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Chapter 27

Chapter 27. Care of Patients with Skin Problems. Mrs. Kreisel MSN, RN NU130 Adult Health 1 Summer 2011. Epidermis.

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Chapter 27

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  1. Chapter 27 Care of Patients with Skin Problems Mrs. Kreisel MSN, RN NU130 Adult Health 1 Summer 2011

  2. Epidermis • The epidermis is the outer layer of skin. The thickness of the epidermis varies in different types of skin. It is the thinnest on the eyelids at .05 mm and the thickest on the palms and soles at 1.5 mm. • The epidermis contains 6 layers. From bottom to top the layers are named: • stratum basale • stratum spinosum • stratum granulosum • stratum licidum • Stratum corneum

  3. The bottom layer, the stratum basale, has cells that are shaped like columns. In this layer the cells divide and push already formed cells into higher layers. As the cells move into the higher layers, they flatten and eventually die. Specialized Epidermal CellsThere are three types of specialized cells in the epidermis. The melanocyte produces pigment (melanin) The Langerhans' cell is the frontline defense of the immune system in the skin The Merkel's cell's function is not clearly known The top layer of the epidermis, the stratum corneum, is made of dead, flat skin cells that shed about every 2 weeks.

  4. DermisThe dermis also varies in thickness depending on the location of the skin. It is .3 mm on the eyelid and 3.0 mm on the back. The dermis is composed of three types of tissue that are present throughout - not in layers. The types of tissue are: collagen elastic tissue reticular fibers Layers of the DermisThe two layers of the dermis are the papillary and reticular layers. The upper, papillary layer, contains a thin arrangement of collagen fibers. The lower, reticular layer, is thicker and made of thick collagen fibers that are arranged parallel to the surface of the skin.

  5. Specialized Dermal CellsThe dermis contains many specialized cells and structures. The hair follicles are situated here with the erector pili muscle that attaches to each follicle. Sebaceous (oil) glands and apocrine(scent) glands are associated with the follicle. This layer also contains eccrine (sweat) glands, but they are not associated with hair follicles. Blood vessels and nerves course through this layer. The nerves transmit sensations of pain, itch, and temperature. There are also specialized nerve cells called Meissner's and Vater-Pacini corpuscles that transmit the sensations of touch and pressure.

  6. Subcutaneous TissueThe subcutaneous tissue is a layer of fat and connective tissue that houses larger blood vessels and nerves. This layer is important is the regulation of temperature of the skin itself and the body. The size of this layer varies throughout the body and from person to person. The skin is a complicated structure with many functions. If any of the structures in the skin are not working properly, a rash or abnormal sensation is the result. The whole specialty of dermatology is devoted to understanding the skin, what can go wrong, and what to do if something does go wrong.

  7. Xerosis (Dryness) • A common problem among older patients • Fine flaking of the stratum corneum • Generalized pruritus • Scratching may result in secondary skin lesions, excoriations (abrasiains of the epideris by trauma, checmicals, burns, or other causes lichenification (cutaneousthicking & hardedning from continued irritation), and infection

  8. Collaborative Management • Nursing interventions aim to rehydrate the skin and relieve itching. • Bathing with moisturizing soaps, oils, and lotions may reduce dryness. • Water softens the outer skin layers; creams and lotions seal in the moisture provided by water.

  9. Pruritus (Itching) • Pruritus is caused by stimulation of itch-specific nerve fibers at the dermal-epidermal junction. • Itching is a subjective symptom similar to pain. • “Itch-scratch-itch” cycle. • Cool sleeping environment is helpful. • Fingernails should be trimmed short. • Antihistamines. • Topical steroids. • NURSING CARE: Major impact on quality of life

  10. Atopic Dermatitis • “Itch-scratch-itch” cycle. • STOP THE PRURITUS • Scratch->lesion->infection->pain

  11. Sunburn • First-degree, superficial burn • Cool baths • Soothing lotions • Antibiotic ointments for blistering and infected skin • Topical corticosteroids for pain

  12. Urticaria (Hives) • Urticaria—presence of white or red edematous papules or plaques of varying sizes • Removal of triggering substances • Antihistamines helpful • Avoidance of overexertion, alcohol consumption, and warm environments, which can worsen symptoms

  13. Trauma • Phases of wound healing: • Inflammatory phase • Fibroblastic or connected tissue repair phase • Maturation or remodeling phase

  14. Process of Wound Healing

  15. Process of Wound Healing (Cont’d) • First intention resulting in a thin scar • Second intention (granulation) and contraction—a deeper tissue injury or wound • Third intention (delayed closure)—high risk for infection with a resultant scar

  16. Partial-Thickness Wounds • Involve damage to the epidermis and upper layers of the dermis • Heal by re-epithelialization within 5 to 7 days • Skin injury immediately followed by local inflammation

  17. Re-epithelialization

  18. Full-Thickness Wounds • Damage extends into the lower layers of the dermis and underlying subcutaneous tissue. • Removal of the damaged tissue results in a defect that must be filled with granulation tissue to heal. • Contraction develops in healing process.

