Skin Integrity Notes

—--------- ALTERED SKIN INTEGRITY —---------- REVIEW: Skin Structure: Layers: - Epidermis - Outer layer of the skin; contains keratinocytes which start in the basal layer and work their way towards the stratum corneum;...

—--------- ALTERED SKIN INTEGRITY —---------- REVIEW: Skin Structure: Layers: - Epidermis - Outer layer of the skin; contains keratinocytes which start in the basal layer and work their way towards the stratum corneum; the outermost layer of the epidermis. Many problems with cell division originate in this layer. - Dermis - Connective tissue below the dermis containing vessels, nerves, lymphatic vessels, hair follicles, sebaceous glands. - Hypodermis (subcutaneous fat) - Made of loose connective tissue (adipose). Serves as insulation, cushion, temp regulation and energy storage. The hypodermis connects with underlying tissues such as bone and muscle. Types of normal bacterial flora include: a. Gram-positive and gram-negative staphylococci b. Pseudomonas c. Streptococcus What are the functions of the Skin? - Serves as a barrier to the external environment - Prevents excess water loss - Melanin absorbs UV rays and prevents from sun damage - Collects sensory information - Controls heat regulation - Endogenous synthesis of vitamin D, which is critical to calcium and phosphorus balance Risk Factors for Skin Problems - Exposure to chemical and environmental pollutants - Exposure to radiation - Race and age - Exposure to the sun or use of indoor tanning (SPF >15) - Lack of personal hygiene habits - Use of harsh soaps or other harsh products - Some medications, such as long-term glucocorticoid, antibiotics, diuretics - Nutritional deficiencies - Moderate to severe emotional stress - Infection, with injured areas as the potential entry points for infection - Repeated injury and irritation - Genetic predisposition - Systemic illnesses Skin Cancer Non-melanoma Cancer v. Melanoma Cancer Non-melanoma: - Develops in the epidermis - Overexposure to the sun is a primary cause; - other causes and conditions that place the individual at risk include: - chronic skin damage from repeated injury and irritation such as tanning and use of tanning beds - genetic predisposition - ionizing radiation - light-skinned race - age older than 60 years - an outdoor occupation - Areas it affects: sun-exposed areas: - Face, head, neck, back of hands, and ears Diagnosis is confirmed by skin biopsy. Types: - Basal cell: Basal cell cancer arises from the basal cells contained in the epidermis; metastasis is rare, but underlying tissue destruction can progress to organ tissue. Waxy, nodule, w/ pearly borders; papule red, central crater, metastasis is RARE - Squamous cell: Squamous cell cancer is a tumor of the epidermal keratinocytes and can infiltrate surrounding structures and metastasize to lymph nodes. Oozing, bleeding, crusting lesions. Potentially metastatic; Larger tumors associated with a higher risk for metastasis Melanoma Cancer:  - Melanoma may occur any place on the body, especially where birthmarks or new moles are apparent; it is highly metastatic to the brain, lungs, bone, and liver, with survival depending on early diagnosis and treatment. Irregular, circular, bordered lesion with hues of tan, black, or blue Rapid infiltration into tissue, highly metastatic Assessment: **When assessing the skin, keep in mind the ABCDE’s of melanomas. - A: Asymmetry - one half unlike the other - B: Border - border irregularity - C: Color - varied pigmentation - D: Diameter - >6mm - E: Evolving - changing in appearance overtime. 1. Change in color, size, or shape of preexisting lesion 2. Pruritus 3. Local soreness ACNE CAUSED BY HORMONES!!!!!! During adolescence sebaceous glands enlarge and produce more sebum under the influence of androgen hormones. A. Description 1. Acne is a chronic skin disorder that usually begins in puberty and is more common in males; lesions develop on the face, neck, chest, shoulders, and back. 2. Acne requires active treatment for control until it resolves. 3. The types of lesions include comedones (open and closed), pustules, papules, and nodules. 4. The exact cause is unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium acnes, the organism that converts sebum into irritant fatty acids. 