NURS 136: Skin Disorder Care Coordination

Coordinating Care for Patients With Skin Disorders

• Dyana Gallant, BSN, RN, CMSRN, presented a recorded lecture for NURS 136 on February 3, 2025, covering Hoffman Chapter 50, pages 1168-1189.
• The lecture discusses coordinating care for patients with various skin disorders.

Objectives

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

Functions of the Integumentary System

• Protection
• The skin acts as a barrier against bacteria and viruses.
• Insulation through temperature regulation.
• Sensory perception
• Movement
• Vitamin D Metabolism

Factors Influencing Skin

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

Skin Infections: Uncomplicated vs. Complicated

• Infections are classified as uncomplicated or complicated.

Uncomplicated Infections

• No systemic symptoms.
• Localized signs and warmth.
• Mild to moderate pain.
• No changes in blood work.

Complicated Infections

• Systemic symptoms: tachycardia, fever, lethargy, disproportionate pain.
• Spreading cellulitis: involves lymph nodes.
• Edema
• Ischemia
• Tissue necrosis
• Moderate pain
• Elevated WBC & CRP

Bacterial Skin Infections: Epidemiology

• Can be community or healthcare-acquired.
• Infections often stem from Staphylococcus aureus and Streptococcus pyogenes.
• Methicillin-resistant Staphylococcus aureus (MRSA) infection after surgery affects up to 33% of patients.

Bacterial Skin Infections: Pathophysiology

• Infections can be non-necrotizing, entering through skin integrity breaches.
• Necrotizing infections spread rapidly and destroy tissue.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

• Resistant to multiple antibiotics.
• Overcrowded living conditions facilitate its spread.
• Transmitted through skin contact and contaminated objects.
• Previous MRSA infections increase risk.
• Common in hospital staff.
• Immunocompromised people are at higher risk.
• Poor hygiene can lead to infection.
• Can occur in young and healthy people.

Impetigo

• Caused by strep, staph, or a combination.
• Facial affection is typical
• Honey colored crust,
• Redness in surrounding area
• Treated with topical Rx antibiotics.
• Very contagious

Folliculitis

• Caused by staph
• Tender to touch
• Commonly occurs on the scalp, beard, and extremities.
• Using soaps like Hibiclens or Dial is advised.
• Topical antibiotics
• Extensive, deep lesions may require systemic antibiotics.

Cellulitis

• Caused by staph aureus or strep.
• Presents as a hot, tender, red, and swollen area with diffuse borders.
• Associated with chills, malaise
• managed with systemic antibiotics and elevation.

Necrotizing Fasciitis

• Life-threatening.
• Rapid spread
• Fever, tachycardia
• Hypotension
• Disproportionate pain.
• Disorientation and edema
• Loss of feeling and vascular occlusion
• Can lead to sepsis

Bacterial Skin Infections: Medical Management - Diagnosis

• Requires laboratory data: culture and sensitivity testing, complete blood count (CBC), serum electrolytes, and C-reactive protein (CRP).
• Biopsies and nasal swabs may be necessary.

Bacterial Skin Infections: Complications

• Overuse and misuse of systemic antibiotics
• Necrotizing infection

Bacterial Skin Infections: Nursing

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

Nursing Interventions: Assessments

• Vital signs.
• Wound and skin assessment.
• Complete blood count (CBC).
• Culture results.
• Nutritional status.

Nursing Interventions: Actions

• Administer antibiotics based on culture results
• Wound care
• Surgical evaluation

Nursing Interventions: Teaching

• Hand washing
• Wound care
• Info about clinical indications of infection
• Nursing Management
• Recovery of infection

Herpes Simplex Virus (HSV): Epidemiology

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

Herpes Simplex Virus (HSV): Pathophysiology

• Primary infection occurs through direct contact with an individual with HSV.
• Secondary infections occur following an exogenous or endogenous trigger, reactivating the dormant virus.
• Triggers: Ultraviolet light, febrile illness, stress.

