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Medical surgical Nursing - II By Kokeb H. (BSc,MSc) April, 2023 Course syllabus Course Title: Medical surgical Nursing – II Module Code: Nurs 3013 EtCTS= 22 Credit hours: 13 Prerequisite: Foundation I and II, Medical Surgical Nursing - I th...
Medical surgical Nursing - II By Kokeb H. (BSc,MSc) April, 2023 Course syllabus Course Title: Medical surgical Nursing – II Module Code: Nurs 3013 EtCTS= 22 Credit hours: 13 Prerequisite: Foundation I and II, Medical Surgical Nursing - I theory and practice Module Description This module is designed to help students to acquire knowledge of various medical and surgical disorders of the Integumentary, endocrine, genitourinary, cardiovascular and nervous system disorders and their treatment It is also designed to enable students to assess, diagnose, plan, implement, monitor and evaluate the outcomes of nursing interventions provided for patients presenting with medical and/or surgical disorders. Module objective After completion of this module the students will be able to assess and manage various medical and surgical disorders of the Integumentary, endocrine, genitourinary, cardiovascular and nervous systems and be competent to provide individualized nursing care using nursing process as a framework. Furthermore, they will demonstrate skills in therapeutic communications in the health institution and in the community Teaching –learning methods Interactive lecture and discussion Small group learning activities: assignment, exercise, case study Individual reading Teaching –learning assessment methods Quiz Assignments Tests & exam Contents Nursing intervention for patients with:- 1. Integumentary disorders 2. Endocrine Disorders 3. Genitourinary disorders 4. Cardiovascular Disorders 5. Neurologic Disorders Total hour load ……168 Total Mark ……32% Integumentary system Disorders Learning objectives Discuss brief anatomy and physiology of the skin. Explain assessment of integumentary system Discuss diagnostic procedures/evaluations used in the diagnosis of Integumentary disorders Differentiate causative/risk/contributing factors of Integumentary disorders Describe the clinical manifestations of patients with Integumentary disorders Cont… Explain pathophysiologic process of Integumentary disorders Explain the medical and or/surgical managements of patients with Integumentary disorders Apply nursing process in managing nursing care of patients with Integumentary disorders Anatomy & Physiology Overview The skin is the largest organ in our body. It comprises about 15% of the body weight. The skin and its derivatives (hair, nails, sweat and oil glands) make up the integumentary system. It is composed of three layers: epidermis, dermis, and subcutaneous tissue (fat). Anatomy &... The epidermis is thickest on the palms and soles and very thin on the eyelids. The dermis is thickest on the back. The amount of fat is generous on the abdomen and buttock compared with the nose and sternum. Anatomy &... Cells of the epidermis Keratinocyte - produces keratin which helps to form the tissues of the hair, nails, and the outer layer of the skin. Covered by thin lipids to give the skin protective capacity from water and heat loss, penetration of microbial agents, and other trauma by physical mechanisms. Cells of epidermis... Melanocytes -they are the melanin (pigment) producing cell of the epidermis. Melanin prevents the skin from UV radiation It is the amount of melanin produced by melanosomes (melanin containing granules), determine difference in skin color. Cells of epidermis... Langerhans' cells (Macrophages) - ingest and destroy dead cells, foreign debris, bacteria. (building immunity to infection). They are found in the epidermis but they constantly move as a result, they transport antigens to the regional lymph nodes. Dermis largest portion of the skin Providing strength and structure. Made up of blood , lymph vessel ,nerve , hair root sweat and sebaceous gland. Subcutaneous skin :inner most layer of the skin which promote skin mobility, mold body counters and insulate the body. Glands of the Skin There are two types of skin glands: sebaceous glands and sweat glands. The sebaceous glands are associated with hair follicles. For each hair there is a sebaceous gland, the secretions of which lubricate the hair and render the skin soft and pliable. Sweat glands are found in the skin over most of the body surface. They are heavily concentrated in the palms of the hands and soles of the feet. Physiological Functions of the