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402 CHAPTER19 IteuetarSste

402

IteuetarSste

6. Whatisthediethistory?Doestheclienthaveany

foodallergies?

B. Physicalassessment.

1. Inspection.

a. Assesstheskinforcolor:jaundice,cyanotic,ushed.

b. Determineifthereareareasofbruising,purpura,or

petechiae.

c. Determineifskinblanchesondirectpressure.

d. Assesslesionsfortype,color,size,distribution,and

grouping;locationandconsistency.

e. Assessforunusualodors,especiallyaroundlesions

orareas(axilla,overhangingabdominalfolds,and groin).

f. Commondermatologicallesions.

(1) Macule:at,circumscribedareaofcolor

changeintheskinwithoutsu rfaceelevation.

(2) Papule:circumscribed,solid,andelevated

lesion.

(3) Nodule:raised,solidlesionthatislargerand

deeperthanapapule.

(4) Vesicle:smallelevationinskinusuallylled

withserousuidorblood;bulla:largerthana

vesicle;pustule:vesicleorbullalledwithpus.

(5) Wheal:elevationoftheskincausedbyedema

ofthedermis. (6) Cyst:massofuid-lledtissuethatextendsto

thesubcutaneoustissueordermis.

PHySIologyoTHESKIn

A. Structure

1. Epidermisoutermostlayer.

2. Der misconnectivetissuebelowepider mis;

vascular;assistsinbodytemperatureandblood

pressureregulation.

3. Hypodermis(subcutaneous)locatedbelowder-

mis;anchorsthemusclesandbonestotheskin.

4. Nail.

a. Consistsofahard,transparentplateofkeratin.

b. Growsfromtheroot,whichliesunderathin

foldofskincalledthecuticle.5. Hair.

a. Presentovertheentirebodyexceptforthe

palmsofthehandsandthesolesofthefeet.

b. Piloerectorresponse:contractionofthet iny

erectormusclesattachedtothehairfolliclethat

leadstohairstandingonendorgooseesh.

6. Sebaceousglands:secretesebum,whichisanoily

secretionthatisemptiedintothehairshaft.

B. Functionsoftheskin.

1. Protection:primaryfunction.

2. Sensory:majorreceptorforgeneralsensation.

3. Waterbalance.

a.600to900mlofwaterislostdailythrough insensibleperspiration.

b. Formsabarrierthatpreventslossofwaterand

electrolytesfromtheinternalenviron ment.

4. Temperatureregulation.

5. InvolvedintheactivationofvitaminD.

6. Involvedinwheal-and-arereaction.

a. Wheal:swelling.

b. Flare:diffusedredness.

c. Theseresponsesareduetolocaledema.

System Assessment

A. Healthhistory(Box19-1). 1. Howlonghastheparticularrash,lesion,or

problembeenpresent?

2. Isthereanyitching,bur ning,ordiscomfor t

associatedwiththeproblem?

3. Hastheclientbeenincontactwithanyirritants,

sun,unusualcold,orunhygienicconditions?

4. Hasanyoneinthefamilyeverhadthissametypeof

problemwithhisorherskin?

5. Istheclienttakinganymedications?

Ski Increasedwrinklingandsagging,redundant

esharoundeyes,slownessofskintoattenwhen

pinchedtogether(tenting)

Dry,akingskin:excoriationfromscratching Decreasedrateofwoundhealing

Evidenceofbruising

Hair Graying,thinning,baldness;dry,scalyscalp

nais Thick,brittlenailswithdiminishedgrowth;

ridging

Prolongedreturnofbloodwithblanching

BOX 19-1 OLDER ADULT CARE FOCUS Differences in Skin Assessment Skin


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CHAPTER19 IteuetarSste 403

2. Palpation.

a. Determinetemperature(usebackofhand),skin

turgor(onolderadultspinchskinonabdomenor

forehead),andmobility.

b. Evaluatemoistureandtexture.

TESTALERT: Assess skin integrity and use

measures to maintain client skin integrity.

BEnIgn&InlAmmAToRyDISoRDERSoTHESKIn

Acne Vulgaris

Acne is an inammatory disorder of the sebaceous

glands and their hair follicles.

Data Collection

A. Morecommoninteenagers;maypersistintoadulthood.

B. Underhormonalinuenceduringpuberty;affectedby

presenceofandrogen,whichstimulatesthesebaceous glandstosecretesebum.

C. Inammatorylesionsorpustules.

D. Cysts:deepnodulesthatmayproducescarring.

Treatment

A. Medical:topicalorsystemictherapy.

Home Care

A. Instructclienttocleansefacetwicedailybuttoavoid

overcleansing.

B. Mayuseapolyesterspongepadtocleanse,becauseit

providesamechanicalremovaloftheepidermallayer.

C. Instructclienttokeephandsawayfromfaceandtoavoid

anyfrictionortraumatothearea;avoidproppinghands

againstface,rubbingface,etc.

D. Emphasizetheimportanceofanutritiousdiet;encourage

adequatefoodintakeanduseofvitaminA.

E. Avoidtheuseofcosmetics,shavingcreams,andlotion,

becausetheymayexacerbateacne;ifcosmeticsaretobe

used,water-basedmake-upispreferable.

