Understanding Skin Layers and Functions

Skin Layers

• The skin consists of the epidermis (outer layer) and dermis (inner layer).
• The epidermis provides protection.
• The dermis provides strength, support, blood, and nutrients to the epidermis.
• Subcutaneous tissue lies beneath the dermis.
• Subcutaneous tissue is composed of adipose tissue, connective tissue, blood vessels, lymphatic vessels, and nerves.
• Subcutaneous tissue anchors the dermis and provides insulation and cushion-like protection.
• Natural flora on the skin's surface protects against harmful microorganisms.

Functions of Skin Layers

• Epidermis protects the body from external factors and prevents water loss.
• Dermis provides structural support, elasticity, and nourishment.
• Subcutaneous tissue anchors the skin, regulates temperature, and offers padding and protection.

Skin Integrity

• Maintaining skin integrity protects against infections and environmental hazards.
• Skin breakdown due to trauma or chronic diseases increases infection risk.
• Subcutaneous tissue cushions and insulates which aids in protection and temperature regulation.

Bacterial Skin Infections Classification

• Skin infections are categorized by depth, tissues involved, and required interventions.
• Uncomplicated infections include cellulitis, folliculitis, impetigo, furuncles, abscesses, and minor wound infections.
• Complicated infections invade deeper tissues and often require surgical debridement while also affecting systemic health.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

• MRSA infections can be community-associated (CA-MRSA) or healthcare-associated (HA-MRSA).
• CA-MRSA is more common in healthy individuals with localized skin infections.
• Risk factors for MRSA include poor hygiene, overcrowding, and skin-to-skin contact.

Epidemiology and Treatment of Skin Infections

• Most skin infections are caused by gram-positive bacteria like Staphylococcus aureus and Streptococcus pyogenes.
• Treatment varies based on patient age, bacterial strain, and comorbidities.
• Prophylactic measures include decolonization of carriers and targeted antibiotic therapy.

Risk Factors

• Factors influencing infection susceptibility include skin ulcerations, venous insufficiency, and immunocompromised states.
• Necrotizing soft tissue infections are life-threatening and involve rapid tissue destruction.
• MRSA infections are associated with various demographic groups and colonization in the nasal passages.

Necrotizing Soft Tissue Infections

• These infections are very serious, potentially life-threatening, and spread rapidly
• They destroy significant amounts of tissue
• Necrotizing infections can penetrate and spread throughout the dermis, subcutaneous tissues, fascia, and muscle.
• These infections are more common in the fascia due to poor blood supply and limited immune function which allows rapid pathogen spread.
• Manifestations include fever, tachycardia, disproportionate pain, disorientation, lethargy, and hypotension.
• Necrotizing fasciitis may present with firmness upon palpation of erythematous skin and leads to edema, vascular occlusion, ischemia, tissue necrosis, loss of feeling, and sepsis.
• Common sites include abdomen, lower extremities, and perineum (Fournier’s gangrene).
• Systemic manifestations may initially be mild but can progress to severe symptoms if untreated
• Fournier’s gangrene is necrotizing fasciitis in the genital or perineal area.

Managing Necrotizing Soft Tissue Infections

• There are no guideline indications for the duration of therapy; short-course therapy can be used for uncomplicated infections
• Treatment duration for complicated infections varies based on patient factors, infection severity, and causative agent.
• Initial diagnostic evaluation includes blood culture, complete blood count, electrolytes, and C-reactive protein.
• Immediate hospitalization is required for marked abnormalities and hypotension.
• Gas production by infectious organisms may necessitate CT scan and surgical exploration.
• Antibiotic therapy that targets staphylococci and streptococci is effective for localized infections.

Necrotizing Soft Tissue Infections: Diagnosis and Treatment

• Initial diagnostic evaluation includes blood culture, complete blood count, electrolytes, and C-reactive protein.
• Hospitalization should be immediate for abnormalities and hypotension.
• Gas production by infectious organisms may require CT scan and surgical exploration.
• Antibiotic therapy targeting staphylococci and streptococci is effective for localized infections.
• Nasal colonization of MRSA is associated with recurrent infections and may require mupirocin.
• Hospitalized patients with complicated infections may require surgical debridement and broad-spectrum antibiotics.

Wound Culturing

• Culturing wounds is unnecessary for localized infections like cellulitis.
• Quantitative tissue biopsy is the gold standard for identifying wound pathogens.
• Surface swab culture may be used for quick identification and treatment.
• Complications of incorrect wound culturing include misidentification of bacteria and antibiotic resistance.
• Delay in treating necrotizing infections can lead to tissue loss and multiple surgeries.
• Decolonization strategies are recommended for patients with recurrent infections.