Skin Display Sensation: contain specialized sensory nerve structures that detect touch, surface temperature, and pain Fluid balance; preventing excess water loss through skin by evaporation. Protection: Provides a protective barrier against mechanical, thermal and physical injury and hazardous substances. Cont… Thermoregulation: the skin regulates body temperature with its blood supply, dilated vessels allow for heat loss, while constricted vessels retain heat. Immunologic: by its protective function &by the immune cells within it Assessment of skin conditions History 1. Evaluation of the lesion Site Duration Manner of spread 2. Associated symptoms Presence of itching, pain, discomfort, or oozing Relieving factors History... 2. Previous illness Personal history of previous systemic illness with dermatological manifestations (e.g. DM, Liver disease, hematological diseases) 3. Family history Family history of any skin disease Family history of systemic diseases with dermatological manifestations History... 4. History of allergy Family and personal history of skin allergy - allergic reaction to foods and medications, history of bronchial asthma, allergic rhinitis, or atopic dermatitis 5. Personal care products Recent use of cosmetic products, soaps or shampoos 6. Medication history Current use of topical or systemic medications with particular attention to antibiotics, chemotherapy ,steroids, hormones and vitamins History.. 7. Occupational and environmental exposure Exposure to known carcinogens, allergens and chemical and physical irritants 8. Sunlight exposure Excessive unprotected sunlight exposure History of photosensitivity Physical examination Description of lesions Assessment of the skin involves the entire skin area, including the mucous membranes, scalp, hair, and nails. Sites involved Duration Distribution Symmetry Affects both sides- may be endogenous Predominantly one side- mostly exogenous Types of lesions Primary lesions Macule: flat lesion due to a localized color change only; the surface is normal (size 1cm) Papule: solid elevated lesion 1cm diameter) which has a round surface (i.e. the thickness is similar to the diameter) Primary lesions... Plaque: (size > 1cm) a raised lesion where the diameter is much greater than the thickness Vesicle: (size < 1cm) a fluid filled lesion (blister) Bullae: blister which is > 1cm in size Pustule when a vesicle contains pus and the size is < 1cm and if it is more than 1cm it is called abscess. Cyst:encapsulated fluid filled or semi solid mass in the subcutaneous tissue or dermis Vesicles Bullae Nodule Secondary lesions Erosion: Loss of superficial epidermis Ulcer: Extending epidermis Scar : a mark left on the skin after healing Keloid :hypertrophied scar tissue, caused by an excess of a protein (collagen) in the skin during healing Atrophy: Aged skin, decrease in size Fissure: Linear crack in the skin Surface features Normal/ smooth: the surface is not different from the surrounding skin and feels smooth Scaly: dry/flaky surface due to abnormal stratum corneum with accumulation of or increased shedding of keratinocytes. Exudate: serum, blood, or pus that has accumulated on the surface. Surface features … Friable: surface bleeds easily after minor trauma Crust: dried serum, pus or blood Excoriation: localized damage to the skin due to scratching. Lichinification: thickening of the epidermis with increased skin markings due to persistent scratching. Umblicated; surface contains a round depression in the centre, characteristics of molluscum contagiosum or herpes simplex. Diagnostic tests (reading assignment) Immunofluorescence(IF) - Designed to identify the site of an immune reaction,immunofluorescence testing combines an antigen or antibody with a fluorochrome dye. - is a histochemical technique employed to detect antibodies bound to antigens in the tissue or in the circulating body fluids. Skin biopsy: minor surgical procedure performed to obtain tissue for microscopy examination. Biopsy is indicated in all conditions or when malignancy is suspected. If exact diagnosis is needed. KOH preparation(potassium hydroxide skin lesion exam): preformed on scaling lesions of the skin, scalp (hair), and nail lesions to examine fungal infections Diagnostic tests… Tzanck smear: is mainly used in an acute setting to rapidly detect a herpes infection or to distinguish Stevens- Johnson syndrome / toxic epidermal necrolysis (SJS/TEN) from staphylococcal scalded skin syndrome. Patch test: used to determine which specific substances cause allergic inflammation