Skin Disorders: NURS 136, Hoffman Ch. 50

Coordinating Care for Patients With Skin Disorders

• The lecture is presented by Dyana Gallant, BSN, RN, CMSRN for NURS 136 on Monday, February 3, 2025.
• The material correlates with Hoffman Chapter 50, pages 1168-1189.

Objectives

• Understand common skin disorders' epidemiology, pathophysiology, and clinical manifestations; includes bacterial, herpes simplex, fungal infections, and psoriasis.
• Diagnostic Evaluation describes methods and results used to confirm skin disorders.
• Interprofessional Management explores the collaborative management of bacterial, herpes simplex, and fungal infections, and psoriasis is investigated, involving multiple healthcare disciplines.
• Complications and Risk Management identifies potential complications and prevention/management strategies for skin disorders
• Nursing Care Planning is developing comprehensive plans for patients with skin disorders, incorporating pharmacological treatments, dietary modifications, and lifestyle interventions to promote optimal outcomes.

Functions of the Integumentary System

• Protection from external elements
• The skin acts as a barrier against bacteria and viruses
• Insulation and temperature regulation are key functions
• Sensory perception allows for detection of touch, temperature, and pain
• Facilitates movement
• Involved in Vitamin D Metabolism

Factors Influencing Skin

• Nutrition impacts skin health
• Hydration maintains skin elasticity and moisture
• Age affects skin thickness and elasticity
• Hygiene influences the presence of bacteria
• Environmental factors like pollution and UV exposure
• Immobility can cause skin breakdown.
• Lifestyle habits (smoking, alcohol) affect skin aging and health
• Medications can cause skin reactions.

Skin Infections: Uncomplicated vs Complicated

• Uncomplicated skin infections do not present systemic symptoms
• Uncomplicated infections show localized signs
• Localized warmth is present in uncomplicated infections
• Mild to moderate pain is associated with uncomplicated infections
• No changes in blood work occur in uncomplicated infections
• Complicated infections involve systemic symptoms like tachycardia, fever, lethargy, and disproportionate pain
• Complicated infections spread cellulitis affecting lymph nodes
• Edema, ischemia, and tissue necrosis can arise with complicated infections
• In complicated cases, moderate to severe pain is present
• Elevated WBC & CRP indicate complicated infections

Bacterial Skin Infections: Epidemiology

• Bacterial infections are community or healthcare-acquired
• Most soft tissue infections are from Staphylococcus aureus and Streptococcus pyogenes
• MRSA affects 33% of patients after surgery

Bacterial Skin Infections: Pathophysiology

• Non-necrotizing infections occur via a breach in skin integrity
• Necrotizing infections spread rapidly and destroy tissue

Methicillin-Resistant Staphylococcus Aureus (MRSA)

• MRSA is resistant to many antibiotics
• Overcrowded living conditions facilitate spread
• Skin-to-skin contact spreads MRSA
• Sharing contaminated objects spreads MRSA
• Previous MRSA infections increase risk
• Hospital professions are at higher risk
• Immunocompromised individuals are at higher risk
• Poor hygiene increases risk
• MRSA can infect healthy/younger patients

Impetigo

• Impetigo is caused by strep, staph, or a combination.
• Impetigo typically affects face
• Forms a honey-colored crust
• The affected area is red
• It is treated with topical antibiotics
• Impetigo is highly contagious

Folliculitis

• Most cases are caused by staph
• The area affected is tender
• Scalp, beard, and extremities areas are commonly affected
• It needs topical antibiotics for treatments
• Use Hibiclens or Dial soap to treat
• Extensive, deep lesions may require a systemic antibiotic

Cellulitis

• Usually, it is caused by staph aureus or strep
• Manifests as a hot, tender, red, and swollen area with diffuse borders
• Chills, malaise, and fever can be present
• Treated with systemic antibiotics and elevation

Necrotizing Fasciitis

• Necrotizing fasciitis is potentially life-threatening
• Has a rapid spread
• Characterized by fever, tachycardia, and hypotension
• Pain is disproportionate to the appearance
• Causes disorientation
• Results in edema
• Causes loss of feeling and vascular occlusion
• Leads to sepsis

Bacterial Skin Infections: Diagnosis

• Diagnosis involves culture and sensitivity tests
• CBC and serum electrolytes are required
• Assess C-reactive protein (CRP) levels
• Conduct biopsies
• Perform nasal swab

Bacterial Skin Infections: Complications

• Complications include overuse and misuse of systemic antibiotics
• Presence of necrotizing infection

Bacterial Skin Infections: Nursing Management

• Clinical manifestations are reliant on the involving organism tissues and comorbidities
• Assess vital signs, wound/skin condition, complete blood count, culture results, and nutritional status