Nursing Management

• Clinical manifestations depend on bacteria, tissue depth, comorbidities, and patient age.
• Wound infection can be indicated by increased pain, erythema, inflammation, and pus in exudate.
• Correct antibiotics verified by wound cultures are essential for successful treatment
• Teach wound care, infection manifestations, and transmission to patients and families
• Rapid evaluation is crucial for a positive prognosis during necrotizing infections
• Surgical evaluation is recommended for areas causing disproportionate pain
• Aggressive therapy with debridement and specialized wound care aids recovery.

Evaluating Care Outcomes for Viral Infections

• Prevent the transmission of herpes simplex virus (HSV)
• Teach individuals with or without an HSV infection safe sex practices, including using a condom and avoiding sexual contact during an outbreak.
• Teenagers and young adults must be aware of the risk of contracting HSV-1 through orogenital sex.
• Refer individuals with a new HSV diagnosis for counseling to cope with feelings of isolation, depression, and anger, and to help them develop and maintain social and intimate relationships.

Fungal Infections

• Fungal infections are caused by dermatophytes (aerobic fungi) and yeasts.
• The clinical impact ranges from mild to fatal.
• Clinical manifestations vary by infection site and depend on the patient’s immune response.
• Fungal infections can spread directly from person to person, through animal contact, or indirectly through contact with inanimate objects that hold skin scales from infected hosts.
• Dermatophytes infect the stratum corneum (dead layer of the skin) and survive on keratin, usually presenting asymmetrically.
• The groin, feet, axillae, and skinfolds are primary places for infection because fungi proliferate in warm, moist environments.
• Tinea describes fungal infections caused by dermatophytes.
• Candida most commonly causes oral or vaginal thrush.
• Invasive fungal or Candida infections affecting the critically ill and immunocompromised patients can have devastating consequences.
• Greater than 4 million healthcare visits per year are related to superficial fungal infections that are most commonly tinea pedis and onychomycosis.
• Onychomycosis accounts for the majority of healthcare visits each year (23.2%), followed by fungal infections of the skin (20.4%) and the feet (18.8%).
• Risk factors include familial fungal infections, male sex, farming/manual labor, and immunosuppressive medications.
• Tinea pedis is most commonly seen among athletes, with prevalence ranging from 25% to 70% over a lifetime.
• Onychomycosis increases with age due to decreased vascular flow, difficulty maintaining foot hygiene, frequent nail injuries, and diabetes.
• Fungal scalp infections are found more frequently among those of lower socioeconomic status.

Candida Infections

• These can range from easily treatable outpatient infections to significant and fatal infections in acutely sick and critically ill populations.
• Three out of four female individuals will experience a vulvovaginal yeast infection with half experiencing more than one.
• Risk factors include tight-fitting or synthetic-fiber clothing, douching too frequently, and bacteria contamination from the rectum.
• Candida infections are usually treated with over-the-counter antifungal medication (such as Monistat) for 1 to 7 days.
• Candida infections in hospitalized patients may be related to the medical treatment of other diseases or infections.
• Candida causes 12% of all hospital-acquired bloodstream infections (BSIs) in the US because of increased empirical use of antimicrobials; immunocompromised patients due to cancer, organ transplants, and chemotherapy; increased survival of the sickest patients; and invasive procedures.
• Mortality rates of Candida BSIs range from 38% to 75% among intensive care unit (ICU) patients and increase the length of hospital stays and additional costs.

Pathophysiology and Clinical Manifestations of Fungal Infections

• Dermatophytes reproduce by spores and cause superficial cutaneous fungal infections that do not spread beyond the epidermis.
• Living in soil, on animals, and on humans, dermatophytes are aerobic fungi that feed on the dead keratin of the skin, hair, and nails.
• Occluded areas are most at risk of infection and an active, raised border is an identifiable characteristic of dermatophyte infections.
• Yeasts multiply by budding and thrive in warm, moist environments on the skin and mucous membranes of the gastrointestinal tract and vagina.
• Fungal infections may present as scaling rashes, plaques, vesicles, or pustules.