of a patient's skin Clinical photographs: Photographs are taken to document the nature and extent of the skin condition and are used to determine progress or improvement resulting from treatment. Inflammatory and allergic conditions Eczema?? Eczema Eczema is a recurrent inflammatory disorder of the skin precipitated by persistent itching followed by erythmatous, edematous vesicular and oozing lesion. Eczema has three stages: acute, sub acute or chronic. In acute stage: - Extreme redness (erythema) - Intense itching, - Bumps, Papules - Fluid-filled blisters(vesicles) - Pain, tenderness, swelling and heat Cont… Sub acute stage: is the transitional phase between the acute and chronic stages. Eczema may also begin at this stage - Flaky, scaly skin - Cracks in the skin - Itching, burning, and/or stinging - Redness that may be less intense, but not always Eczema... In chronic stage: - thickening of the skin, hyper pigmentation and lichinification due to long-term scratching. Eczema is not a specific disease. It is characterized by a vicious cycle of inflammation – itch – scratch. Classification of eczema 1. Endogenous – Atopic (personal/a family history of eczema, asthma, or allergic rhinitis – Seborrhoeic (due to an overgrowth of a type of yeast that normally lives in these areas) 2. Exogenous – Contact dermatitis ( irritant and allergic contact) – Photo dermatitis (Phototoxic and photo allergic) 3. Unclassified (special group) – Neurodermatitis (characterized by chronic itching or scaling) – Juvenile palmar - plantar dermatitis (sweaty-sock syndrome): is a disorder commonly seen in toddlers and school-age children. It consists of chronic symmetric, scaly, erythema (redness or rash) with cracking and fissuring on the toes and soles of feet. Clinical presentation Bacterial infected eczema Childhood eczema Atopic Dermatitis An in inflammatory disorder of the skin The patient inherits an increased tendency of becoming sensitized to various environmental allergens. This tendency is inherited as a polygenic recessive character (kind of inheritance in which the trait is produced from the cumulative effects of many genes) - Several relatives of the patient also often suffer from one of the atopic disorder which includes asthma, uritcaria and allergic dermatitis. Atopic... Approximately 70% of patients with atopic dermatitis have a family history of atopy. The hall mark of atopic eczema is pruritus and dryness of the skin. Diagnostic Criteria for Atopic Dermatitis Major criteria: three of the following – Pruritus – Typical morphology and distribution Flexural lichenification (The parts of the skin that touch when a joint flexes (bends))in adults Facial and extensor involvement in children – Chronic or chronically relapsing dermatitis – Personal or family history of atopic diseases Minor Criteria: three of the following Dryness of the skin Ichthiosis/ A group of skin disorders characterised by dry, scaly or thickened skin IgE reactivity, Elevated serum IgE Early stage of onset Tendency to cutaneous infection Itching when sweating Intolerance to wool and lipid solvents Treatment 1. General Measures Counseling; that it is not curable but controllable by treatments; Avoidance of factors that promotes dryness, itching or inflammation, such as excessive bathing and exposure to volatile chemicals (gasoline, kerosene) Avoidance of contact with local irritants like woolen garments; use soft cotton garments. Treatment... Clothing and linens should be washed in mild detergents and rinsed well. Soaps should be used when they are necessary In severe cases, hospitalization for a short period may promote rapid reduction of symptoms mainly by providing a changed environment Treatment... 2. Specific Specific measures are aimed at modifying the following pathogenetic factors: dryness, inflammation, infection, and itching. Treatment... Steroids: topical, systemic A mild topical steroid such as hydrocortisone 1% (cream for acute or wet, ointment for chronic or dry lesions) once to twice daily until lesions clear, usually in about 2 weeks In severe or refractive cases a stronger steroid e.g. betamethasone 0.1% once daily for 1-2 weeks. Do not use strong steroids in the face. Treatment... Always use topical steroids intermittently when they are used over longer periods of time. Chronic lichenified cases: coal tar 2-10% cream/ointment at night. For severe itchiness use antihistamines e.g. promethazine 25 mg at night. In severe or widespread infection give antibiotics (cloxacillin, erythromycin). 