F. Instructtheclienttoadministermedicationappropri-

ately:topicalapplication;avoidsunlightwhileusing

medications,etc.

Psoriasis

Psoriasis is a chronic inammatory disorder

characterized by rapid turnover of epidermal cells.

Data Collection

A. Silveryscaling,plaquesontheelbows,scalp,knees,

palms,soles,andngernails.

B. Ifscalesarescrapedaway,adarkredbaseofthelesion

isseen,whichwillproducemultiplebleedingpoints.

C. Mayimprovebutoftenrecursthroughoutlife.

D. Bilateralsymmetryofsymptomsiscommon.

Treatment

A. Medical.

1. Topicaltherapy.

a. Coaltarpreparation(Anth ralin).

b. Corticosteroids. 2. Photochemotherapy(PUVAtherapy):psoralen,

ultravioletAtherapy(mustwearprotectiveeyewear

duringtreatmentandfor24hoursaftertherapy).

3. Systemictherapy:antimetabolites(methotrexate);

immunosuppressants.

Home Care

A. Encourageverbalizationofan xietyregarding

appearance.

B. Instructclienttouseasoftbrushtoremovescaleswhile

bathing.

C. Assessclienttodeterminefactorsthatmaytriggerskin condition(e.g.,emotionalstress,trauma,seasonal

changes).

D. Makesureclientunderstandstreatmentandimplications

ofcarerelatedtoPUVAtherapyandothertreatments.

Atopic Dermatitis

Atopicdermati tis (also called eczema) is a supercial

chronic inammatory disorder associated with allergy with

a hereditary tendency (atopy); condition usually occur

during infancy, usually between 2 and 6 months of age.

Data CollectionA. Reddenedlesions,occuronthecheeks,arms,andlegs;

antecubitalandpoplitealspaceinadults;mayhave

oozingvesicles.

B. Intenseitching(worseatnight).

C. Infantswitheczemaaremorelikelytohaveallergiesas

childrenandadultsanddevelopasthma.

Treatment

A. PruritusistreatedwithBenadryl,topicalsteroids,and

withimmunomodulators.

Home CareA. Teachparentsaboutdietaryrestrictions;providethem

withwrittenguidelines.

B. Keepngernailsandtoenailscutshort.

C. Feedthechildwhenheiswellrestedandisnotitching.

D. Childshouldwearnonirritatingclothing;wooland

abrasivefabricsshouldbeavoided.

E. Tepidbathwithmildsoaporaeumulsifyingoil

followedimmediatelybyapplicationofanemollient;

coolcompressestodecreaseitching.


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Contact Dermatitis

Contactdermatitis is an inammatory skin reaction

that results because the skin has come in contact with a

specic irritant - diaper dermatitis (prolonged contact with

urine, feces, ointments, soaps, or fricition) or an allergen

(allergic contact dermatitis, which is usually a symptom of

delayed hypersensitivity).

Data Collection

A. Pruritus;hive-likepapules,vesicles,andplaques(more

chronic).

B. Sharplycircumscribedareas(withoccasionalvesicle

formation)thatcrustandooze.

Treatment

A. Medical.

1. Topicalsteroids;oralsteroidsforseverecases.

2. Antihistamines,antipruriticagents,andantifungals

(diaperdermatitis). 3. Aveeno(oatmeal)bathsandtopicalsoaks.

Home Care

A. Teachimportanceofwashingexposedskinwithcool

waterandsoapassoonaspossibleafterexposure(within

15minutesisbest).

B. Providecool,tepidbath;trimngernails,anduse

measurestocontrolitching.

C. Frequentdiaperchanges,keepskindry,anduse

protectiveointment(zincoxideorpetrolatum).

Pressure Ulcer

Apressureulcer(decubitusulcer,bedsore ) is localized

injury to the skin and/or underlying tissue usually over a

bony prominence, as a result of pressure, or pressure in

combination with shear and/or friction.

NURSING PRIORITY: Identify potential for

skin breakdown: a pressure ulcer can be and should be

prevented. Identify those clients at increased risk for

ulcer development and begin preventative care as soon

as possible. Do not wait for the reddened area to occur

before preventative measures are initiated.

Assessment

A. Riskfactors/etiology.

1. Prolongedpressurecausedbyimmobility.

2. Malnutrition,hypoproteinemia,vitamindeciency.

3. Infection,advancingage.

4. Skindryness,maceration,excessiveskinmoisture.

5. Equipmentsuchascasts,restraints,tractiondevices,etc.

B. ClinicalmanifestationsseeFigure19-1.

Treatment

A. Medicalandsurgical.

1. Debridement(init ialcareistoremovemoist,

devitalizedtissue).

a. Sharpdebridement:useofascalpelor

otherinstrument;usedprimarily,especiallywith

cellulitisorsepsis.

Suspected Deep Tissue Injury: Purpleor maroonlocalized area

ofdiscoloredintactskin orblood-lledblister duetodamageof

underlyingsofttissuefrompressureand/orshear.Theareamaybe

preceded by tissue that is painf ul, rm ,mushy,b oggy,warmer or

coolerascomparedtoadjacenttissue.