Bacterial Skin Infections: Actions

• Actions involve the administration of antibiotics based on the culture results
• Perform wound care correctly
• Order surgical evaluation

Bacterial Skin Infections: Teaching

• Teach on the the importance of hand washing
• Teaching on wound care is key
• Educate on clinical manifestations of infection

Bacterial Skin Infections: Evaluation

• Assess 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 infection occurs following an exogenous or endogenous trigger that reactivates the dormant virus, such as UV light, febrile illness, or stress

Herpes Simplex Virus (HSV): Clinical Manifestations

• Fever
• Malaise
• Myalgia
• Anorexia
• Irritability
• Cervical or inguinal lymphadenopathy can occur
• Result in lesions on the lip, face, mucous membranes

Herpes Simplex Virus (HSV): Diagnosis

• Diagnosis is based on clinical presentation
• Diagnosed with virological testing
• Diagnosed with serological type-specific glycoprotein testing

Herpes Simplex Virus (HSV): Treatments

• Administer systemic antiviral therapy
• Give episodic or suppressive therapy

Herpes Simplex Virus (HSV): Complications

• Psychosocial stress
• Represents a risk factor for HIV acquisition
• Results in disseminated neonatal herpes

Herpes Simplex Virus (HSV): Nursing Management

• HSV infection may be asymptomatic
• Assess pain, fever, oral cavity/genital lesions, sexual history, skin/mucous membranes, HSV transmission knowledge, pregnancy status, and ability to cope

Herpes Simplex Virus (HSV): Nursing Interventions

• Perform laboratory testing
• Administer medications as ordered
• Collaborate with healthcare team

Herpes Simplex Virus (HSV): Teaching

• Teaching should include actions of antiviral medications, safe sex practices, and considerations in pregnancy

Herpes Simplex Virus (HSV): Evaluation

• Evaluate the patient's engagement in in safe sexual practices and their ability to cope with isolation and depression

Herpes Simplex Virus (HSV) Quick Facts

• Most common viral infection
• Has two types: HSV 1 (cold sores) and HSV 2 (genital)
• It is a lifelong virus
• Manifests within 2 weeks of transmission
• Symptoms: fever, malaise
• It can cause cervical/inguinal lymph node enlargement
• Resultant facial or genital lesions

Chicken Pox & Shingles

• A varicella zoster virus
• Vaccinate with Varicella Vaccine
• Signs & Symptoms: Skin Lesions, Fever, Itching
• If acquired, supportive care is with antivirals,antihistamines, and pain medication.

Molluscum Contagiosum

• A poxvirus
• Raised with a fluid-filled appearance
• Causes bumps
• The effected area experiences pain and itch
• There is no antiviral treatment

Viral Skin Infections: Nursing Management

• Administer antivirals (acyclovir, valacyclovir)
• Assess patient
• Track vital signs
• Manage the pain
• Offer emotional Support
• Educate patient

Viral Skin Infections: Side Effects

• Side Effects of antiviral medications may include: severe nausea, fatigue, irritability, flu-like symptoms and body aches
• Strict adherence to regimen, so patient compliance is critical
• Supportive care will be needed.

Fungal Infections: Epidemiology

• Account for 4 million healthcare visits per year

Fungal Infections: Pathophysiology

• Caused by yeasts or dermatophytes

Fungal Infections: Diagnosis

• Is by evaluating History and physical
• A potassium hydroxide microscopy

Fungal Infections: Treatments

• Utilize antifungal agents

Fungal Infections: Complications

• Critically ill and immunocompromised patients can experience complications
• High mortality of invasive candida

Fungal Infections: Nursing Management

• Careful assessment of high-risk patients

Fungal Infections: Nursing Interventions

• Assess skin
• Assess for the presence of pruritus
• Assess for current/recent infections
• Test their liver function
• Assess their Health history

Fungal Infections: Interventions

• Practice meticulous hand washing
• Perform cultures as needed
• Ensure patients administer antifungal medications as prescribed
• Cleanse incontinent episodes ASA P
• Separate skin folds with gauze or dressings to keep dry

Fungal Infections: Teaching

• The patient should avoid tight fitting clothes
• Clinical manifestations of fungal infections
• Patients should complete antifungal infection medications as prescribed

Fungal Infections: Evaluation

• Evaluate the patient' knowledge of clinical manifestations
• Avoid complications such as a bloodstream infection

Tinea Capitis

• Location in SCALP
• Clinical Manifestations: Scaly scalp, Alopecia and Broken hair
• Treatments involve oral antifungals (Fluconazole) and topical antifungals (Lamisil)

Tinea Corporis

• The location of Tinea Corporis is on the BODY
• Clinical Manifestations: Patches/Plaques, Raised borders and Central clearing
• Patients can be treated with Topical antifungals