2. Seborrheic dermatitis A papulosquamous disorder (skin lesions characterized by well-demarcated, red or purple papules and plaques with scales), patterned on the sebum-rich areas of the scalp, the face, and the trunk. Excessive production of sebum Seborrheic Dermatitis … Commonly aggravated by changes in humidity, trauma (e.g., scratching), seasonal changes, and emotional stress. May worsen in immunosuppressive diseases. Clinical presentation Skin lesions present as greasy scale over red, inflamed skin. Infectious eczematoid dermatitis, with oozing and crusting, suggests secondary infection. A seborrheic blepharitis may occur independently. Clinical presentation... Distribution follows the oily and hair-bearing areas of the head and, the neck such as the scalp, the forehead, the eyebrows, the lash line, the nasolabial folds, the beard, and the postauricular skin. Commonly seborrheic dermatitis is secondarily infected by bacteria. Clinical presentation... Clinical presentation... Clinical presentation... Treatment Topical corticosteroids, creams, lotions Systemic ketoconazole or shampoos can be given if it is sever. Dandruff responds to more frequent shampooing. Salicylic acid, tar, selenium, sulfur, and zinc all are effective in shampoos and may be alternated. Treatment... Selenium sulfide (2.5%) or ketoconazole shampoos may help. When sever ketoconazole 200mg tab can be given for 2 to 3 week and Antibiotics if it is infected Psoriasis? Psoriasis Psoriasis is a chronic noninfectious inflammatory disease of the skin in which the production of epidermal cells occurs at a rate that is approximately 6 -9 times faster than normal rate. Increased proliferation of epidermal cells induced by abnormal reaction of immune system. Psoriasis… This abnormal process does not allow formation of the normal protective layers of the skin. The onset may occur at any age but is most common between the ages of 10 and 40 years, but may occur at any age. Cause The exact cause of psoriasis is not well determined. However, there appears to be a hereditary defect that causes over production of epidermal cell. A combination of specific genetic make-up and environmental stimuli may trigger the onset of the disease. Aggravating / triggering factors Emotional stress - inflammation stars Anxiety Trauma/injury to the skin – induce scratching Infections; causes your body to release more cytokines, proteins that affect body cells production Seasonal changes - cold and dry weather in winter Hormonal changes - High levels of estrogen Cigarette smoking; nicotine causes your body to release more cytokines. Alcohol consumption - Nonsteroidal anti-inflammatory drugs Clinical manifestation Lesions appear as dark red, raised plaque lesion covered with silvery scales Lesions produce multiple bleeding points when the scales are scraped away These patches are not moist and mostly is not itchy When psoriasis occurs on the palms and soles, it can cause pustular lesions Lesions can be symmetrical Particular sites of the body tend to be affected Scalp The area over the elbows and knees, lower part of the back & genitalia The extensor surfaces of the arms and legs, Over the sacrum and the inter gluteal fold If nails are involved, it may be presented by – Pitting – Discoloration – Crumbling beneath the free edge and – Separation of the nail plates Diagnostic Finding The presence of the classic plaque-type lesions generally confirms the diagnosis of psoriasis. When in doubt, the assess for signs of nail and scalp involvement and for a positive family history. Clinical manifestation … Clinical manifestation … Clinical manifestation … Clinical manifestation … Complications Arthritis (the relation is not understood) Erytherodermic psoriasis (involving the whole-body surface) - often appears in people with chronic psoriasis after infections or after exposure to certain medications, including withdrawal of systemic corticosteroids. Treatment Goal: To reduce the rapid turnover of the epidermis and to promote resolution of the psoriatic lesions There is no known cure. – Advise that the disease may persist for life with remission and exacerbation. – Control the problem: Remove precipitating/aggravating factors Reduce stress Teach patient that treatment of severe psoriasis can be time consuming Treatment … There are three type of treatment: Topical treatment Photo therapy treatment Systemic treatment Topical treatment Sunlight Corticosteroids Calcipotrience Coal tar Moisturizes Bath solution Salicylic acid Phototherapy UVB photo therapy: type B ultraviolet, a