Skin Disorders 4-2-08

4-2-08

Sue Renfrow

Skin Disorders Acne Vulgaris •

Disorder affecting skin follicles

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Begins at puberty

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Most cases are between 12-35 years of age affects males and females equally

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Sign and symptoms

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o

Closed comedones (whiteheads)

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Open comedones (black heads)

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Papules, pustules, nodules, and cysts

Acne Treatment o

Mild cases-may just need to wash twice daily with cleansing soap.

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Topical

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Benzoyl peroxide preparations

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Vitamin A (tretinoin) topical

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Antibiotics (tetracycline, clindamycin, erythromycin)

PO Medications 

Antibiotics (tetracycline, doxycycline, minocycline)

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Oral retinoids

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Accutane (isotretinoin) synthetic vitamin A compound

Nursing Consideration o

The healthcare provider may under estimate the relative importance of the disease to the adolescent.

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They may not be motivated to follow the treatment plan

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Families need to be involved in the treatment for encouragement

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Educate about factors that aggravate and damage the skin

Bacterial Disorders-Pyodermas •

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Impetigo o

Contagious to others or other parts of skin

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Common in children, may be seen in adults

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Signs and symptoms 

Small, red macule then vesicle then rupture than exudates then crust (honeycomb-yellow and crusty)

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Matted hair if on scalp

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Itching, burning

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May have swelling of their lymph nodes

Treatment o

Teach good hand washing so that it doesn’t spread

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Keep fingernails cut so that it doesn’t get under fingernails

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Wash bed sheets in hot water

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Use bacterial soap to bathe them

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Wear gloves while applying antibiotic to area

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Put them in cool water to prevent itching

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Pat them dry

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Use separate towels, bathe daily, cut fingernails, and avoid contact

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Topical antibiotics 

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Systemica antibiotics-treat deep infectionand prevents acute glomerulonephritis 

Folliculitis

Area must be soaked, crust removed and cleaned with antibacterial soap before applying topical

Penicillin or erythromycin

4-2-08

Sue Renfrow

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Infection that arises within the hair follicles (beard bumps) women sometimes get it on their legs

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Deep in one or more hair follicles and spreading into the surrounding areas

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Signs and symptoms o

Red, painful

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Once it gets infected it is called Furuncles or (“boil” or “risen”) basically an abscess

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Carbuncle=Extension of a furuncle that has invaded several follicles and is large and deep seated o

Signs and symptoms 

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Pain, Cellulitis, fever, leukocytosis, and possible spread into the blood stream

Treatment: folliculitis, furuncles, and Carbuncles o

Don’t mash or squeeze them

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Warm soaks increase vasculariztion and hasten suppuration

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Isolate drainage

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May require I&D carbuncles

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Culture and sensitivity

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May be put on antibiotics

Mycotic (Fungal) Infections •

Tinea o

Tinea Pedis-atheletes foot

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Tinea corporis-body (ringworm) apply shampoo every two weeks (cants and dogs)

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Tinea capitus- head

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Groin- jock itch

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Under nails-hard yellow nails

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Fungus in general o

Candidia (yeast infection) or thrush

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Treatment 

Nystatin

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Oral antifungal (rifatin B)

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Change socks regularly

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Keep feet dry

Parasitic skin disorders •

Pediculosis o

Lice infestation on the outside of the host’s body

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Pediculosis capitus-hardest to get rid of

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Pediculosis corporis

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Pediculosis pubis (crabs)

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Signs and symptoms 

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Itching visible infestation

Treatment 

Skin must be dry before you apply OTC shampoos

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Wash linens

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Wash everything in house with hot water

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Shampoo your rugs

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Vacuum drapes

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Treat entire family

Scabies o

Clinical manifestation usually starts about 4 weeks

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Infestation of the skin by the itch mite, frequently found in unsanitary living conditions

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Signs and symptoms 

Severe itching (especially at night), redness, burrows in skin

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Usually found in webs of fingers and toes

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Female crawls underneath your skin, laying eggs

Treatment 

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Same as lice

Skin Neoplasms o

o

o

Basal cell carcinoma 

Most common type of skin cancer

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Usually on sun exposed parts of the body