5. Exacerbations coincide with the menstrual cycle in female clients because of hormonal activity; oily skin and a genetic predisposition may be contributing factors. B. Assessment 1. Closed comedones are whiteheads and non inflamed lesions that develop as follicles enlarge, with the retention of horny cells. “White head” 2. Open comedones are blackheads that result from continuing accumulation of horny cells and sebum, which dilates the follicles. “Black head” 3. Pustules and papules result as the inflammatory process progresses. 4. Nodules result from total disintegration of a comedone and subsequent collapse of the follicle. 5. Deep scarring can result from nodules. C. Interventions 1. Instruct the client in prescribed skin-cleansing methods, with emphasis on not scrubbing the face and using only prescribed topical agents. – Mild soap-no more than 2-3 times per day 2. Instruct the client in the administration of topical or oral medications as prescribed. Benzoyl peroxide a. Can produce drying and peeling b. Severe local irritation (burning, blistering, scaling, swelling) may require reducing the frequency of applications. c. Some products may contain sulfites; monitor for serious allergic reactions. Clindamycin and erythromycin a. Both products are antibiotics that suppress the growth of P. acnes. Hormonal medications a. Hormonal medications such as oral contraceptives and spironolactone may be prescribed to treat acne in female clients. b. These medications decrease androgen activity, resulting in decreased production of sebum. c. Spironolactone is teratogenic; therefore, contraception during its use is necessary. d. Side and adverse effects of spironolactone include breast tenderness, menstrual irregularities, and hyperkalemia. 3. Instruct the client not to squeeze, prick, or pick at lesions. 4. Instruct the client to use products labeled noncomedogenic and cosmetics that are water based and to avoid contact with products with an excessive oil base. 5. Instruct the client on the importance of follow-up treatment. Cellulitis A. Description Cellulitis is an infection of the dermis and underlying hypodermis; the causative organism is usually group A Streptococcus or Staphylococcus aureus. When skin integrity has been altered because of skin breaks, tears, or damage secondary to systemic disease, an opportunity for pathogens to invade is provided. Good hygiene practices can help to inhibit infections, but even people with good hygiene can acquire infections. B. Risk Factors 1. Immunocompromised 2. Cancer 3. Diabetes 4. Alcohol and drug abuse 5. Obesity C. Assessment 1. Pain and tenderness 2. Erythema and warmth 3. Edema 4. Fever 5. Skin Tracking 6. With more severe infections Fever Chills Malaise Lymphadenopathy D. Physical Exam Examine skin carefully Streaking Warmth Extent of redness Open wound drainage Radial or pedal pulses when appropriate Temperature E. Diagnostic Test 1. Gram stain C & S of wound  2. CBC 3. Blood cultures if extensive E. Interventions 1. Promote rest of the affected area. 2. Apply warm compresses as prescribed to promote circulation and to decrease discomfort, erythema, and edema. 3. Apply antibacterial dressings, ointments, or gels as prescribed. 4. Administer antibiotics as prescribed for an infection; obtain a culture of the area before initiating the antibiotics. Furuncles/Carbuncles (BOIL OR ABCESS) A. Description Furuncles (Abscess or Boil) Deep infection by staphylococci around hair follicles often associated with severe acne or seborrheic dermatitis Often recurs with scarring Carbuncles Several furuncles developing in adjoining hair follicles. Multiple drainage points. Very painful Systemic signs Most frequent causative organism is S. Aureus B. Clinical Manifestations Painful, tender erythematous area that drains pus and necrotic debris when ruptured Common sites: face, back of neck, axillae, breasts, buttocks, perineum, thighs Characterized by malaise, regional adenopathy, and elevated body temperature C. Predisposing factors Chronic Staph carrier Diabetes Obesity Poor hygiene D. Distribution Hair bearing area Beard Axilla Occipital scalp Areas of friction Waistline Groin Buttocks Axilla E. Management Incision and drainage Culture only if antibiotic doesn’t work or repeat episodes Topical antibiotics o Bactroban cream o Erythromycin 2% solution Oral antibiotic o Dicloxacillin o Keflex o Doxycycline Warm, moist heat Stress good hygiene IMPETIGO Group A Beta hemolytic strep or Staph or combination Contagious Associated with poor hygiene Primarily seen on face Pruritic vesicular lesions with thick honey-colored crusts surrounded by erythema Treatment: o Medication: PCN, systemic or topical o Local treatment: saline soak, soap and water cleaning, meticulous care regimen Potential for glomerulonephritis if not treated. Scabies Mechanism of Action Allergic reaction to eggs, feces, and mite parts The Sarcoptes scabiei mite penetrates outer layer of skin and deposits eggs Rarely occurs in dark-skinned people Clinical Manifestations Severe itching, especially at night, between fingers and toes, on flexor surfaces of wrists and genitalia, and in axillary folds Erythematous papules with possible vesiculation  Interdigital web crusting HERPES SIMPLEX 1 AND 2 Types HSV-1 generally affects the mouth area HSV-1 and HSV-2 affect the genitals Etiology and Pathophysiology Recurrent and lifelong Exacerbated by sunlight, trauma, menses, stress, and systemic infection Contagious Transmitted by respiratory droplets or virus-containing fluid (i.e., bodily fluids) Infection in one area is easily transmitted to another Clinical Manifestations Symptoms occur 2 days to 2 weeks after contact Painful local reaction Single or grouped vesicles on erythematous base Systemic symptoms (flu-like symptoms) or none Treatment: Oral antiviral med, topical compresses HERPES ZOSTER (SHINGLES) A. Description 1. With a history of chickenpox, shingles is caused by reactivation of the varicella zoster virus; shingles can occur during any immunocompromised state in a client with a history of chickenpox. 2. The dormant virus is in the dorsal nerve root ganglia of the sensory cranial and spinal nerves. 3. Herpes zoster eruptions occur in a segmental distribution on the skin area along the infected nerve and show up after several days of discomfort in the area. 4. Diagnosis is determined by visual examination and by Tzanck smear to verify a herpes infection and viral culture to identify the organism. 5. Postherpetic neuralgia (severe pain) can remain after the lesions resolve. 6. Herpes zoster is contagious to individuals who never had chickenpox and who have not been vaccinated against the disease. B. Clinical Manifestations 1. Linear distribution along a dermatome 2. Grouped vesicles and pustules (looks like chicken pox) 3. Unilateral on trunk, face, and lumbosacral areas with burning, itching, pain, and neuralgia preceding breakouts C. Assessment 1. Unilaterally clustered skin vesicles along peripheral sensory nerves on the trunk, thorax, or face 2. Fever, malaise 3. Burning and pain 4. Paresthesia (NERVE PAIN!!!) 5. Pruritus D. Interventions 1. Isolate the client, because exudate from the lesions contains the virus (maintain standard and other precautions as appropriate, such as contact precautions, if vesicles are present). 2. Assess for signs and symptoms of infection, including skin infections and eye infections; skin necrosis can also occur. 3. Assess neurovascular status and seventh cranial nerve function; Bell’s palsy is a complication. 4. Use an air mattress and bed cradle on the client’s bed if hospitalized and keep the environment cool; warmth and touch aggravate the pain. 5. Prevent the client from scratching and rubbing the affected area. 6. Instruct the client to wear lightweight, loose cotton clothing and to avoid wool and synthetic clothing. 7. Teach the client about the prescribed therapies; astringent compresses may be prescribed to relieve irritation and pain and to promote crust formation and healing. 8. Teach the client about measures to keep the skin clean to prevent infection. 9. Teach the client about topical treatment and antiviral medications; antiviral therapies begun within 3 days of rash reduce pain and lessen likelihood of postherpetic neuralgia. 