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Chapter 61

Management of Patients With


Dermatologic Problems

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Question
It is believed that the natural wound healing process
should not be disrupted. Unless a wound is infected or
has heavy discharge, how many days should acute
wounds be left covered?
A. 1
B. 2
C. 3
D. 4

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Answer
A. 1

It is believed that the natural wound healing process


should not be disrupted. Unless the wound is infected or
has heavy discharge, acute wounds should be left
covered for only 1 day.

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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, wound care and dressings, and
providing for patient hygiene.
Nursing care also needs to address the educational,
emotional, and psychosocial needs of the patient.

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Infectious Diseases of the Skin
Bacterial infections
Impetigo
Folliculitis, furuncles, and carbuncles
Viral infections
Herpes zoster
Herpes simplex: orolabial, genital
Fungal infections: tinea pedis, tinea coporis, tinea capitis,
tinea cruris, tinea unguium

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Impetigo

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Herpes Zoster (Shingles)

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Patient Education: Bacterial Infections
Impetigo is contagious and may spread to other parts of
patients body or to other persons.
Patient education regarding antibiotics, hygiene, and skin
and lesion care.
Dont share towels, combs, and so on.
Bathe daily with antibacterial soap.
Furuncles, boils, or pimples should never be squeezed.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Patient Education: Viral Infections
Herpes zoster: instruction regarding prescribed antiviral
medications, lesion care, dressings, and hand hygiene
Herpes simplex: instruction regarding prescribed antiviral
medications and prophylactic medication use, instruction
regarding spread of herpes, and measures to reduce
contagion of partner or of neonates born to mothers with
genital herpes

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Patient Education: 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, and so on.
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 capitis is temporary.
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Parasitic Skin Infestations
Pediculosis (lice): pediculosis capitis, pediculosis corporis,
Phthirus pubis
Scabies (mites): Sarcoptes scabei

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Patient Education: Pediculosis Capitis
Head lice may infest anyone and are not a sign of
uncleanliness.
Instruction in use of shampoo (lindane [Kwell] or
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, and so on.
All family members and close contacts must be treated.
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Patient Education: Pediculosis Corporis
and Pubis
Pediculosis corporis is a disease related to poor hygiene and of
those who live in close quarters.
Pediculosis pubis is common and spread chiefly by sexual contact.
Bathe in soap and water and apply prescription scabicide or OTC
permethrin (NIX). If eyelashes are involved, Vaseline may be
applied twice a day for 8 days. Mechanically remove any nits.
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 also be scheduled for checkup to
assess for coexisting sexually transmitted disease.

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Patient Education: Scabies
Mite frequently involves 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;
and apply prescription scabicide lindane, crotamiton, or 5%
permethrin to entire body, not including 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.
Repeat the treatment in 1 week to prevent reinfestation
Pruritus may continue for several weeks and does not mean
retreatment is required.
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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, primary those of
European ancestry
Improves and recurs; a lifelong condition
May be aggravated by stress, trauma, seasonal and
hormonal changes
Treatment: baths to remove scales and medications

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Psoriasis

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Nursing Process: The Care of the Patient
With PsoriasisAssessment
Appearance of the skin
Coping of the patient with condition
Note impact of the disease on patient activities and
interactions

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Nursing Process: The Care of the Patient
With PsoriasisDiagnoses
Deficient knowledge
Impaired skin integrity
Disturbed body image

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Collaborative Problems and Potential
Complications
Infection
Psoriatic arthritis

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Nursing Process: The Care of the Patient
With PsoriasisPlanning
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

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Interventions
Patient education regarding the disease, skin care, and
treatment regimen
Measures to prevent skin injury: avoid picking or
scratching
Measures to prevent skin dryness: use of emollients,
avoid excessive washing, and use warm (not hot) water,
pat dry
Use of the therapeutic relationship for support and to aid
coping

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Question
Is the following statement true or false?