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Begins as a small, waxy nodule with rolled translucent bordersmay have small vessels visible in it

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May be shiny, gray, flat, or yellowish

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Rarely metastasizes but recurrence is common

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Usually good prognosis

Squamous Cell Carcinoma 

Malignant proliferation arising from epidermis

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Usually on sun damaged skin-but not always

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May arise from normal skin or pre-existing lesions

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Rough , thickened, scaly tumor may be asymptomatic or bleed

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Metastasis via blood or lymphatic system

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Prognosis depends on metastasis

Malignant Melanoma 

Cancerous neoplasm in which atypical melanocytes are present in the epidermis and the dermis

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Lesion may be circular with irregular borders, it may be flat, or

elevated and palpable, may be a combination of colors-brow, tan, black, and mixed with other colors 

Prognosis depends on size and if lymph nodes are involved

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Frequently metastasized to bone, lung, liver

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Cause unknown

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If greater than 1.5 ml in thickness life expectancy less than five years

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KNOW CHART IN BOOK ON PREVENTION

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Incidence-doubled in last 30 years

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Diagnosis-punch biopsy

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TNM

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o

o

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Tumor thickness

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Node involvement

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Metastasis

Classification and staging •

Clark and Breslow classifications

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Levels 1-5

Screening for skin cancer 

A asymmetry

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B irregular border

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C variegated color

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D diameter

Treatment 

Remove the tumor and any involved tissue and nodes

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Chemotherapy may be used for metastatic melanoma but generally with poor results

4-2-08

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Regional perfusion with chemotherapeutic agent if malignant melanoma in an extremity is being tried

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Immunotherapy used with varied success

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Pain management when needed

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Teaching

Allergies •

Occurs when the body is invaded by a an antigen

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Antigens are usually proteins

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The body thinks that the antigen is a foreign invader and sends lymphocytes to the rescue, when they respond then antibodies are produced to interact with the antigen and protect the body for the foreign invader

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The antibodies are immunoglobulins

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Include IgA, IgE, IgD, IgG, and IgM

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They are found in lymph nodes, tonsils, appendix, Peyer’s patches, of intestinal tract and blood and lymph circulation

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Each type has its own functions

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IgE is the one we will be talking about

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IgE is located in respiratory and oral mucosa

Hypersensitivity Reaction o

An abnormal heightened reaction to any type of stimuli

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Usually does not occur with first exposure

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Four types of hypersensitivity reactions 

Anaphylactic (type 1) •

Immediate reaction beginning within minutes of exposure to an antigen

May be local or systemic response

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Mediated by IgE antibodies

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Requires previous exposure to the antigen

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Characterized by vasodilation increase causes increase in mucous secretions

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Cytotoxic- type 2 –blood reaction

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Immune complex- type 3

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Delayed type-type 4

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Also known as cellular hypersensitivity

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Occurs 24-72 hours after exposure to allergen

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Mediated by sensitized T cells and macrophages

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Examples; contact dermatitis, reaction to PPD (TB skin test), poison Ivy

Diagnostic Tests •

CBC-usually normal

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Serum IgE level

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Skin tests

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Scratch

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Prick

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Intradermal

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RAST test

Anaphylaxis 

Clinical response to an (type 1 hypersenstivity reaction, IgE mediated) immunologic reaction between a specific antigen and an antibody

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Triggered by exposure via inhalation, injection, ingestion, or skin contact

4-2-08

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Life threatening

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Happens within seconds to minutes from exposure to antigen

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Give Epinephrine, then oxygen, then IV in them, then give Benadryl IV, give solumedrol, sometimes epinephrine drip and go to ICU

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Characterized •

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Mild o

Peripheral tingling, fullness in mouth and throat, nasal congestion, sneezing, tearing

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O2 sat and watch them

Moderate o

Flushing, warmth, anxiety, bronchospasm, edema of airway, cough, wheezing and itching is added

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Give Benadryl IV

Severe o

Same symptoms as moderate, but abrupt onset, can have abdominal cramping, vomiting, and diarrhea, and advance to cardiac arrest

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Epinephrine, oxygen, may have to intubate

Local o

s/s appear at site of allergen-antibody interaction

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includes hay fever, hives, allergic gastroenteritis