10. The vaccination for shingles, is recommended for adults 50 years of age and older to reduce the risk of occurrence and the associated long-term pain. 11. Antiviral medications may be prescribed. Acyclovir Famvir Valtrex 12.Post-herpatic neuralgia Elavil Neurontin Nerve block TINEA INFECTIONS (FUNGI) Capitis (Scalp) Corporis- A dermatophyte fungus that requires keratin to grow, such as that found in hair, nails, and skin. Ring-like erythematous scaly appearance; Appearance anywhere on the bod  Cruris (Groin)- A dermatophyte that presents in the groin area. Well-defined scaly plaque; Does not affect mucous membranes Pedis (Feet)- This is a dermatophyte that is found on the feet. Interdigital scaling and maceration with scaly plantar surfaces; Erythema, pruritus, and painful blistering Unguium (Nails)- A dermatophyte found under the nails (fingers or toes). This dermatophyte is commonly known as toenail fungus, but it can be found in hands as well. Scaly skin under distal nail plate Unguium or Onychomycosis A. Description Fungal infection of the nails usually toenails. Common in elderly Artificial nails Pedicures B. Clinical Presentation Nails thick, yellow No pain C. Treatment Sporonox, Lamisil or other o Treat for three months Penlac topical solution o Apply to nail and surrounding skin QD o Treat for 3 months o Trim nail as it grows Tinea Pedis (ATHLETES FOOT!!!!!) A. Description Fungal infection of the skin on feet. B. Predisposing Factors Warm, moist skin Common shower stalls Diabetes Immunocompromised C. Symptoms Pruritis Rash D. Physical Exam Rash: red spots May be white and moist between toes Tinea Capitis Tinea Corporis Tinea Curis CRADLE CAP RINGWORM JOCKITCH Candidiasis A. Description 1. A superficial fungal infection of the skin and mucous membranes 2. Also known as a yeast infection (oral candidiasis), or thrush when it occurs in the mouth 3. Risk factors include immunosuppression, long-term antibiotic therapy, diabetes mellitus, and obesity. 4. Common areas of occurrence include skin folds, perineum, vagina, axilla, and under the breasts. B. Assessment Mouth: white, cheesy plaque Vagina: vaginitis with red edematous, painful vaginal wall, white patches, discharge, and pruritus Skin: diffuse papular erythematous rash C. Interventions 1. Teach the client to keep skin fold areas clean and dry. 2. For the hospitalized client, inspect skin fold areas frequently, turn and reposition the client frequently, and keep the skin and bed linens clean and dry. 3. Provide frequent mouth care as prescribed and avoid irritating products. 4. Provide food and fluids that are tepid in temperature and nonirritating to mucous membranes. 5. Antifungal medications may be prescribed. Nystatin (Mycostatin) oral suspension, cream, or powder Scabies A. Description Common highly pruritic transmissible ectoparasite infection. B. Cause Caused by Sarcoptes scabiei Adult female mite burrows into skin shortly after contact Incubation period four weeks from initial contact Transmitted person to person Transmission via clothing less common May affect entire families Frequently seen in institutionalized persons C. Signs/Symptoms Pruritis always present: most intense at night Pruritis frequently less intense in the HIV patient D. History Onset, duration, location of lesions Itching; worse at night? Friends or family with symptoms? Self-treatment and effectiveness of treatment E. Diagnostic Tests Microscopic examination of skin scraping in oil immersion F. Treatment Elimite Apply to all skin from neck down Leave on for 8-14 hours Shower with soap and water Kwell Apply as above  NOT for pregnant or nursing mothers All household members should be evaluated and treated as necessary Pruritus: Atarax OTC lotions G. Patient Education Launder all bedding and clothing in hot water and on hot dryer cycle Place clothing that cannot be laundered in plastic storage bags for at least four days Urticaria AKA Hives A. Description A clinical manifestation of immunologic and inflammatory mechanisms. Produced by the release of histamine from mast cells. B. Clinical Presentation Transient wheals or swelling of the skin The process is dynamic, with new lesions evolving in new locations as old ones are resolving Itching Occurs spontaneously; a single lesion resolves in 24 hours Erythema and edema in upper dermis Usually raised or irregularly shaped wheals Can occur anywhere on the body C. Physical