Application of scabicide immediately after bathing and


before the skin dries and cools increases percutaneous
absorption of the scabicide and the potential for central
nervous system abnormalities.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Answer
True

Application of scabicide immediately after bathing and


before the skin dries and cools increases percutaneous
absorption of the scabicide and the potential for central
nervous system abnormalities.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Nursing Process: The Care of the Patient
With Blistering DiseasesAssessment
Appearance of the skin
Monitor VS frequently and assess for signs and
symptoms of infection
Pain, pruritus, and discomfort
Coping of the patient with condition
Note impact of the disease on patient activities and
interactions

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Nursing Process: The Care of the Patient
With Blistering DiseasesDiagnoses
Acute pain: skin and oral cavity
Impaired skin integrity
Anxiety
Ineffective coping
Deficient knowledge

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Collaborative Problems and Potential
Complications
Infection and sepsis
Fluid volume deficit and electrolyte imbalance

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Nursing Process: The Care of the Patient
With Blistering DiseasesPlanning
Major goals may include
Relief of pain and discomfort for lesion
Skin healing
Reduced anxiety
Improved coping
Absence of complications

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Interventions
Meticulous oral hygiene
Avoid commercial mouthwashes
Keep lips moist with lip balm, petroleum, or lanolin
Cool mist humidified air
Cool, wet dressing or baths; hygiene measures
Apply powder liberally to keep skin from adhering to sheets
Monitor for and prevent hypothermia
Skin care may be similar to that of the patient with extensive
burns
Measures to prevent secondary infections
Encourage adequate fluid and nutritional intake
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Nursing Process: The Care of the Patient
With Toxic Epidermal Necrolysis and
StevensJohnson SyndromeAssessment
Skin inspection
Oral cavity inspection
Vital signs
Respiratory secretions
Fatigue
Pain level
Coping mechanism

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Nursing Process: The Care of the Patient
With Toxic Epidermal Necrolysis and
StevensJohnson SyndromeDiagnoses
Impaired tissue integrity (i.e., oral, eye, and skin)
related to epidermal shedding
Deficient fluid volume and electrolyte losses related to
loss of fluids from denuded skin
Risk for imbalanced body temperature (i.e.,
hypothermia) related to heat loss secondary to skin loss
Acute pain related to denuded skin, oral lesions, and
possible infection
Anxiety related to the physical appearance of the skin
and prognosis
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Collaborative Problems and Potential
Complications

Sepsis
Conjunctival retraction, scars, and corneal lesions

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Interventions
Maintaining skin and mucous membrane integrity
Attaining fluid balance
Preventing hypothermia
Relieving pain
Prevent infection, consider reverse isolation
Reducing anxiety
Monitoring and managing potential complications
Promoting home and community-based care

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Skin Cancer
Frequently related to sun exposureprevention: use of
sunscreen and avoid 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
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Basal Cell Carcinoma and Squamous Cell
Carcinoma

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Kaposis Sarcoma
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

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Melanoma
Risk factors
Worldwide incidence and mortality rates are increasing
Peak incidence, 20 to 45 years of age
Types: superficial spreading, lentigo-maligna melanoma,
nodular melanomas
Treatment: surgical excision, other therapies

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Melanoma

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Nursing Process: The Care of the Patient
With MelanomaAssessment
Inspect skin carefully
Ask specific questions about pruritus, tenderness, pain,
changes in moles, or new pigmented lesions
Assess knowledge level and risk factors
Assess coping and anxiety
Refer to Figures 61-5 and 61-6

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Nursing Process: The Care of the Patient
With MelanomaDiagnoses
Acute pain
Anxiety
Depression
Deficient knowledge

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Collaborative Problems and Potential
Complications
Metastasis
Infection of surgical site

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Nursing Process: The Care of the Patient
With MelanomaPlanning
Major goals may include
Relief of pain and discomfort
Reduced anxiety and depression
Increased knowledge of early signs of melanoma
Absence of complications

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


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, involve family in discussion

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Question
When assessing the patients skin for possible melanoma,
what type of lesion would be of most concern as
potential melanoma?
A. A small papule with a dry, rough scale
B. A firm, nodular lesion topped with crust
C. A pearly papule with a central crater and a waxy border
D. An irregularly shaped lesion

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins


Answer
D. An irregularly shaped lesion

A small papule with a dry, rough scale would be actinic


keratosis, which can be a precancerous skin lesion. A
firm, nodular lesion topped with crust is usually a sign of
squamous cell carcinoma. A pearly papule with a central
crater and a waxy border is a lesion expected with basal
cell carcinoma. An irregularly shaped lesion is common
with melanomas.

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins