Chapter 56 Management of Patients With Dermatologic Problems

1. Chapter 56 Management of Patients With Dermatologic Problems

2. Care of Patients With Skin Conditions • Objectives of therapy are to prevent additional damage, prevent secondary infection, reverse inflammatory processes, and relieve symptoms • Nursing care includes administration of topical and systemic medications and providing wound care, dressings, and patient hygiene • Nursing care also needs to address the educational, emotional, and psychosocial needs of the patient

3. Psoriasis • A chronic, noninfectious inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate • Affects about 2% of the population, primarily those of European ancestry • Improves and recurs; a life-long condition • May be aggravated by stress, trauma, and seasonal and hormonal changes • Treatment: baths to remove scales and medications;see PUVA therapy (Table 56-6 )

4. Psoriasis (cont.)

5. Nursing Process—Assessment of the Patient With Psoriasis • Appearance of the skin • Coping of the patient with condition • Note impact of the disease on the patient activities and interactions

6. Nursing Process—Diagnosis of the Patient with Psoriasis • Deficient knowledge • Impaired skin integrity • Disturbed body image

7. Collaborative Problems/Potential Complications • Infection • Psoriatic arthritis

8. Nursing Process—Planning the Care of the Patient With Psoriasis • Major goals may include: • Increased understanding of psoriasis and the treatment regimen • Achievement of smoother skin with control of lesions • Development of self-acceptance • Absence of complications

9. Interventions • Patient teaching regarding the disease, skin care, and treatment regimen; see Chart 56-5 • Measures to prevent skin injury: avoid picking or scratching • Measures to prevent skin dryness: use emollients, avoid excessive washing, use warm (nothot) water, and pat dry • Use of the therapeutic relationship for support and to aid coping

10. Infectious Diseases of the Skin • Bacterial infections • Impetigo • Folliculitis, furuncles, and carbuncles • Viral infections • Herpes zoster • Herpes simplex: orolabial and genital • Fungal infections: tinea pedis, tinea corporis, tinea capitis, tinea cruris, tinea unguium; see Table 56-5

11. Impetigo

12. Herpes Zoster (Shingles)

13. Tinea Corporis (Ringworm) of the Face

14. Patient Teaching—Bacterial Infections • Impetigo is contagious and may spread to other parts of a patient’s body or to other persons • Patient teaching regarding antibiotics, hygiene, and skin and lesion care • Do not share towels, combs, etc. • Bathe daily with antibacterial soap • Furuncles, boils, or pimples should never be squeezed

15. Patient Teaching—Viral Infections • Herpes zoster: provide instruction regarding prescribed antiviral medications, lesion care, dressings, and hand hygiene • Herpes simplex: provide instruction regarding prescribed use of antiviral and prophylactic medications, information about the spread of herpes, and measures to reduce contagion of partner or of neonates born to mothers with genital herpes

16. Patient Teaching—Fungal Infections • Instruction regarding medications, use of oral and topical agents, and shampoos • Instructions regarding hygiene; use clean towels and washcloths every day • Do not share towels, combs, etc. • Keep skin folds and feet dry • Wear clean, dry, cotton clothing including underwear and socks; avoid synthetic underwear, tight-fitting garments, wet bathing suits, and plastic shoes • Avoid excessive heat and humidity • Hair loss associated with tinea capitus is temporary

17. Parasitic Skin Infestations • Pediculosis (lice): pediculosis capitus, pediculosis corporus, and phthirius pubis • Scabies (mites): Sarcoptes scabiei

18. Patient Teaching—Pediculosis Capitis • Head lice may infest anyone and are not a sign of uncleanliness • Provide instruction in use of shampoo (lindane: Kwell; pyrethrin: RID) and combing of hair with fine-tooth comb dipped in vinegar to remove all nits • Note lindane may have toxic effects and must be used only as directed • All articles of clothing and bedding must be disinfected, washed in hot water, or dry cleaned; furniture and floors should be frequently vacuumed • Do not share combs, hats, etc. • All family members and close contacts must be treated

19. Patient Teaching—Pediculosis Corporis and Pubis • Pediculosis corporis is a disease related to poor hygiene and occurs in those who live in close quarters • Pediculosis pubis is common and spread chiefly by sexual contact • Bathe in soap and water; apply prescription scabicide or an OTC permethrin, such as NIX; mechanically remove any nits; if eyelashes are involved, Vaseline may be applied twice a day for 8 days

20. Patient Teaching—Pediculosis Corporis and Pubis (cont.) • All family members and sexual contacts must be treated and instructed regarding personal hygiene • All clothing and bedding must be washed in hot water or dry cleaned • Patient and partner should be scheduled for a medical checkup to assess for coexisting sexually transmitted disease

21. Patient Teaching—Scabies • Mites frequently involve fingers and hands; contact may spread infection; health care personnel should wear gloves when providing care until infection is ruled out • Instruct patient to take a warm, soapy bath; allow skin to cool; apply the prescription scabicide lindane, crotamiton, or 5% permethrin to entire body, notincluding the face or scalp; leave on for 12 to 24 hours • Wash clothing and bedding in hot water and dry in a hot dryer • Treat all contacts at the same time • Pruritus may continue for several weeks and does not mean retreatment is required