Further description:Deeptissueinjurymaybedifculttodetectin

individualswithdarkskintones.Evolutionmayincludeathinblister

overadarkwoundbed.Thewoundmayfurtherevolveandbecomecoveredbythineschar.Evolutionmayberapidexposingadditional

layersoftissueevenwithoptimaltreatment.

Stage I: Intactskinwithnon-blanchablerednessofalocalizedarea

usuallyoverabonyprominence.Darklypigmentedskinmaynothave

visibleblanching;itscolormaydifferfromthesurroundingarea.

Further description:Theareamaybepainful,rm,soft,warmer

orcoolerascomparedtoadjacenttissue.StageImaybedifcultto

detectin individualswith darkskin tones.Mayi ndicateatrisk

persons(aheraldi ngsignofrisk)

Stage II: Partialthickness lossofderm ispresentingas ashallow

openulcerwitharedpinkwoundbed,withoutslough.Mayalso

presen tasanint actoropen/ru pture dserum-lle dbliste r.

Further description:Presentsasashinyordryshallowulcerwithout

sloughorbruising.*Thisstageshouldnotbeusedtodescribeskin

tears,tapeburns,perinealdermatitis,macerationorexcoriation.

*Bruisingindicatessuspecteddeeptissueinjury

Stage III: Full thickness tissue loss. Subcutaneous fat may be

visiblebutbone,tendonormusclearenotexposed.Sloughmaybe

present butd oes not obscure the depth oft issue loss. Mayi nclude

underminingandtunneling.

Further description:ThedepthofastageIIIpressureulcervaries

by anatomic al location. The bridge of the nose, ear, occiput and

malleolusdonothavesubcutaneoustissueandstageIIIulcerscan

be shallow. In contr ast, area s of signi cant adiposit y can develop

extremelydeepstageIIIpressureulcers.Bone/tendonisnotvisible

ordirectlypalpable.

Stage IV: Fullthicknesstissuelosswithexposedbone,tendonor

muscle.Sloughorescharmaybepresentonsomepartsofthewound

bed.Ofteni ncludeunderm iningandt unneli ng.

Further description: ThedepthofastageIVpressureulcervaries

by anatomic al location. The bridge of the nose, ear, occiput and

malleolusdonothavesubcutaneoustissueandtheseulcerscanbe

shallow.StageIVulcerscanextendintomuscleand/orsupporting

structures(e.g.,fascia,tendonorjointcapsule)makingosteomyelitis

possible.Expo sedbone/tend onisvisibleordi rectlypalpable.

Unstageable:Fullthicknesstissuelossinwhichthebaseoftheulcer

iscoveredbyslough(yellow,tan,gray,greenorbrown)and/oreschar

(tan,brownorblack)inthewoundbed.

Further description:Untilenoughsloughand/orescharisremoved

toexposethebaseofthewound,thetruedepth,andthereforestage,

cannotbedetermined.Stable(dry,adherent,intactwithouterythema

oructuance) eschar onthe heels serves as thebodys natural

(biological)coverandshouldnotberemoved.

Figure 19-1:Stages of Pressure Ulcers

IgURE 19-1 Staes Pressure Ucers Reprinted withpermission: National Pressure Ulcer Advisory Panel. (2007). PressurUlcer Stages Revised by NPUAP. Retrieved July 31, 2008 from http:/www.npuap.org/resources.htm


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b. Mechanicaldebridement:wet-to-drydressings,

hydrotherapy,woundirrigation,anddextranomers

(smallbeadspouredoversecretingwoundstoabsorb

exudate).

c. Enzymaticandautolyticdebridement:useof

enzymesorsyntheticdressingsthatcoverwoundand

self-digestdevitalizedtissuebytheactionof

enzymesthatarepresentinwounduids.2. Woundcleansing(usenormalsalinesolutionformost

cases).

a. Useminimalmechanicalforcewhencleansingto

avoidtraumatothewoundbed.

b. Avoidtheuseofantiseptics(e.g.,Dakinssolution,

iodine,hydrogenperoxide).

3. Dressings(shouldprotectwound,bebiocompatible,and

hydrate).

a. Moistenedgauze.

b. Film(transparent).

c. Hydrocolloid(moistureandoxygenretaining).

NURSINGPRIORITY: Keep the ulcer tissue moist

and the surrounding intact skin dry.

B. Dietary.

1. Increasedcarbohydratesandprotein.

2. IncreasedvitaminCandzinc.

Nursing Intervention

v Goal: Topreventorrelievepressureandstimulate

circulation.

A. Frequentchangeofposition;turnclientevery1to2

hours.B. Specialbedswithmattressesthatprovidefora

continuouschangeinpressureacrossthemattress.

C. Siliconegelpadsplacedunderthebuttocksofclientsin

wheelchairs.

D. Sheepskinpadstoprovideasoftsurfacetoprotectthe

skinfromabrasion.

E. Eggcrateorfoammattresstoallowcirculationunderthe

bodyandkeeptheareadry.

F. Activeandpassiveexercisestopromotecirculation.

v Goal: Tokeepskincleanandhealthyandpreventthe

occurrenceofapressureulcer.

A. Washskinwithmildsoapandblotcompletelydrywith

softtowel. 1. Avoidhotwaterandexcessiverubbing.