Tinea Cruris

• Tinea Cruris is the GROIN, and it also known as Jock itch
• Clinical Manifestations: Red/brown plaques, Central clearing, Vesicles or pustules to borders, Pruritis and Scrotum spared
• Can be treated with Topical Antifungals

Tinea Pedis

• Tinea Pedis is on the Feet
• Clinical Manifestations include: Maceration between toes and Dry scaling of soles of feet
• Treatment involves: Keeping feet dry/ventilated and taking Topical/PO antifungal medications

Oral Candidiasis "Oral Thrush"

• Is present in the Mouth
• Clinical Manifestations: Creamy, white plaques and Thick White coating on the tongue
• Patients can be treated with PO antifungal swish & swallow (Nystatin) as well as PO tablet (Fluconazole)

Vaginal Yeast Infection, Vulvovaginal candidiasis

• In the Vagina and Vulva with Thick discharge that can result in pruritus
• Treatments: Topical, Intravaginal and PO antifungals

Intertrigo

• Present in Skin folds (armpits, under breasts/abdomen), characterized by Maceration, Erythema, Itching and Burning
• You need to Eliminate causative factors and Separate skin folds, keep skin dry. You can also topically administer Antifungal powders (Nystatin)

Onychomycosis

• Present on the Nails
• Clinical Manifestations feature Yellow, Brittle/thick nails and Subungual hyperkeratosis
• Treatment involves utilizing Topical/PO antifungals, Nail lacquer solutions, Laser treatments and Nail removal

Antifungal Medications: Nursing Considerations

• Antifungal medications should be assessed for for minimal side effects
• Many antifungals are available over-the-counter (OTC)
• Antifungals can inhibit healthy bacteria growth and result in a secondary bacterial infections needing antibiotics
• Skin issues should always be looked at by a physician/dermatologist to ascertain if it is fungal or bacterial, as it plays an important role in the treatment

Psoriasis: Epidemiology

• Psoriasis affects 7.5 million people amounting in 2% of population

Psoriasis: Pathophysiology

• Has an unknown cause
• Epidermal thickness with increased vascularity and inflammation

Psoriasis: Diagnosis

• Diagnosis has no laboratory tests
• Clinical manifestations

Psoriasis: Treatments

• Goal is to reduce clinical manifestations
• Can be treated by administering Topical creams, UV light therapy and Systemic medications

Psoriasis: Complications

• Patients can develop Cancer, cardiovascular disease, Crohn’s disease, metabolic syndrome,uveitis and liver disease
• Can result in depression and anxiety

Psoriasis: Assessment and Analysis

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

Psoriasis: Interventions

• Check patient's vital signs for their pain, and skin and mood

Psoriasis: Actions

• Administer Medications as per the provider's order
• Watch Monitor for side effects of treatments
• Use topical preparations with emotional support
• Refer to counselling

Psoriasis: Teaching

• Proper hand washing
• Teach patients about Clinical manifestations
• Teach patients about signs of skin infection
• Teach patients to limit sunlight exposure

Psoriasis: Evaluating Care Outcomes

• Need to provide emotional support and recommend referrals and family education

Psoriasis Quick Facts

• Autoimmune skin disease with no cure
• Has periods of exacerbation and remission
• Caused by Genes, Immune system and Environmental factors
• Two types: plaque psoriasis and erythroderma
• Can lead to psoriatic arthritis

Psoriasis: Nursing Management

• Perform Skin assessments
• Educate patient to reduce symptoms
• Administer UV light therapy
• Apply Topical steroid creams
• Can administer Systemic medications
• Tell them dry patches can lead to open sores as they equal to risk for infection
• Provide emotional support
• Refer to counseling/support groups

General Skin Notes

• Role is essentially like acting at the physician’s eyes
• Become informed with the organization’s policy on skin assessment
• Always conduct 4-Eyed Skin Assessment
• Implement orders as written
• Implement the use of dressings accordingly
• Help patients to turning/reposition and hygiene practices

Skin Breakdown Prevention

• Utilize pressure mattresses and surfaces.
• If possible keep HOB elevated at an appropriate degree for their condition.
• If patients sits in chair a lot, use waffle cushions or other approved cushions.
• If significant bony prominences use approved padded dressings
• Use pillows for the arms and knees
• Moisture provide barriers for incontinence IE: use zinc-oxide ointment
• Moisturize any dry skin
• Avoid tape, instead use gauze wrap
• Check their Braden Scale Score for Skin Breakdown for the RIS

Lecture on skin disorders for NURS 136, correlating with Hoffman Chapter 50. Covers epidemiology, pathophysiology, clinical manifestations, and interprofessional management of bacterial, herpes simplex, fungal infections, and psoriasis. Includes nursing care planning, complications, and risk management.