herpes Simplex Virus (HSV): Medical Management - Diagnosis

• Based on clinical presentation.
• Virological and serological type-specific glycoprotein testing can be done.

Herpes Simplex Virus (HSV): Medical Management - Treatment

• Systemic antiviral therapy.
• Episodic or suppressive therapy.

Herpes Simplex Virus (HSV): Complications

• Psychosocial stress can occur.
• Represents a risk factor for HIV acquisition.
• Disseminated neonatal herpes can be passed on during pregnancy.

Herpes Simplex Virus (HSV): Nursing Management - Assessment and Analysis

• HSV infection may be asymptomatic.

Herpes Simplex Virus (HSV): Nursing Interventions - Assessments

• Assess for pain and fever.
• Assess for oral cavity and genital lesions.
• Obtain a sexual history.
• Assess skin and mucous membranes.
• Assess knowledge of HSV transmission.
• Perform a test for pregnancy.
• Evaluate the ability to cope with the diagnosis.

Herpes Simplex Virus (HSV): Nursing Interventions - Actions

• Conduct laboratory testing.
• Administer medications as ordered.
• Collaborate with the interprofessional team.

Herpes Simplex Virus (HSV): Nursing Interventions - Teaching

• The actions of antiviral medications should be explained.
• Provide education on safe sex practices.
• Discuss considerations of HSV infection in pregnancy.

Herpes Simplex Virus (HSV): Nursing Management - Evaluating Care Outcomes

• Ensure that patients engage in safe sexual practices.
• Assess their ability to cope with feelings of isolation and depression.

Herpes Simplex Virus (HSV)

• The most common viral infection.
• Two types: HSV 1 (cold sores) and HSV 2 (genital).
• Lifelong virus.
• Manifests within 2 weeks of transmission.
• Causes fever, malaise, and cervical/inguinal lymph node enlargement.
• Can cause facial or genital lesions.

Chicken Pox & Shingles (varicella zoster virus)

• Immunization through the Varicella vaccine
• Causes skin Lesions, fever and itching.
• Provide supportive care with antivirals, antihistamines, and pain relief.

Molluscum Contagiosum (poxvirus)

• Causes raised, "fluid-filled” bumps as well as pain and itching.
• There is no antiviral treatment available.

Viral Skin Infections: Nursing Management

• Administration of antivirals (acyclovir, valacyclovir).
• Perform an assessment and monitor vital signs.
• Provide pain management and emotional support.
• Education is required.
• Side effects of antiviral medications: severe nausea, fatigue, irritability with "flu-like" symptoms, and body aches are often unpleasant for most patients.
• Strict adherence to the medication regimen is needed.
• Supportive care is required.

Fungal Infections: Epidemiology

• Account for 4 million healthcare visits per year.

Fungal Infections: Pathophysiology

• Involvement of yeasts and dermatophytes.

Fungal Infections: Medical Management - Diagnosis

• Diagnosis involves history and physical examination.
• Potassium hydroxide microscopy.

Fungal Infections: Medical Management - Treatment

• Antifungal agents.

Medical Management - Complications

• Can be critical in immunocompromised patients.
• Has high mortality of invasive candida.

Fungal Infections: Nursing Management - Assessment and Analysis

• Careful assessment of high-risk patients

Fungal Infections: Nursing Interventions - Assessments

• Assess the skin conditions
• Assess for pruritus
• Assess for current and recent infections
• Check liver function
• Look at the health history

Fungal Infections: Nursing Interventions - Actions

• Engage in meticulous hand washing.
• Perform cultures as needed.
• Administer antifungal medications as prescribed.
• Cleanse incontinent episodes ASAP.
• Separate skin folds with gauze or dressings to keep dry

Fungal Infections: Nursing Interventions - Teaching

• Avoid tight-fitting clothes
• Describe clinical manifestations of fungal infections
• Complete antifungal infection medications as prescribed.

Fungal Infections: Nursing Management -

• Evaluate care outcomes
• Test knowledge of clinical manifestations
• Avoid complications and bloodstream infection

Tinea Capitis

• Location: Scalp
• Clinical Manifestations: scaly scalp, alopecia and broken hair.
• Treatment includes oral antifungals such as Fluconazole and topical antifungals such as Lamisil.

Tinea Corporis

• Location: Body
• Clinical Manifestations: Patches/plaques with raised borders and central clearing.
• Treatment includes topical antifungals.