2. Uselotionorprotectivemoisturizerafterbathing.

B. Inspectskinfrequently,especiallyoverbony

prominences.

NURSING PRIORITY: Avoid massage over

bony prominences. When the side-lying position is used in

bed, avoid positioning client directly on the trochanter use

the 30 lateral inclined position. Do not use donut-type

devices. Maintain the head of the bed at or below 30 or

at the lowest degree of elevation. Encourage chair-bound

persons, who are able, to shift weight every 15 minutes.

C. Removeanyforeignmaterialfromthebed,becauseit

mayserveasasourceofirritation;keepsheetstightly

stretchedonbedtopreventwrinkles.

v Goal: Topromotehealingofpressureulcer.

A. Usemethodsdiscussedtodecreasethepressureonthe

areainwhichthepressureulcerisfound.

1. Air-uidizedbeds-stageIIIorstageIVpressure

ulcers

2. Staticsupportsurfaces-notrecommendedforStage

IIIorIV.

B. Keeptheulcerareadry.

1. Minimizeskinexposuretomoisturecausedby incontinence,perspiration,orwounddrainage.

2. Useonlyunderpadsorbriefsthataremadeof

materialsthatabsorbmoistureandprovideaquick-

dryingsurfacenexttotheskin.

3. Positiontheclientwiththeulcerexposedtoair;may

uselighttoincreasedryingandpromotehealing.

C. Useskinbarrierstodecreasecontaminationandincrease

healingofanoninfectedulcer.

D. Observetheulcerforsignsofinfection.Infectedulcers

willhavetobedebrided,ifhealingistooccur.

SKInInECTIonSAnDInESTATIonS

Impetigo

Impetigo is a bacterial skin infection caused by

invasion of the epidermis by pathogenic Staphylococcus

aureus and/or group A beta-hemolytic streptococci.

Data Collection

A. Pustule-likelesionswithmoisthoney-coloredcrusts

surroundedbyredness.

B. Pruritus;spreadstosurroundingareas.

C. Appearsmorecommonlyontheface,especiallyaround

themouth.

Treatment

A. Medical.

1. Local:topicaltreatment.

a. Gentlewashingtwotothreetimesadayto

removecrusts.

b. Topicalmupirocin(Bactroban)antibioticcream,

ifonlyacoupleoflesionsarefound.

2. Systemicantibiotictherapyisthetreatmentofchoice

withextensivelesions.


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Home Care

A. Teachtheclientandfamilytheimportanceofgoodhand

washingandthatlesionshealwithoutscarring.

B. Encourageadherencetotherapeuticregimen,especially

takingthefullcourseofantibiotics.

C. Untreatedimpetigomayresultinglomerulonephritis.

Cellulitis

Cellulitis is an inammation of the subcutaneous tissues

often following a break in the skin caused byStaphylococcus

aureus, Streptococcus, or Haemophilus infuenzae.

Data Collection

A. Intenseredness,edemawithdiffuseborder,and

tenderness.

B. Chills,malaise,andfever.

Treatment

A. Medical.

1. Moistheat,immobilization,andelevationofpart.

2. Systemicantibiotictherapyisthetreatmentof

choicewithextensivelesions.

Home Care

A. Teachtheclientandfamilytheimportanceofgoodhand

washing.

B. Encourageadherencetotherapeuticregimen,especially

takingthefullcourseofantibiotics.

Fungal (Dermatophyte) InfectionsAssessment

A. Types.

1. Tineacorporis(ringworm):temporaryhairloss,if

scalpisaffected.

2. Tineacruris(jockitch):small,red,scalypatchesin

thegroinarea.

3. Tineapedis(athletesfoot):scaling,maceration,

erythema,blistering,andpruritus;usuallyfound

betweenthetoes.

4. Tineaunguium(onychomycosis):thickened,

cr umblingnails(usuallytoes)withyellowish

discoloration. 5. Candidiasis:causedbyCandida albicans,knownas

moniliasis,mayaffectoralmucosa,groin,andmoist

areas;whiteplaquesinmouth;diffuseredrashon

skin.

Treatment

A. Topicalantifungalcream(seeAppendix19-1).

B. Oralantifungalmedication.

B. Systemictherapy:Griseofulvin;usedprimarilyfor

extensivecases.

Home Care

A. Topreventathletesfoot,clientshouldbeinstructed

tokeepfeetasdryaspossibleandwearsocksmadeof

absorbentcotton.

1. Talcumpowderorantifungalpowdermaybeused;

Tinactinmaybeappliedtwicedaily.

2. Encourageaerationofshoestoallowthemto completelydryout.

B. Clientshouldmaintainhygienicmeasurestopreventthe

spreadoffungaldiseases,specicallyringwormofthe

scalp.

1. Familymembersshouldavoidusingthesamecomb.

2. Scarvesandhatsshouldbewashedthoroughly.

3. Examinefamilyandhouseholdpetsfrequentlyfor

symptomsofthedisease.

C. Clientshouldavoidinfection.

1. Anyactivitythatallowsheat,friction,and

macerationtooccurmayleadtoskinbreakdownand

infection.

2. Loose-ttingclothingandcottonunderwearareto

beencouraged.

