Chapter 50

1. Chapter 50 Skin Disorders

2. Learning Objectives • Describe the structure and functions of the skin. • List the components of the nursing assessment of the skin. Define terms used to describe the skin and skin lesions. • Explain the tests and procedures used to diagnose skin disorders. • Explain the nurse’s responsibilities regarding the tests and procedures for diagnosing skin disorders. • Explain the therapeutic benefits and nursing considerations for patients who receive dressings, soaks and wet wraps, phototherapy, and drug therapy for skin problems. • Describe the pathophysiology, signs and symptoms, diagnostic tests, and medical treatment for selected skin disorders. • Assist in developing a nursing care plan for the patient with a skin disorder.

3. Anatomy and Physiology of the Skin

4. Definition The skin is an organ that covers the body surface Two distinct layers

5. Epidermis Outermost layer that covers the dermis Continually produces new cells to replace those at the surface Produce melanin, a dark pigment, that helps determine the color of the skin Strong ultraviolet light, such as in sunlight, stimulates the production of melanin

6. Dermis Strong connective tissue that contains nerve endings, sweat glands, hair roots Well supplied with blood vessels, causing the skin to redden when surface vessels are dilated Subcutaneous tissue lies beneath the dermis

7. Figure 50-1

8. Appendages Hair, nails, and sebaceous glands Hair root located in tube in dermis called a hair follicle Arrector muscles located around hair follicles contract, causing hairs to stand erect and gooseflesh skin Sebaceous glands secrete oily substance: sebum Sweat glands, in most parts of the skin, secrete through skin surface water that contains salts, ammonia, amino acids, lactic acid, ascorbic acid, uric acid, and urea

9. Functions Protection Temperature regulation Secretions Sensation Synthesis of vitamin D Blood reservoir

10. Age-Related Changes Wrinkling a result of thinning skin layers and degeneration of elastin fibers Sweat glands decrease, although production changes little until advanced age Production of sebum decreases, becoming apparent earlier in women than in men Dryness and pruritus are common Skin pales because the number of cells that produce melanin decreases

11. Age-Related Changes Skin lesions are more common Lentigines Senile purpura Senile angiomas Seborrheic keratoses Acrochordons By age 50, nearly half have some gray hair Men begin to lose hair from the scalp in their 40s; by their 80s many almost bald

12. Age-Related Changes Scalp hair thins in women as well but usually less obvious Increase in facial hair in both sexes Men may have increased hair in the nares, eyebrows, or helix of the ear Nails flatten; become dry, brittle, and discolored

13. Figure 50-2

14. Health History Chief complaint and history of present illness Discomfort, pruritus, color changes, lesions, hair loss, or abnormal hair growth Onset of condition/precipitating or alleviating factors Past medical history Previously diagnosed skin diseases or problems, current and recent medications, and allergies Diabetes mellitus, cancer, kidney failure, thyroid disease, liver disease, and anemia

15. Health History Review of systems Change in skin color or pigmentation, change in a mole, sores slow to heal, itching, dryness or scaliness, excessive bruising, rashes, lesions, hair loss, unusual hair growth, changes in nails Functional assessment Past and present occupations, exposure to chemicals or other irritants, skin care habits, sun exposure Recent changes in the work or living environment Current stresses and sources of anxiety

16. Physical Assessment Skin color and variations in pigmentation Document dilated blood vessels and angiomas Nevi (moles) inspected for irregularities in shape, pigmentation, and ulcerations or changes in surrounding skin If a rash, location, distribution, and characteristics. If any drainage, the color, amount, and odor are noted

17. Figure 50-3

18. Physical Assessment Palpate skin for temperature, moisture, texture, thickness, edema, mobility, and turgor Mobility and turgor Hair color, distribution, oiliness, and texture. The scalp is inspected for scaliness, infestations, and lesions Shape/contour of the fingernails and toenails Color of the nail bed Capillary refill checked by applying pressure to the nail to cause blanching and then releasing

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20. Diagnostic Tests and Procedures Microscopic examination of skin specimens Potassium hydroxide (KOH) examination Tzanck smear Scabies scraping Wood’s light examination Patch testing for allergy Biopsy Shave biopsy Punch biopsy Surgical excision

21. Therapeutic Measures Dressings Protect wounds; retain surface moisture Types: wet, dry, absorptive, and occlusive Negative pressure wound therapy Reduce healing time of traumatic wounds, dehisced surgical wounds, pressure and chronic ulcers Soaks and wet wraps Soothe, soften, and remove crusts, debris, and necrotic tissue

22. Therapeutic Measures Phototherapy Ultraviolet light in combination with photosensitive drugs promotes shedding of the epidermis Drug therapy Topical drugs: keratolytics, antipruritics, emollients, lubricants, sunscreens, tars, anti-infectives, glucocorticoids, antimetabolites, antihistamines, antiseborrheic agents, and vitamin A derivatives

23. Disorders of the Skin

24. Pruritus Etiology and risk factors Triggered by touch, temperature changes, emotional stress, and chemical, mechanical, and electrical stimuli Prominent symptom of psoriasis, dermatitis, eczema, insect bites

25. Pruritus Medical treatment Stress management and avoidance of known irritants, sudden temperature changes, and alcohol, tea, and coffee Lubricants in the bathwater and emollients applied after bathing also may help Medications include corticosteroids, antihistamines, and local anesthetics

26. Pruritus Assessment Collect data about symptoms that may help determine the cause The history of the current illness is important because pruritus may be just one symptom of a condition that requires attention