treatment for skin eruptions using artificial ultraviolet light. PUVA (ultraviolet A (UVA): a combination of psoralen (P) and long-wave ultraviolet radiation (UVA) that is used to treat psoriasis and some other several severe skin conditions. - Psoralen is a drug taken by mouth that makes the skin disease more sensitive to ultraviolet light. Systemic therapy Methotrexate Cyclosporine Hydroxyurea Retionoids Antibiotics Nursing management Teach patient to avoid picking or scratching the psoriatic area Teach patient to avoid any topical irritant or allergy- producing Substance Teach patient to report to physician for any infection that appears to aggravate the psoriasis Caution patient about medication because some drugs may worsen psoriasis Nursing management … Patents need a balanced life, including recreation, exercise & rest Prevent drying of the skin Avoid frequent washing Water should not be too hot, Avoid vigorous rubbing by towel after bath Use skin emollients – Help patient move toward self-acceptance – Advice to be exposed to the sun Acne vulgaris Acne vulgaris is a chronic, inflammatory disease of the pilosebaceous units of the skin. Pilosebaceous unit= hair + hair follicle + sebaceous gland It is a common inflammatory disorder affecting face, chest and back but it may occur at any site. Acne is the most commonly encountered skin condition, affecting an estimated 85% of the population between 12 & 35 years of age. Characteristics Characterized by the presence of – closed comedones (white heads) Open comedones (black heads) are primary lesions while Papules, Pustules, and Nodules & cysts are secondary lesions Becomes more marked at puberty Occurs when the pilosebaceous duct is plugged Pathophysiology Acne occurs through the interplay of 4 major factors: Excess sebum production Follicular plugging with sebum and keratinocytes Colonization of follicles by Cutibacterium acnes, a normal human anaerobe Release of multiple inflammatory mediators Pathophysiology … Secondary Triggers Mechanical obstruction (e.g., helmets) Increased hormonal activity (e.g., menstrual cycles, puberty) Stress (due to increased output of hormones from the adrenal gland) Cosmetics and emollients (occlude follicles and cause an acne form eruption) Medications with halogens (iodine, chlorine, bromine) Lithium, barbiturates, androgens Anabolic steroids Pathophysiology … 1. Increased Sebum Production Maturation of the adrenal gland or an increase in the number of cells of the sebaceous gland can lead to excess sebum production Cont… 2. Abnormal Epithelial Desquamation Hyperkeratinization of the hair follicle prevents the normal shedding of follicular keratinocytes This results in follicular canal widening and increased cell production Abnormal Epithelial Desquamation … Sebum mixes with excess loose cells in the follicular canal to form a keratinous plug, or microcomedo “Blackhead” – open comedo; color due to the oxidation of tyrosine to melanin upon exposure to air “Whitehead” – closed comedo; due to inflammation or trauma to the follicle Pathophysiology … 3. Bacterial Growth The occluded follicle is rich in lipids as this is a major component of sebum This environment fosters the growth of Propionibacterium acnes, a bacteria that is part of the normal flora of the skin Pathophysiology … 4. Inflammation P. acnes provokes an inflammatory response by breaking down triglycerides found in sebum to free fatty acids and glycerol, and these compounds are proinflammatory P. acnes leads to further inflammation by releasing chemotactic factors that result in WBC activity Factors which contribute to the development of the acne lesion are: – Excess secretion of sebum – Obstruction of the pilosebeaues orifice – Inflammation as a result of pcapionobacterum acne and leakage of content of pilosebeaceoues content Clinical manifestations Acne may present on the face, neck, chest, back, shoulders, or upper arms Acne can be described in terms of: Type of lesion Classification of severity Lesions can take months to heal completely, and fibrosis associated with healing may lead to permanent scarring Clinical manifestations … Non-Inflammatory Comedonal “Whitehead” – dilated hair follicle filled with keratin, sebum, and bacteria, with an obstructed opening to the skin “Blackhead” – dilated hair follicle filled with keratin, sebum, and bacteria, with a wide opening to the skin capped with a blackened mass of skin debris Clinical manifestations … Inflammatory Papulo-pustular Papule – small bumps less than 5mm in diameter Pustule – small bump