Parasitic Infestations

A. Pediculosis.

1. Types.

a. Pediculus humanus capitis:headlice.

b. Pediculus humanus corporis:bodylice.

c. Phthirus pubis:pubicliceorcrabs.

2. Clinicalmanifestations.

a. Intensepruritus,whichmayleadtosecondary

excoriationandinfection.

b. Tiny,red,noninammatorylesions. c. Eggs(nits)ofbothheadandbodyliceareoften

attachedtothehairshafts.

d. Pubicliceareoftenspreadbysexualcontact.

B. Scabies:aninfestationoftheskinbyitchmites.

1. Intenseitching,especiallyatnight.

2. Burrowsareseen,especiallybetweenngers,onthe

surfacesofwrists,andinaxillaryfolds.

3. Redness,swelling,andvesicularformationmaybe

noted.

Treatment

A. Pediculosis. 1. Permethrin1%liquid(Nix):effectiveagainstnits

andlicewithjustoneapplication;shampoohair

rst,leaveNixonhairfor10minutes,rinseoff;may

repeatin7days.

2. Pyrethrincompounds(e.g.,Rid)forpubicandhead

lice.

B. Scabies:Permethrin5%cream(Elimite).Creamis

appliedtotheskinfromheadtosolesoffeetandlefton

for8to14hours,thenwashedoff;onlyoneapplication

needed.


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Home Care

A. Allfamilymembersandclosecontactsneedtobe

treatedforparasiticdisorders;licecansurviveup

to48hours;nitscanhatchin7-10dayswhenshedinthe

environment.

B. Beddingandclothingthatmayhaveliceornitsshould

bewashedordrycleaned;furnitureandrugsshouldbe vacuumedortreated.

C. Nursesshouldweargloveswhenexaminingscalpto

preventspreadtoothers.

D. Whenshampooinghair,useane-toothcombor

tweezerstoremoveremainingnits.

Viral Infections

A. Herpessimplexvirus(feverblister,coldsore):herpes

virustype1(HSV-1).

1. Painful,localreactionconsistingofvesicleswithan

erythematousbase;mostoftenappearsaroundthe

mouth. 2. Contagiousbydirectcontact;isrecurrent(lesions

appearinsameplace);thereisnoimmunity.

3. NottobeconfusedwithHSV-2,whichprimarily

occursbelowthewaist(genitalherpes).

4. ItispossiblefortheHSV-1tocausegenitallesions

andforHSV-2tocauseorallesions(seeSexually

TransmittedDiseasesinChapter17).

B. Herpeszoster(shingles).

1. Relatedtothechickenpoxvirus:varicella.

2. Contagioustoanyonewhohasnothadchickenpox

orwhomaybeimmunosuppressed.

3. Linearpatchesofvesicleswithanerythematousbase

arelocatedalongspinalandcranialnervetracts. 4. Oftenunilateralandappearsonthetrunk;however,

mayalsoappearontheface.

5. Pain,burning,andneuralgiaoccuratthesitebefore

outbreakofvesicles.

6. Oftenprecipitatedbythesamefactorsasherpes

simplexinfection.

C. Herpeticwhitlow:occursonngertipsandaroundnail

cuticles;oftenseeninmedicalpersonnel.

Treatment

A. Usuallysymptomatic;applicationofsoothingmoist

compresses.B. Analgesics;gabapentin(Neurontin)forpostherpetic

neuralgia.

C. Antiviralagents(seeAppendix19-1).

D. Zostervaccineisrecommendedforadultsover60years.

Home Care

A. Alleviatepainbyadministeringanalgesics.

B. Antihistaminesmaybeadministeredtocontrolthe

itching.

C. Usually,lesionshealwithoutcomplications;herpes

simplexusuallyhealswithoutscarring,whereasherpes

zostermaycausescarring.D. Ifhospitalized,establishcontactprecautionsforherpes

zoster.

mAlIgnAnTSKInnEoPlASmS

Malignant Melanoma

Data Collection

A. Riskfactors

1. ChronicUVexposurewithoutprotectionor

overexposuretoarticiallight(tanningbed).

2 Fairskin,genetic(rstdegreerelative).3. Hasthehighestmortalityrateofanyformofskincancer

a. Oftenappearsinpreexistingmolesintheskin.

b. Commonsitesincludebackandlegs(women);trunk

head,andneck(men).

c. Suddenorprogressivechangeorincreaseinsize,

color,orshapeofamole.

4.Symptoms(Box19-2).

TreatmentA. Surgical.

1. Excisionalsurgery;lasertreatment.

2. Cryosurgery.

3. Electrodesiccationandcurettage.

B. Medical. 1. Radiationtherapy.

2. Chemotherapyandbiologictherapy.

Home Care

A. Teachtheimportanceofavoidingunnecessaryexposure

tosunlight.

B. Applyprotectivesunscreenwhenoutside.

C. Teachthewarningsignsofcancer.

Melanomastendtohave:

A Asymmetry

B BorderIrregularity

C ColorVariegation

D Diametergreatthan6mm

EEvolvingorchanginginsomeway

BOX 19-2 MALIGNANT MELANOMA


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Burns

A. Typesofburnsthermal,electrical,chemical,smoke

andinhalation.