Tinea Cruris

• Location: Groin (Jock itch)
• Clinical Manifestations: Red/brown plaques with central clearing, vesicles or pustules to borders, and pruritis with a spared scrotum.
• Treatment includes topical Antifungals

Tinea Pedis

• Location: Feet
• Clinical Manifestations: Dry scaling of soles of feet and Maceration between toes
• Treatment involves keeping feet dry/ventilated, topical antifungal, and PO antifungal

Oral Candidiasis “Oral Thrush”

• Location: Mouth
• Clinical Manifestations include: Creamy white plaques, thick white coating often on tongue.
• Treatment includes: PO antifungal swish & swallow (Nystatin), PO tablet (Fluconazole).

Vaginal Yeast Infection (Vulvovaginal candidiasis)

• Location: Vagina and Vulva
• Clinical Manifestations: Thick discharge and pruritis.
• Treatments: Topical antifungals, intravaginal antifungals (miconazole) and PO antifungals (fluconazole).

Intertrigo

• Location: Skin folds, armpits, and under breasts/abdomen
• Clinical Manifestations: Maceration, erythema, itching and Burning
• : Treatment: Eliminate causative factors, separate skin folds with InterDry, keep skin dry, and Topical Antifungal powders (Nystatin).

Onychomycosis

• Location: Nails
• Clinical Manifestations: yellow nails, brittle/thick nails and subungual hyperkeratosis.
• Treatment: Topical/PO antifungals, nail lacquer solutions, laser treatments, Nail removal

Antifungal Medications Nursing Considerations

• Have minimal side effects.
• Many antifungals have OTC availability.
• Antifungals can inhibit healthy bacteria growth and result in a secondary bacterial infection needing antibiotics.
• Skin issues should always be looked at by a physician/dermatologist, as fungal versus bacterial plays an important role in treatment

Psoriasis: Epidemiology

• Affects 7.5 million people that is about 2% of the population.

Psoriasis: Pathophysiology

• The cause is unknown.
• Epidermal thickness and increased vascularity and inflammation.

Psoriasis: Medical Management - Diagnosis

• Done by examining clinical manifestations.
• No laboratory tests.

Psoriasis: Medical Management- Treatment

• Reduces clinical manifestations.
• Involves topical creams, UV light therapy, and systemic medications.

Psoriasis: Complications

• Associated with a high risk of other diseases: Cancer, cardiovascular disease, Crohn’s disease, metabolic syndrome, uveitis, and liver disease.
• Depression and anxiety.

Psoriasis: Nursing Management - Assessment and Analysis

• Assessment of full health history, family history, and quality of life are imperative.

Psoriasis: Nursing Interventions - Assessments

• Monitor vital signs, and assess pain, skin condition, and mood.

Psoriasis: Nursing Interventions - Actions

• Administer ordered medications.
• Monitor for side effects of treatments.
• Apply topical preparations.
• Provide emotional support
• Refer patients to counseling.

Psoriasis: Nursing Interventions - Teaching

• Proper hand washing techniques.
• Clinical manifestations of infection
• Signs of skin infection should be discussed.
• Limit sunlight exposure.

Psoriasis: Nursing Management - Evaluating Care Outcomes

• Ensure that emotional support and referrals and family education are in place to enhance patient's quality of life.

Autoimmune Skin Disease: Psoriasis

• No cure available
• Can be affected by exacerbation & remission
• Affected by Genes, the Immune system and Environment
• Two types: Plaque psoriasis and, Erythroderma
• Can lead to psoriatic arthritis

Nursing Management

• Skin assessments
• Reduce symptoms
• UV light therapy
• Topical steroid creams
• Systemic medications
• Education about dry patches leading to open sores and hence being a risk for infection
• Emotional support
• Referral to counselling and support groups

General Skin Notes

• It is said that as a nurse you are the physician’s eyes
• You must become informed with the organization’s policy on skin assessment
• 4-Eyed Skin Assessment must be done
• Implement orders as written
• There must be an order if there is a dressing on a patient
• Assist the patient in turning/repositioning
• Assist the patient in hygiene practices

Skin Breakdown Prevention

• Utilize pressure mattresses and surfaces.
• Keep the HOB elevated to an appropriate degree for their condition.
• Use waffle cushions or other approved cushions if patients sit in a chair a lot.
• If there are significant bony prominences use approved padded dressings.
• Use pillows for arms and knees if appropriate.
• Use moisture barriers for Incontinence (IE: zinc-oxide ointment).
• Moisturize skin.
• Avoid tape; use gauze wrap.
• Focus on your Braden Scale Score for Skin Breakdown RISK.

Lecture for NURS 136 on coordinating care for patients with skin disorders. Covers epidemiology, diagnosis and treatment, complications and nursing plans. Based on Hoffman Chapter 50.