Exam History Specific questions as to what may be triggering reaction New foods, medications Environmental exposure Hair perm or dye Lotions, soaps, perfumes, hair spray Stress Recent illness D. Assessment Assess respiratory status Assess skin carefully o Rash o Where are hives concentrated? o Breaks in skin E. Diagnostic Test None recommended for acute onset Laboratory studies are usually normal  Allergy testing F. Management Remove cause if possible Medications for itching Antihistamines Eczematous Dermatitis A. Description Eczema is a superficial inflammation of the skin The terms eczema and dermatitis are often used interchangeably There are about 20 forms of eczema B. Clinical Presentation Hands are most affected Intensity of inflammation is related to the concentration of the irritant, exposure time, and the state of the epidermal barrier. Redness Pruritis Small papules and vesicles Severe cases, large vesicles and pruritic papules, edema. C. Assessment History o Yard work o Hiking o Family member working around poison ivy Physical Examination o Examine skin o Determine the distribution of the eruption D. Management Antipruritic o Benadryl o Atarax Topical Steroids Antihistamine Topical antipruritic o Calamine or Caladryl lotion Oral Corticosteroid IM steroid Psoriasis A. Description Psoriasis is a chronic, noninfectious skin inflammation occurring with remissions and exacerbations involving keratin synthesis that results in psoriatic patches; it may lead to an infection in the affected area. Various forms exist, with psoriasis vulgaris being the most common.  Possible causes of the disorder include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be a cause. The disorder may be exacerbated using certain medications. Koebner phenomenon is the development of psoriatic lesions at a site of injury, such as a scratched or sunburned area. Prompt cleansing of the area may prevent or lessen this phenomenon. In some individuals with psoriasis, arthritis develops, which leads to joint changes like those seen in rheumatoid arthritis. The goal of therapy is to reduce cell proliferation and inflammation, and the type of therapy prescribed depends on the extent of the disease and the client’s response to treatment. B. Assessment Pruritus Shedding: Silvery-white scales on a raised, reddened, round plaque that usually affects the scalp, knees, elbows, extensor surfaces of arms and legs, and sacral regions Yellow discoloration, pitting, and thickening of the nails are noted if they are affected. Joint inflammation with psoriatic arthritis C. Interventions and client education No cure, reduce the inflammation and rapid growing of epidermal cells. Provide emotional support to the client with associated altered body image and decreased self-esteem. Instruct the client in the use of prescribed therapies and to avoid over-the-counter medications. o Topical ▪ Coal Tar a. Suppresses DNA synthesis, miotic activity, and cell proliferation b. Has an unpleasant odor and may cause irritation, burning, and stinging; can also stain the skin and hair and increase sensitivity to sun c. May increase risk for cancer development in high doses ▪ Glucocorticoids a. Used for mild psoriasis b. Should not be applied to the face, groin, axilla, or genitalia, because the medication is readily absorbable, making the skin vulnerable to glucocorticoid-induced atrophy o Systemic ▪ Methotrexate a. Reduces proliferation of epidermal cells b. Can be toxic; causes gastrointestinal effects such as diarrhea and ulcerative stomatitis and bone marrow depression leading to blood dyscrasias  c. Can be hepatotoxic; hepatic function should be monitored during therapy d. This medication is teratogenic; women of child-bearing age should wait 3 months after discontinuation of the medication before becoming pregnant. ▪ Phototherapy Instruct the client not to scratch the affected areas and to keep the skin lubricated as prescribed to minimize itching. Monitor for and instruct the client to recognize and report the signs and symptoms of secondary skin problems, such as infection. Instruct the client to wear light cotton clothing over affected areas. Assist the client to identify ways to reduce stress if stress is a predisposing factor.