B. Fluidshiftconsiderations.

1. Fluidshiftandedemaformationoccurwithin24to

48hoursafterburninjury.

2. Fluidmobilizationoccurswithinapproximately18to 36hoursafterburninju ry.

Data Collection

A. Criteriasuggestingpulmonarydamage.

1. Historyofburninjuryoccurringwithinaconnedarea.

2. Burnsaroundtheface,neckormouthorintheoral

mucosa.

B. Circulatorystatus.

1. Tachycardiaandhypotensionmayoccurearly.

2. Evaluateurineoutput.

C. Identifywhenclientatelast;checkgastrointestinal

function.D. Evaluateresponsetouidtherapy.

E. Evaluatecirculatorystatusoftheextremities.

NURSING PRIORITY: The client with burn

injury is often awake, mentally alert, and cooperative at

rst. The level of consciousness may change as respiratory

status changes or as the uid shift occurs, precipitating

hypovolemia. If the client is unconscious or confused,

assess him or her for the possibility of a head injury.

F. Determinetheseverityoftheburninjury(Box19-3and

Figure19-2). 1. Neckandfaceburnsmayleadtomechanical

occlusionoftheairwayduetoedema.

2. Circumferentialburns(burnssurroundinganentire

extremity)mayleadtoimpairedcirculationfrom

edemaformationandlackofelasticityoftheeschar,

leadingtocompartmentalsyndrome.

Supercialorrst-degreeburn:Areaisreddened

andblancheswithpressure;noedemapresent;area

isgenerallypainfultotouch. Partial-thicknessorsecond-degreeburn:Dermis

andepidermisareaffected;formationoflarge,

thick-walledblisters;underlyingskiniserythematous.

Full-thicknessorthirdandfourth-degreeburn:All

oftheskinisdestroyed;mayhavedamagetothe

subcutaneoustissueandmuscle;usuallyhasadry

appearance,maybewhiteorcharred;willrequire

skingraftingtocoverarea;underlyingstructures

(fascia,tendons,andbones)areseverelydamaged,

usuallyblackened.

BOX 19-3 DEPTH OF BURNS

3. Age.

a. Infantshaveanimmatureimmunesystemand

poorbodydefense.

b. Olderadultclientshealslowly;morelikely

tohavewoundinfectionproblemsand

pulmonarycomplications.

4. Presenceofotherhealthproblems:

a. Diabetesandperipheralvasculardiseasedelay

woundhealing.

b. Poornutr itionalstate.

c. Ch roniccondit ionsthatcompromiseimmune

system.

Treatment

A. Stabilizationofairway,breathing,andcirculation.

B. Iftheburnareaissmall,applycoldcompressesor

immerseinjuredareaincoolwatertodecreaseheat;ice

shouldnotbedirectlyappliedtotheburnarea.

C. Administertetanusinjection.

D. Fluidresuscitation;IVuids.

E. NPO;mayneedanasogastrictube.

F. Analgesicsaregivenintravenously;intramuscularly,

subcutaneously,orallyadministeredmedicationsmay

notabsorbeffectively.

G. Methodsofwoundcare(areaiscleanedanddebridedof

necroticburnedtissue).

1. Openmethod(exposure):Burniscoveredwitha

topicalantibioticcream,andnodressingisapplied.

2. Closedmethodofdressing:Finemeshisusedto

covertheburnedsurface;maybeimpregnatedwith

antibioticointmentorointmentmaybeapplied

beforethedressingisapplied.

3. Escharotomy:Procedureinvolvesexcisionthrough

theeschartoincreasecirculationtoanextremity

withcircumferentialbu rns.

a. Enzymaticdebriders:Collagenase,brinolysin,

andAccuZymemaybeused.

IgURE19-2 DereeBurbTissuelaer (From ZerwekhJ., Claborn, J. Memory Notebook of Nursing, Vol. 2, 2008, NursingEducation Consultants.)


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1. Thenurseunderstandsthatpressureulcersaremost

commonlycausedbywhatproblem?

1 Musclesthatarenotbeingusedinpassiveexercises.

2 Poornutrition,resultingininadequateproteinin

take.

3 Irritationofabonyprominencethatiscoveredby

infectedskin.

4 Pressurecuttingoffbloodsupplytotheaffected

areaoftheskin.

2. Inreport,thenurseistoldtheclienthasastage1pres-

sureulcer.Whatwouldthenurseexpecttondon

assessmentofthearea?

1 Aareaoferythemathatdoesnotblanchwithdigital

pressure.

2 Amoistareawheretheskinhassloughed.

3 Awell-circumscribedareathathasacentercraterin

subcutaneoustissue.

4 Areddenedareaofirritationandscalyplaqueson theskin.

3. Aclienthasapressureulcerthathasnecrosisinthe

subcutaneousleveloftissue.Thereisunderminingof

thesurroundingtissue.Whatisthenursingcareforthis

stageofapressureulcer?

1 Carefullycleantheareawithhydrogenperoxide

andapplyadrydressing.

2 Gentlymassagetheareaaroundthenecrosisto

stimulatehealing.

3 Applyacleandressingandencourageanincreased

uidintake.

4 Keeppressureofftheareaandanticipateprocedure

fordebridement.4. Whichofthefollowingnursinginterventionswillassist

inreducingpressurepointsthatmayleadtopressure

ulcers?