Tinea Infections

• Diagnosis is made with a history, physical exam, and potassium hydroxide (KOH) microscopy.
• KOH microscopy has a 76.5% sensitivity and 81.6% negative predictive value with skin scraping and a drop of 10%-20% KOH solution to view through a microscope.
• A Wood's lamp examination can diagnose tinea versicolor which fluoresces pale yellow to white, but is not otherwise helpful in diagnosing fungal infections because of the declining number of infections that now fluoresce under UV light.

Treatment and Prevention of Fungal Infections

• Antifungal agents are primary agents used to treat fungal infections.
• Research shows better healthcare provider education is needed to prevent ineffective therapies because of a lack of knowledge of the medications and incorrect diagnoses.
• Prevention involves avoiding wearing tight shoes, moisture and perspiration, contacting surfaces with bare skin, and sharing contaminated personal items.
• Prevent infection by washing hands well
• Prevent hospital infections by keeping skinfolds dry and clean with frequent turning of bed-bound patients and by cleansing and drying incontinence and wound exudates.
• Complications occur when fungal infections are not treated promptly and are allowed to proliferate, especially in the critically ill and immunocompromised.
• Rapid diagnosis of Candida is difficult because of the time needed for finalization, delaying treatment and increasing mortality.
• The Candida colonization index is the ratio of the number of body sites that grow the same Candida species divided by the number of body sites tested and is acquired from surveillance cultures from multiple patient body sites in the ICU a few times per week up to daily.
• A Candida colonization index of 0.5 identifies patients colonized and at great risk for developing invasive candidiasis so clinicians can promptly treat patients with antifungal medications and reduce morbidity from candidemia.
• Risk identification scales consider admitting diagnoses, corticosteroid and immunosuppressant medication use, antibiotic use, parenteral nutrition, and central venous catheter presence.

Herpes Simplex Virus (HSV)

• HSV exists as two types: HSV-1 and HSV-2.
• HSV-1 causes oral mucosal lesions or 'cold sores,' while HSV-2 causes genital herpes (GH).
• Increasingly, HSV-1 is causing genital herpes due to orogenital sexual contact.

Epidemiology of HSV

• HSV-1 and HSV-2 are common lifelong viral infections transmitted through body fluids or skin contact.
• HSV-1 can be transmitted without sexual contact, often in childhood through sharing utensils.
• HSV-2 causes painful anogenital lesions and is a prevalent sexually transmitted infection (STI).
• HSV-1 and HSV-2 can also cause herpetic whitlow, with HSV-1 responsible for about 60% of cases.
• 60-95% of adults are infected with HSV-1, with a high incidence in young adults.
• CDC reports 16.2% of people in the US aged 14-49 are infected with GH.
• Females are twice as likely as males to be infected, with higher prevalence among Blacks and the HSV-2 prevalence is 41.8% among Blacks, with 48% prevalence in Black females.

Pathophysiology and Clinical Manifestations of HSV

• Primary infection is the first exposure to the virus, leading to clinical manifestations like fever and lesions.
• HSV remains dormant in ganglia after primary infection until reactivated by triggers.
• Secondary infections occur due to reactivation triggers, resulting in milder symptoms than primary infections.
• Symptoms of primary infection include fever, malaise, and lesions on the lips, face, or genitals.
• Secondary infections are preceded by a prodrome and present with fluid-filled vesicles.
• Recurrences are more common in genital herpes caused by HSV-2 than HSV-1.

Management for HSV

• Diagnosis based on clinical presentation may be nonspecific due to asymptomatic primary infections.
• A clinical diagnosis of GH can be challenging due to asymptomatic primary infections and nonspecific symptoms.
• Laboratory analyses like virological and type-specific serological testing are crucial for accurate identification of HSV-1 or HSV-2 infections.
• False negatives and positives can occur in serological testing, necessitating confirmatory tests, especially for recent infections.
• The presence of HSV-2 antibodies indicates anogenital transmission and requires tailored education and counseling.
• Treatment decisions and counseling should consider the type of infection, recurrence, and risk factors.
• Systemic antiviral chemotherapy forms the basis of medical treatment for GH, with options that include acyclovir, valacyclovir, and famciclovir but antiviral medications don’t eradicate the latent virus.
• Suppressive therapy with antivirals may decrease recurrence frequency and transmission risk which is essential for optimal outcomes with counseling.
• IV acyclovir is the better choice for severe cases or complications with shared decision-making
• GH diagnosis can impact quality of life, leading to psychosocial stress, isolation, and fear of transmission.
• HSV-2 infection increases the risk of acquiring and transmitting HIV.
• Complications during pregnancy include the risk of disseminated neonatal herpes, emphasizing the need for antiviral therapy and potential cesarean sections.
• Open epithelial lesions pose a risk of secondary bacterial infections; because of this, wound care and infection prevention are important.
• Monitor and intervene during and after treatment
• Clinical manifestations of primary HSV infections include fever, malaise, myalgias, and painful lesions on various body parts
• Because asymptomatic HSV infections are common, emphasize the need for thorough examination
• Check the lymph nodes and lesions carefully
• GH diagnosis has a major psychosocial effect.
• Educate patients on identifying symptoms, transmission risks, and treatment for self-management and support
• Involve the interprofessional teams for comprehensive care and good patient education.