with a visible central core of purulent material Nodulocystic Nodule – bump greater than 5mm in diameter Clinical manifestations … Clinical manifestations … Diagnosis The diagnosis of acne is established by observation of acne lesions The presence of 5-10 comedones is usually considered to be diagnostic Management Therapeutic Objectives To prevent the formation of new acne lesions To heal existing lesions To prevent or minimize scarring Treatment Options Non-pharmacologic Surface skin cleansing Topical products Oral antibiotics Hormonal agents Non-Pharmacologic Treatment Surface skin cleansing with soap and water has a relatively small effect on acne because it has minimal impact within follicle Skin scrubbing or excessive face washing does not necessarily open or cleanse pores and may lead to skin irritation Use of gentle, nondrying cleansing agents is important to avoid skin irritation and dryness during some acne therapies Pharmacologic Treatment Topical Products Benzoyl peroxide Retinoid analogues Topical antibiotics Benzoyl Peroxide (2.5%, 10%) antibacterial agent that is bacteriostatic against P. acnes Increases the sloughing rate of epithelial cells and loosens the follicular plug structure Proven effective in the treatment of acne Dosing To limit irritation and increase tolerability, begin with lowest concentration and increase either the strength or application frequency Patients should apply the product to cool, clean, dry skin no more than twice daily Retinoid Analogues Decreases cohesiveness of cells, leading to extrusion of the comedones and inhibition of new comedo formation Effectiveness in the treatment of acne is well documented Retinoid Analogues … Tretinoin (topical vitamin A acid) Availability – wide variety of dosage forms and concentrations, including Retin-AMicro Dosing – applied once nightly Adapalene (Differin) Availability – 0.1% gel, cream, alcoholic solution, and pledgets Dosing - applied once daily at night or in the morning Tazarotene (Tazorac) Availability – 0.05% and 0.1% gel or cream Dosing – applied once nightly Topical Antibiotics Both erythromycin and clindamycin have demonstrated efficacy and are well tolerated Also available in combination with benzoyl peroxide Dosing Erythromycin – applied once or twice daily Clindamycin – applied once or twice daily In combination with benzoyl peroxide – applied once or twice daily Oral Antibiotics Standard of care in the management of moderate and severe acne as well as in treatment-resistant forms of inflammatory acne Examples: Minocycline – reserved for patients who do not respond to other oral antibiotics or topical products; superior to doxycycline in reducing P. acnes Doxycycline – more effective than tetracycline Tetracycline – least expensive and most often prescribed for initial therapy Oral Antibiotics … Erythromycin – effective, but use is limited to those who cannot use the tetracyclines (e.g., pregnant women or children under 8 years Trimethoprim-Sulfamethoxazole – effective, but use is limited to those who cannot use the tetracyclines or erythromycin, or in case of resistance to these antibiotics Clindamycin – use is limited by diarrhea Oral Antibiotics … Dosing Minocycline – 50-100mg once to twice daily Doxycycline – 50-100mg once to twice daily Tetracycline – 250-500mg twice to four times daily Erythromycin – 250-500mg twice daily Trimethoprim-Sulfamethoxazole – 160/800mg twice daily Hormonal Agents Estrogen-containing oral contraceptives can be useful in the treatment of acne in some women Surgical management Surgical treatment of acne consists of - Comedo extraction, - Injections of corticosteroids into the inflamed lesions, and incision and - Drainage of large, fluctuant (ie, moving in palpable waves), nodular cystic lesions. Nursing management Inform patient that acne arises because of combination of factors Instruct patient to wash the face with mild soap and water twice a day to remove surface oils and prevent obstruction of the oil glands Caution the patient to avoid scrubbing the face constantly Hair should be kept off the face and shampooed daily if necessary Nursing management … Inform patient that all forms of friction and trauma should be avoided Teach patient that squeezing merely worsens the problem, this may be cause of post inflammatory hyperpigmantation Teach patient to be consistent with treatment because the problem is chronic Advise patient that cosmetics, shaving creams, and lotions can agitate acne Reassurance and emotional support, reduction of stress Thank you! Questions?