Selectallthatapply:

1 Positiontheclientdirectlyonthetrochanterwhen

side-lying.

2 Avoidtheuseofdonutdevices.

3 Massagebonyprominences.

4 Elevatetheheadofthebedaslittleaspossible.

5 Whenside-lyingusethe30lateralinclinedposition.

6 Avoiduninterruptedsittinginanychairorwheel-

chair.

5. Whatwouldthenurseteachanolderadultclientregard- inghowtocareforherdry,itchyskin?

1 Useamoisturizeronalldryskinareas.

2 Wearclotheswith80%ormoreofcottonbers.

3 Showertwiceadaywithmildsoap.

4 Wearprotectivepadsondryskinareas.

6. Aclienthasathird-degreecircumferentialburnonhis

leftupperarm.Escharhasformedontheburnarea.

Whatismostimportantforthenursetoassess?

1 Evaluatearoundtheescharforpresenceofinfection.

2 Statusofcirculationinthelefthand.

3 Presenceofbilateralbreathsounds.

4 Statusofurinaryoutputandhydration.

7. Whatwillbeimportantforthenursetotelltheparents

ofachildwhohasaproblemwithheadlice?

1 Washthechildshairwithacoaltarbasedshampoo

andrinsethoroughly.

2 Thoroughlywashallofthechildsbeddingand

clothes.

3 Useananti-itchcream,butmakesuretheirritated

areasdonotgetinfected.

4 Useanantibioticointmentaftershampooingwith

Permethrin1%(Nix).

8. Anolderadultclientinalong-termcarefacilityhas

beendiagnosedwithherpeszoster.Whatisimportant

nursingmanagementforthisclient?

1 Dailyapplicationofanantifungalcreamtoaffected

areas.

2 Maintainclientonstandardprecautions.

3 Applywarmsoakstoareaofvesicles. 4 Assisttheclienttodealwiththeneuralgia.

9. Aclienthasbeendiagnosedwithbasalcellcarcinoma

andtheareahasbeenexcised.Whatwillbeimportant

forthenursetoexplaintothispatient?

1 Pain,bu rning,andneuralgiamayoccurinthe

affectedarea.

2 Itisveryimportanttousesunscreenanytimeyou

gooutside.

3 Useanant iinammatoryointmenttopreventa

secondaryinfectioninthearea.

4 Oncetheareahasbeenexcised,thereshouldbeno

furtherproblems.

10. Aclienthasbeendiagnosedwithpsoriasis.Whatwould beimportantforthenursetodiscusswiththisclient?

1 Theuseoftopicalsteroidsandultravioletlightwill

helptocontroltheproblem.

2 Theareashouldbecleansed,scalesremoved,and

thentheantibioticointmentapplied.

3 Warm,moistpackscanbeappliedtotheareato

assistinthedebridingofthelesion.

4 Theproblemusuallygoesawaywithtreatment,but

theareamayremaintendertothetouch.

11. Achildhasscabies.Whatshouldthenurseexplainto

themother?

1 Carefullyremovenitsfromareaandthenwashwith

alcohol. 2 SpreadElimitecreamalloverbody,leaveonfor8

to12hours,andthenwashoff.

3 Applymoistsoaksofantifungalmedicationon

burrowedskinlesionsfor1to2hours,thenrinse.

4 Encourageexposuretosunlighttodrytheareaand

applyantibioticointment.

Answers and rationales to these questions are in the section a

the end of the book titled Chapter Study Questions: Answers

and Rationales.

StudQuestis:IteuetarSste


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Appendix 19-1 SKIN DIAGNOSTIC STUDIES

SkitestiPurpose:conrmsensitivitytoaspecicallergenbyplacingantigenonordirectlybelowskin(intradermal)tocheckfor

presenceofantibodies.

1. Twomethodsallergenappliedtoarmsorback.

Cutaneousscratchtest(alsoknownasatineorprick test)

Intracutaneousinjection-highriskofsevereallergicreaction

Patchtestusedtodetermineifclientisallergictotestingmaterial(smallamountappliedonback)returnsin48hours

forevaluation.

2.Interpretingresults.

Immediatereaction:appearswithinminutesaftertheinjection;markedbyerythemaandawheal;denotesapositive

reaction.

Positivereaction:localwheal-and-areresponseoccurs.

Negativereaction:inconclusive;mayindicatethatantibodieshavenotformedyetorthatantigenwasdepositedtoo

deeplyinskin(notanintradermalinjection);mayalsoindicateimmunosuppression.

3. Complications:rangefromminoritchingtoanaphylaxis(seeChapter5).

NURSINGPRIORITY: Never leave client alone during skin testing due to risk of anaphylaxis. If a severe reaction

occurs, anticipate antiiammatory topical cream applied to skin site (scratch test) or a tourniquet applied to the arm

(intracutaneous test) and possible epinephrine injection.

BipsTypes:punch,excisional,incisional,shave

1. Verifyifinformedconsentisneeded.

2. Applydressingandgivepostprocedureinstructionswatchforbleeding.

SkiCuturePurpose:identifyfungal,bacterial,andviralorganisms.