Psoriasis

• Psoriasis is a chronic inflammatory disorder where raised, scaling, erythematous plaques primarily develop on extensor surfaces.
• This is a lifelong condition with exacerbations and remissions
• Treatments can manage symptoms.
• Psoriasis is an immune disorder that causes chronic skin inflammation with thick, red patches covered in silvery scales.
• Conditions like infections, stress, and medications can worsen this
• 2% of the population is affected and the Global Psoriasis Atlas helps improving understanding.
• Psoriasis before 30 goes hand in hand with psoriatic or erythrodermic arthritis.
• genetic, immune system, and environmental factors cause it
• Increased epidermal thickness, vascularity, and inflammation are key facts

Psoriasis Types and Details

• accelerated shedding is why scaly plaques form
• plaque psoriasis is the most common type impacting over 80% with centripetal distribution
• elevated ESR and C-reactive protein levels means its psoriatic
• Goals = manage care and improve the quality of life with UV therapy
• Risks for other factors include malignancy or anxiety
• Psoriatic effects are important to diagnose with a treatment plan
• Thickening of epidermis and silvery plaques are most key factor
• Depression are all psychological factors that may impact treatment

Lacerations

• These are breaks from either sharp objects
• They can be superficial
• Knives cutting are a common occurance with various factors involved with treatment
• Abrasions due to shear forces and other factors may involve epidermis
• Minor abrasions don't require treatment
• Excoriation means superficial abrasions
• Blisters mean cell separation occurred
• Moisture adds to this
• Skin Tears are caused by minor traumas with annual increases each year

Skin structure and function from injuries:

• All skins have functions and homeostasis
• Wound Cascade means hair follicles aid and repair dermis
• 4 Phases are inflammation and proliferation, maturation
• Hemostasis means platelets are activated
• Edema and pain occurs during inflammatory period
• Keratinocytes and collagen deposit which occurs due nutrition can help
• Maturation will occur in full time

Management during traumas:

• Immunizations are recommended as Tetanus vaccines
• Evaluation is important through perfusion
• Blood supply means good healing with ABl testing
• Nutritional levels should be checked for up to 60% of risk
• Steroids aren't great factors, vitamin A is needed
• Shearing and friction are good and bad forces which minimizes adjustive angles during bed shifts

Management during the surgery

• Primary means an incision
• secondary means to till
• Tertiary means using grafts in the injuries
• Risk of course is infection and the nurse will conduct analysis to check the vitals

Skin Issues and Damages

• Assess trauma for overall care
• Support and psychological needs are for the patient
• Long pressure can impact ulcers

Causes Pressure injuries

• Compression is from shear to ischema
• Bony prominences are factors for issues
• Device related issues

Additional Factors include

• Oxygen levels
• Lymphatic function and pressure
• Sharing forces all affect how tissues work and damages

Shearing injuries

• Damaging tissue and skin with collagen and fibers
• Mucosal damage and medical impact
• Wounds all have to be assessed

Nursing during all cases means care

• Assess history
• Assess risks through scales
• Provide treatment or assess nutrition values with the proper interventions.
• All wounds measured carefully and assessed for product needs
• Sharp debridement might mean anesethia
• Proper skin assess for healing
• Follow up with proper treatment plans

Epidermology

• There are main types and skin are from cancers and carcinomas and non-melanomas
• Sunlight is how skin cancer can develop
• Ulcerations and plaques are all skin cancer aspects
• rarely does carcinoma metastazie but can damage other tissues
• High melanin means tumors

Management with procedures

• Mohs; Surgery is the most important
• Radiation is another way to heal and treat issues
• Chemos are the most effective but will undergo inflammation
• Immunotherapy has some great and bad results. psychological help may also make a situation look better
• Teaching patients is a must in skin cancer and prevention