  19. Pressure Ulcer • Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period. • Mechanical forces that create ulcers: • Pressure • Friction • Shear

  20. Shearing Force

  21. Identification of High-Risk Patients • Mental status changes • Independent mobility • Nutritional status • Incontinence

  22. Pressure-Relieving Techniques • Adequate pressure relief key to prevention of pressure ulcers • Capillary closing pressure • Pressure-relief products and devices • Positioning Turn & Position q2h • Nutritional Status: Supplements & frequent snacks

  23. Wound Assessment • Pressure ulcers and their features are classified and assessed in four stages: • Stage I • Stage II • Stage III • Stage IV

  24. Four Stages of Pressure Ulceration

  25. Wound Assessment • Location • Size • Color • Extent of tissue involvement • Cell types in the wound base and margins • Exudate • Condition of surrounding tissue • Presence of foreign bodies

  26. Wound Contamination/Wound Infection • A wound that is exposed is always contaminated but not always infected. Contamination is the presence of organisms without any manifestations of infection. • Wound infection is contamination with pathogenic organisms to the degree that growth and spread cannot be controlled by the body’s immune defenses.

  27. Nonsurgical Management • Dressings: • Mechanical débridement • Natural chemical débridement • Hydrophobic material • Hydrophilic material

  28. Nonsurgical Therapy • Physical therapy • Drug therapy • Nutrition therapy • New technologies: • Electrical stimulation • Vacuum-assisted wound closure (VAC) • Hyperbaric oxygen (HBO) • Topical growth factors • Skin substitutes

  29. Hyperbaric Oxygen Therapy

  30. Surgical Management • Surgical débridement • Skin grafting

  31. Community-Based Care • Home care management • Health teaching • Health care resources

  32. Bacterial Infections • Folliculitis—superficial infection involving only the upper portion of the follicle • Furuncle (boil)—much deeper infection in the follicle • Cellulitis—generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue

  33. Furuncle

  34. Cellulitis

  35. Herpes Simplex Virus • Type 1 herpes simplex virus (HSV-1)—classic recurring cold sore • Type 2 herpes simplex virus (HSV-2)—genital herpes • Herpes zoster (shingles) • Herpetic whitlow—a form of herpes simplex infection occurring on the fingertips of medical personnel who have come in contact with viral secretions

  36. Herpes Zoster/Shingles • Caused by reactivation of the dormant varicella-zoster virus in patients who have previously had chickenpox. • Multiple lesions occur in a segmental distribution on the skin area innervated by the infected nerve. • Eruption lasts several weeks. • Postherpetic neuralgia occurs after lesions have resolved.

  37. Nursing Care of Herpes • Priority: Antiviral Therapy • pain management • Neuralgia Itching, spreading, recurrence= nursing education

  38. Fungal Infections (Dermatophyte) • Tineapedis: fungul infection of the foot • Tineamanus:fungul infection of the hand • Tineacruris: fungus disease in the scrotal, anal or genital areas • Tineacapitis:fungul infection of the scalp • Tineacorporis: red, elevated, scaly patches over the body • Candida albicans Tinea= fungus/ring worm

  39. Assessment • History • Laboratory assessment: • Tzancksmear: BX of tissue to determine cell type in a vesicular disease • Swab culture • Potassium hydroxide (KOH) test if positive eliminates need for a C&S b/c it takes to long

  40. Interventions • Skin care with proper cleansing • Isolation Precautions • Drug therapy

  41. Skin Care • Bathe daily with an antibacterial soap. • Remove any pustules or crusts gently. • Apply warm compress twice a day to furuncles or areas of cellulitis. • Apply Burow'ssolution (drying agent for weeping skin lesions) to viral lesions. • Avoid excessive moisture. • Ensure optimal patient positioning.

  42. Drug Therapy for Skin Disorders • Antibacterial drugs • Antifungal drugs • Anti-inflammatory drugs

  43. Cutaneous Anthrax • Infection caused by the spores of the bacterium Bacillus anthracis • Diagnosis based on appearance of the lesions and culture or anthrax antibodies in the blood • Oral antibiotics for 60 days—ciprofloxacin or doxycycline

  44. CutaneousAnthrax

  45. Pediculosis • Pediculosis—infestation by human lice: • Head lice—pediculosis capitis • Body lice—pediculosis corporis • Pubic or crab lice—pediculosis pubis • Pruritus most common symptom • Drugs • Laundering of clothing and bed linen

  46. Scabies • Scabies is a contagious skin disease caused by mite infestations. • Scabies is transmitted by close and prolonged contact or infested bedding. • Examine skin between fingers and on the palms. • Infestation is confirmed by an examination of a scraping of a lesion under a microscope.

  47. Common Inflammations • Contact dermatitis, atopic dermatitis • Interventions include: • Steroids • Avoidance of oil-based products • Antihistamines • Compresses and baths

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