22. Nursing Process—Assessment of the Patient With Blistering Diseases • Appearance of the skin • Monitor VS frequently and assess for signs and symptoms of infection • Pain, pruritus, and discomfort • Coping skill of the patient with the condition • Note impact of the disease on the patient’s activities and interactions

23. Nursing Process--Diagnosis of the Patient With Blistering Diseases • Acute pain: skin and oral cavity • Impaired skin integrity • Anxiety • Ineffective coping • Deficient knowledge

24. Collaborative Problems/Potential Complications • Infection and sepsis • Fluid volume deficit and electrolyte imbalance

25. Nursing Process—Planning the Care of the Patient With Blistering Diseases • Major goals may include: • Relief of pain and discomfort of lesion • Skin healing • Reduced anxiety • Improved coping • Absence of complications

26. Interventions • Provide meticulous oral hygiene • Avoid commercial mouthwashes • Keep lips moist with lip balm, petroleum, or lanolin • Provide cool humidified air • Apply cool, wet dressing or baths; initiate hygiene measures • Apply powder liberally to keep skin from adhering to sheets

27. Interventions (cont.) • Monitor for and prevent hypothermia • Skin care may be similar to that of the patient with extensive burns • Initiate measures to prevent secondary infections • Encourage adequate fluid and nutritional intake

28. Skin Cancer • Frequently related to sun exposure; prevention involves use of sunscreen and avoidance of sun exposure • Incidence is increasing • Prevention of all types of skin cancer involves protection from excessive sun exposure • Basal cell carcinoma • Most common type and most successfully treated because tumors remain localized • Squamous cell carcinoma • Prognosis depends upon presence of metastasis • Treatment involves eradication of the tumor

29. Basal Cell Carcinoma and Squamous Cell Carcinoma

30. Skin Cancer • Malignant melanoma • Risk factors: see Chart 56-8 • Worldwide incidence and mortality rate are increasing • Peak incidence occurs between ages 20 to 45 • Types: superficial spreading, lentigo-maligna melanoma, and nodular melanomas • Treatment: surgical excision and other therapies

31. Malignant Melanoma

32. Nursing Process—Assessment of the Patient With Malignant Melanoma • Inspect the skin carefully • Ask specific questions about pruritus, tenderness, pain, changes in moles, and new pigmented lesions • Assess knowledge level and risk factors • Assess coping and anxiety

33. Nursing Process—Diagnosis of the Patient With Malignant Melanoma • Acute pain • Anxiety • Depression • Deficient knowledge

34. Collaborative Problems/Potential Complications • Metastasis • Infection of surgical site

35. Nursing Process—Planning the Care of the Patient With Malignant Melanoma • Major goals may include: • Relief of pain and discomfort • Reduced anxiety and depression • Increased knowledge of early signs of melanoma • Absence of complications

36. Interventions • Pain: provide appropriate analgesics and measures to promote comfort • Provide emotional support; allow patient to express feelings, clarify misconceptions, and supply information; support coping; and involve family in the discussion

37. Kaposi’s Sarcoma (KS) • A malignancy of endothelial cells that line the blood vessels: dark reddish-purple lesions of the skin, oral cavity, GI tract, and lungs • Categories • Classic KS • Endemic (African) KS • Immunosuppression: associated KS • Occurs in transplant recipients and people with AIDS • Much more aggressive form that involves multiple body organs

38. AIDS-Related Kaposi’s Sarcoma

39. Dermatologic and Reconstructive Surgeries • Skin grafts • Autografts, allografts, and xenografts • Split thickness or full thickness • Pedicle flaps and free flaps • Chemical peels • Dermabrasion • Facial reconstruction surgery • Rhytidectomy (face lift)

40. Laser Treatment of Lesions • Argon laser • Carbon dioxide laser • Pulse-dye laser

41. Layers of Skin Appropriate for Split-Thickness and Full-Thickness Grafts

42. Common Donor Graft Sites

43. Nursing Process—Assessment of the Patient With Facial Reconstructive Surgery • Emotional responses • Coping mechanisms and support • Patient knowledge and understanding • Assess family coping, knowledge, and support

44. Nursing Process—Diagnosis of the Patient With Facial Reconstructive Surgery • Ineffective airway clearance • Pain • Deficient knowledge • Imbalanced nutrition • Impaired verbal communication • Disturbed body image/self-esteem/self-concept • Anxiety • Coping impairments

45. Collaborative Problems/Potential Complications • Infection • Bleeding and hematoma formation • Compromised circulation of flap and tissue necrosis

46. Interventions • Provide patient and family teaching and support • Monitor airway and for signs of hypoxia • Keep head slightly elevated to minimize edema • Provide analgesics as prescribed • Maintain aseptic technique • Provide frequent, gentle oral hygiene

47. Interventions (cont.) • Monitor nutritional status: I&O, weight, serum protein, and electrolyte levels • Provide individualized nutritional care • Address communication needs preoperatively; use pencil and paper, pictograph board, or other methods as needed; refer patient to speech therapy • Provide emotional reassurance and support • Encourage socialization as appropriate