Systemic o

Peripheral vasodilation, bronchospasm, laryngeal edema, dyspnea, cyanosis, respiratory, skin and GI systems involved

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Life threatening

Treatment 

Prevention-limit contact with the allergen

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Close monitoring/assessment of CV and respiratory status

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100% O2

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Epinephrine 1:1000 SC and/ or IV

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Antihistamines and corticosteroids

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Volume expanders to maintain Blood pressure

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Vasopressors to bring up blood pressure

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Aminophylline-only given to asthmatics when having allergic reaction

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IV glucagon

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Trach or intubation may be necessary

Teaching 

Avoidance of allergens

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Carry Epi Pen (0.3mg for adults and 0.01mg/kg for children)

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Inject Epi-Pen at mid part of outer thigh

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Medic alert bracelet worn at all times

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Healthcare providers must take careful histories and be alert to possibility of allergy at all times

Allergic Rhinitis •

Inflammation on nasal mucosa

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Most common form of respiratory allergy mediated by Type 1 immediate reaction

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Caused by air born pollens or molds that are ingested or inhaled so it tends to be seasonal

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Nasal stuffiness, discharge, sneezing, headache, nasal itching

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Management o

Diagnosis based on history, physical exam, and diagnostic test results

4-2-08

Sue Renfrow o

Treat with Benadryl be sure to watch them

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Goal is to provide relief of symptoms

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Avoidance therapy

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Treatment may include

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Pharmacological therapy

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Adrenergic agents

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Mast cell stabilizers

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Immunotherapy

Contact Dermititis •

Delayed hypersensitive reaction

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Itching, burning, erythema, skin lesions, peeling

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Patch test is used to diagnosed

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Treated with antihistamines, wash after exposure to allergen with soap and water topical corticosteroids

Latex Allergy •

Allergic reaction to natural rubber proteins

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Spina bifida babies

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Be aware of high risk populations

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Cross reactions seen with kiwis, bananas, avocadoes

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s/s o

contact dermatitis

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angioedema

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laryngeal edema

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hypotension

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cardiac arrest if type 1 reaction

Epidemiology

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History o

Era 1 sanitary statistics

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Era 2 infection disease (germ theory by Robert Cook)

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Era 3 chronic disease and black box

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New Era

Goals o

To prevent or limit the consequences of illness and disability in humans and maximize their state of health

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Epidemiology emerged because of the need to determine the etiology of disease conditions so that prevention and control measures could be instituted

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Epidemiologic /Nursing Both processes have evolved from the problem-solving process

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Both are designed to provide a framework for investigating health-related problems, obtaining new knowledge, and planning, implementing, meeting, and evaluating specific interventions

Sources of Epidemiologic Data o

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Traditional sources of epidemiologic data are those collected routinely by national or state governments

Levels of prevention o

Primary-used to prevent health care problems (teaching, immunizations)

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Secondary-focuses on early identification, treatment, and monitoring of existing health problems. (screening -mammograms, cholesterol screenings, etc.)

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Tertiary prevention-is the primary focus of Health Place. (ADLs, Rehab)

Epidemiologic in Community Nursing •

Schools

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Workplace

4-2-08 •

Sue Renfrow Special population (homeless shelters, women abuse clinics)

Epidemiology in infection control •

Nosocomial infections-infections appearing in hospitalized patients that were not present or incubating at the time of admission

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Advisory and regulatory agencies o

CDC

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JCAHO

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OSHA

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AJIC-American journal of infection control

Mortality Rates •

Death rates are common incidence rates that are calculated for public health purposes

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Number of people 65 years and older dying from lung cancer in Boston, MA (divided)

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Number of people 65 years and older in Boston, MA (times) based of 10

Morbidity •

Statistics from reportable diseases are population-based, but other morbidity statistics may be based on survey data of data obtained from institutional records

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Number of conditions or events occurring in a period of time

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KNOW THE DIFFERENCE BETWEEN THE TWO mortality/morbidity

Child birth •

World Health Organization (WHO) estimates 500,000 women die each year in connection with pregnancy and childbirth

Role of Nursing •

Prevention

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Emerging trends

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Community intervention

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Future challenges (cloning, gene splicing)