Herpes Simplex Virus (HSV): Clinical Manifestations

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

Herpes Simplex Virus: Medical Management - Diagnosis

• Diagnosis based on clinical presentation.
• Virological and serological testing is available
• Serologic type-specific glycoprotein may be used

Herpes Simplex Virus: Medical Management - Treatment

• Systemic antiviral therapy.
• Episodic or suppressive therapy

Herpes Simplex Virus: Complications

• Psychosocial stress.
• Risk factor for HIV acquisition
• Disseminated neonatal herpes (passed on to newborns during pregnancy).

Herpes Simplex Virus: Nursing Management

• Assessment of A symptomatic HSV infection.

Herpes Simplex Virus: Nursing Interventions - Assessment

• Assess pain
• Fever
• Oral cavity
• Genital lesions
• Sexual history
• Assessment of knowledge of HSV transmission
• Testing for pregnancy and the ability to cope with the diagnosis.

Herpes Simplex Virus: Nursing Interventions - Actions

• Laboratory testing.
• Administer medications as ordered.
• Collaboration with interprofessional team.

Herpes Simplex Virus: Nursing Interventions - Teaching

• Provide education on antiviral medications
• Teach safe sex practices
• Address considerations of HSV infections in pregnancy
• Nursing Management
• Assessment of safe sex practices

Herpes Simplex Virus (HSV)

• Common viral infection.
• Two types: HSV-1 (cold sores) and HSV-2 (genital).
• Lifelong virus.
• Appears within 2 weeks of transmission..
• Fever, malaise
• Cervical/Inguinal lymph node enlargement.
• Can cause facial or genital lesions.

Chicken Pox and Shingles (Varicella Zoster Virus)

• Immunizations – Varicella Vaccine!
• Symptoms include skin lesions, fever, and itching.
• Supportive care includes antivirals, antihistamines, and pain management

Molluscum Contagiosum (Poxvirus)

• Characterized by raised, fluid-filled bumps.
• Causes pain and itch
• No antiviral treatment

Viral Skin Infections Nursing Management

• Administration of antivirals (acyclovir, valacyclovir).
• Assessment and monitoring vital signs.
• Pain management providing emotional support
• Education
• The side effects of antiviral medications are unpleasant to most patients
• Severe nausea
• Fatigue
• Irritability
• Flu-like symptoms
• Body aches
• Strict adherence to regimen
• Supportive care

Fungal Infections: Epidemiology

• 4 million healthcare visits per year.

Fungal Infections: Pathophysiology

• Caused by yeasts and dermatophytes.

Fungal Infections : Medical

• Medical History with physical
• Medical diagnosis with potassium hydroxide microscopy
• Treat with antifungal agents

Fungal Infections: Complications

• Critically ill and immunocompromised patients
• High mortality of invasive candida

Fungal Infections: Nursing Management

• Assessing high-risk patients.

Fungal Infections: Nursing Interventions - Assessment

• Assess skin
• Pruritus
• Current and recent infections
• Liver functions and health history

Fungal Infections: Nursing Interventions - Actions

• Meticulous hand washing.
• Perform cultures as needed.
• Administer antifungal medications
• Cleanse incontinent episodes immediately
• Separate skin folds using gauze/dressings to keep dry.

Fungal Infections: Nursing Interventions - Teaching

• Avoid tight clothing.
• Teach the clinical manifestations of fungal infections. Complete prescribed antifungal infection medications

Fungal Infections: Nursing Management - Evaluation

• Evaluation of clinical manifestations
• Knowledge of evaluation of complications
• Bloodstream infection

Tinea Capitis

• Location: SCALP
• Clinical manifestations are scaly scalp, alopecia, and broken hair.
• Treatment: Oral antifungals (Fluconazole) or topical antifungals (Lamisil).

Tinea Corporis

• Location is on the body.
• Clinical manifestations include patches/plaques, raised borders, and central clearing.
• Treatment: Topical antifungals.