1. Scraporswabaffectedarea;labelspecimenandsendtolab.


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Appendix 19-2 MEDICATIONS USED IN SKIN DISORDERS

gEnERAlnURSIngImPlICATIonS Topicalmedicationsareusedprimarilyforlocaleffectswhensystemicabsorptionisundesirable.

Fortopicalapplication:

Applyaftershowerorbathforbestabsorption,becauseskinishydrated.

Applysmallamountofmedicationandrubinwell.

medicatis SideEects nursiIpicatis

AnTIUngAl:Ihibitsrdaaesuaceebrae,eitherateripereabiitrdisrupticeitsis.

Clotrimazole(Lotrimin):topical

Nystatin(Mycolog):topical

Ketoconazole(Nizoral):PO,topical

Griseofulvin(Fulvicin):PO

Nausea,vomiting,abdominalpain.

Hypersensitivityreaction:rash,urticaria,

pruritus.

Hepatotoxicity.

Gynecomastia(ketoconazole).

1. Monitorhepaticfunction(whenoral

medicationisgiven).

2. Avoidalcoholbecauseofpotentialliver

problems.

3. Checkforlocalburning,irritation,or

itchingwithtopicalapplication.

4. Prolongedtherapy(weeksormonths)

isusuallynecessary,especiallywith

griseofulvin(Fulvicin).

5. Takegriseofulvin(Fulvicin)withfoods

highinfat(e.g.,milk,icecream)todecreaseGIupsetandassistin

absorption.

6. Uses:tineainfections,fungalinfections,

candidiasis,diaperdermatitis.

AnTIVIRAl:Reducesvirasheddi,pai,adtiethea.

Acyclovir(Zovirax):topical,PO,IV.

Penciclovir(Denavir):topical

Vidarabine(Ara-A, Vir-A):IV,ophthalmic

IV:phlebitis,rash,hives.

PO:nausea,vomiting.

Topical:burning,stinging,pruritus.

Anorexia,nausea,vomiting.

Ophthalmic:burning,itching.

1. Applytopicallytoaffectedareasixtimes

perday.

2. Avoidauto-inoculation;washhands

frequently;applywithglovedhand.

3. Avoidsexualintercoursewhilegenital

lesionsarepresent.

4. Drinkadequateuids.5. InfuseIVpreparationsover1hour;use

aninfusionpumpforaccuratedelivery.

6. Uses:herpesinfections.

AnTIInlAmmAToRy:Decreasestheifaatrrespse.

Triamcinoloneacetonide( Aristocort):topical Skinthinning,supercialdilatedblood

vessels(telangiectasis),acne-likeeruptions,

adrenalsuppression.

1. Triamcinoloneandhydrocortisone

creamscomeinvariousstrengthsand

potency.Watchthepercentstrength.

2. Applied2-3timesaday.

3. Useanocclusivedressingonlyif

ordered.

4. Encourageclienttousetheleastamount

possibleandfortheshortestperiodof

time.

ImmUnoSUPPRESAnT:SuppressesTcesaddecreasesreaeaseifaatrediatrs;aterativetuccrticids

Pimecrolimuscream(Elidel):topical

Tacrolimusointment(Protopic):topical

Erythema,pruritus

Burningsensatonatapplicationsite

1.Teachclientstousesunscreen,asmakes

clientsensitizedtoUVlight.

2.Longtermeffectscanleadtoskincancer

andlymphoma.

GI,Gastrointestinal;IV,intravenously;PO,bymouth(orally).


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Appendix 19-3 TOPICAL ANTIBIOTICS FOR BURN TREATMENT

medicatis SideEects nursiIpicatis

ToPICAlAnTIBIoTICS:Prevetadtreatiectiatthebursite.

Silversulfadiazine(Silvadene) Hypersensitivity:rash,itching,orburning

sensationinunburnedskin

1. Liberalamountsarespreadtopically

withasterile,glovedhandoron

impregnatedgauzerollsovertheburned

surface.

2. IfdiscolorationoccursintheSilvadene

cream,donotuse.

3. Athinlayerofcreamisspreadevenly

overtheentireburnsurfacearea;reap-

plicationisdoneevery12hours.

4. Clientshouldbebathedortubbeddaily

toaidindebridement.

5. Medicationdoesnotpenetrateeschar.

6. Forclientswithextensiveburns,monitor

urineoutputandrenalfunction;asigni-

cantamountofsulfamaybeabsorbed.

Mafenideacetate(Sulfamylon 10%) Pain,burning,orstingingatapplicationsites;excessivelossofbodywater;excoriationof

newtissue;maybesystemicallyabsorbed

andcausemetabolicacidosis.

1. Bacteriostaticmedicationdiffusesrapidlythroughburnedskinandescharandis

effectiveagainstbacteriaunderthe

eschar.

2. Dressingsarenotrequiredbutarefre-

quentlyused.Athinlayerofcreamis

spreadevenlyovertheentireburn

surface.

3. Monitorrenalfunctionandpossibleaci-

dosis,becausemedicationisrapidly

absorbedfromtheburnsurfaceand

eliminatedviathekidneys.

4. Painoccursonapplication.

5. Watchforhyperventilation,asacompen-

satorymechanismwhenacidosisoccurs.