27. Pruritus Interventions Lubricants/emollients; adding oils to bathwater Advise to avoid bathing in very hot water Administer medications or instruct patient in their use Inspect skin daily to determine effects of treatment Explain possible causes of pruritus and encourage the patient to avoid them

28. Atopic Dermatitis (Eczema) Pathophysiology Acute stage: red, oozing, crusty rash and intense pruritus Subacute stage: redness, excoriations, and scaling plaques or pustules. Fine scales may give skin a silvery appearance Chronic stage: the skin becomes dry, thickened, scaly, and brownish gray

29. Atopic Dermatitis (Eczema) Etiology and risk factors Personal or family history of asthma, hay fever, eczema, or food allergies People with atopic dermatitis have an immune dysfunction, but it is not known whether that dysfunction is a cause or an effect of the disorder

30. Figure 50-6

31. Atopic Dermatitis (Eczema) Medical diagnosis Health history and physical examination Skin biopsy, serum immunoglobulin E levels, and cultures; allergy tests Medical treatment Topical corticosteroids; systemic antihistamines

32. Atopic Dermatitis (Eczema) Assessment Allergies, bathing practices, and current medications Interventions Impaired Skin Integrity Risk for Infection Disturbed Body Image

33. Seborrheic Dermatitis Pathophysiology Chronic inflammatory disease of the skin Affects scalp, eyebrows, eyelids, lips, ears, sternal area, axillae, umbilicus, groin, gluteal crease, and under the breasts Areas affected by this condition may have fine, powdery scales, thick crusts, or oily patches Scales may be white, yellowish, or reddish Pruritus is common

34. Seborrheic Dermatitis Etiology and risk factors The cause is unknown May be an inflammatory reaction to infection with the yeast Malassezia

35. Seborrheic Dermatitis Medical diagnosis Health history and physical examination Medical treatment Topical ketoconazole (Nizoral), sometimes with topical corticosteroids Shampoos that contain selenium sulfide (Selsun), ketoconazole, tar, zinc pyrithionate, salicylic acid, or resorcin

36. Seborrheic Dermatitis Assessment Inspect and describe the affected areas Interventions Explain the condition and reinforce the physician’s instructions for treatment

37. Psoriasis Pathophysiology Abnormal proliferation of skin cells Classic sign: bright red lesions that may be covered with silvery scales Etiology and risk factors Caused by rapid proliferation of epidermal cells Usually chronic with cycles of exacerbations and remissions

38. Psoriasis Medical diagnosis Health history and physical examination Medical treatment No cure; usually treated with topical medications: corticosteroids, tazarotene, Estar (coal tar), and vitamin D derivatives

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40. Psoriasis Assessment Describe symptoms and treatments Inspect affected areas for lesions and scales Document joint pain or stiffness because the condition may cause arthritis Interventions Ineffective Therapeutic Regimen Management Disturbed Body Image Social Isolation

41. Intertrigo Pathophysiology Inflammation where two skin surfaces touch: axillae, abdominal skinfolds, and under the breasts The affected area is usually red and “weeping” with clear margins; may be surrounded by vesicles and pustules Etiology and risk factors Results from heat, friction, and moisture between touching surfaces

42. Intertrigo Medical diagnosis and treatment Based on site/appearance of inflamed skin If the skin not broken, wash with water twice daily; rinse and pat dry; soft gauze used to separate layer of tissue and absorb moisture For severe inflammation or fungal infection: topical corticosteroid or antifungal agent

43. Intertrigo Assessment Complaints of pain, irritation, or redness in body folds Inspect susceptible areas daily

44. Intertrigo Interventions Areas where skin surfaces are in contact must be kept clean and dry Apply topical medications as ordered Report increasing redness and tenderness, fever, and broken skin to the physician Encourage women with pendulous breasts to wear a soft, supportive bra If incontinence has contributed to perineal intertrigo, position patient with legs apart to allow moisture to evaporate

45. Fungal Infections Pathophysiology Tinea pedis (athlete’s foot) Tinea manus (hand) Tinea cruris (groin) Tinea capitis (scalp) Tinea corporis (body) Tinea barbae (beard) Candidiasis: affects skin, mouth, vagina, gastrointestinal tract, and lungs

46. Fungal Infections Etiology and risk factors Spread through direct contact or by inanimate objects Lesions may be scaly patches with raised borders Pruritus common symptom Medical diagnosis Confirmed by microscopic examination of skin scrapings Medical treatment Fungal: treated with antifungal powders and creams Oral candidiasis: treated with clotrimazole troches, nystatin mouthwash or lozenges, oral amphotericin B

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48. Fungal Infections Assessment Conditions that might make a person susceptible to fungal infections Inspect the skin and mucous membranes for lesions Interventions Disturbed Body Image Altered Oral Mucous Membrane Risk for Injury

49. Acne Pathophysiology Affects the hair follicles and sebaceous glands Comedones (whiteheads, blackheads), pustules, cysts Often develop on the face, neck, and upper trunk Etiology and risk factors Androgenic hormones cause increased sebum production; bacteria proliferate, causing sebaceous follicles to become blocked and inflamed Medical diagnosis Health history and physical examination findings

50. Acne Medical treatment Topical medications: antibiotics, keratolytics such as benzoyl peroxide, topical vitamin A preparations Oral antibiotics given over several months Nonpharmacologic treatment: comedo extraction or cryotherapy Dermabrasion to reduce scarring