Tinea Cruris

• Location: Groin (jock itch).
• Clinical manifestations are red/brown plaques, central clearing, vesicles, and itching
• Scrotum usually spared.
• Treatment is topical antifungals.

Tinea Pedis

• Location: Feet.
• Clinical manifestations include maceration between toes and dry scaling of the soles.
• Treatment involves keeping feet dry and ventilated, topical antifungals, or PO antifungals.

Oral Candidiasis "Oral Thrush"

• Located in the mouth
• Clinical manifestations are creamy, white plaques and thick white coating often on the tongue.
• Treatment involves PO antifungal swish and swallow Nystatin or PO tablet Fluconazole.

Vaginal Yeast Infection

• Location: Vagina and vulva.
• Clinical manifestations are a thick discharge and pruritus.
• Treatments include topical, intravaginal (miconazole), and PO antifungals (fluconazole).

Intertrigo

• Location: Skin folds.
• Clinical manifestations are maceration & erythema, itching & burning.
• Treatment focuses on eliminating causative factors, separating skin folds
• Topical antifungal powders like Nystatin

Onychomycosis

• Location: Nails.
• Clinical features are yellow, brittle/thick nails with subungual hyperkeratosis.
• Treatment: Topical/PO antifungals, nail lacquer solutions, laser treatments, or nail removal.

Antifungal Medications Nursing Considerations

• Low side effects.
• Many antifungals available over-the-counter (OTC).
• Antifungals can inhibit healthy bacteria growth, resulting in secondary bacterial infection needing antibiotics.
• Skin issues should be assessed by a physician/dermatologist.

Psoriasis: Epidemiology

• Affects 7.5 million people: 2% of population.

Psoriasis: Pathophysiology

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

Psoriasis: Medical Management - Diagnosis

• Diagnosed via clinical manifestations.
• No laboratory tests required.

Psoriasis: Medical Management - Treatment

• UV light therapy
• Topical creams
• Systemic medications.
• Reduce clinical manifestations

Psoriasis: Complications

• High risk of other diseases
• Cancer, cardiovascular disease, Crohn’s disease, metabolic syndrome, uveitis, and liver disease.
• Depression and anxiety

Psoriasis: Nursing Management -

• Assess full health history, family history, and assessing the patient's quality of life

Psoriasis: Nursing Interventions

• Actions are to administer ordered medications, monitor for side effects, and topical preparations
• Provide emotional support and referral to counseling.

Psoriasis: Nursing Interventions - Teaching

• Teaching to properly wash hands
• Teach clinical manifestations and signs of skin infection and limit sunlight exposure.

Psoriasis: Nursing Management - Evaluation

• Assess how emotional support, referrals, and family education will help enhance the patient’s quality of life.

Autoimmune Skin Disease Psoriasis

• No cure.
• Exacerbation & Remission.
• Genes, Immune system and Environment plays an important role
• Two types: Plaque psoriasis and Erythroderma.
• Can lead to psoriatic arthritis.

Management of Psoriasis

• Skin assessments
• Reduce symptoms.
• UV light therapy or topical steroid creams.
• Systemic medications.
• Education about infection risk: dry patches.
• Emotional support and referral to counseling/support groups.

General Skin Notes for Nursing

• You are the physician's eyes;
• Get informed with organization's policy on skin assessment and implement orders properly.
• There should be an implement orders as wriiten.
• Assist patient in turning and hygiene practices.

Skin Breakdown Prevention

• Utilize pressure mattresses and lift the head of the bend to an appropriate position.
• Assess the patient needs to be sitting in a chair.
• Consider waffle cushions
• Asses bony prominences
• Pillows for arms and knees.
• Barriers to moisture for incontinence like zinc-oxide, moisturize the skin.
• Avoid tape. Use gauze wrap if possible.
• Focus on your Braden Scale Score for Skin Breakdown.