INTEGUMENTARYINTEGUMENTARYOBJECTIVES 1-11OBJECTIVES 1-11

Integumentary system is made up of:Integumentary system is made up of: Skin, accessory structures, and Skin, accessory structures, and

subcutaneous tissuessubcutaneous tissues Body covering separating internal Body covering separating internal

environment from external environment from external environmentenvironment

Barrier against pathogens, most Barrier against pathogens, most chemical, and injury to inner structures.chemical, and injury to inner structures.

Is an organ, the largestIs an organ, the largest 2 layers; epidermis and the dermis2 layers; epidermis and the dermis

EPIDERMISEPIDERMIS

Stratified,squamous epithelial tissueStratified,squamous epithelial tissue AVASCULAR; nourishment from DERMISAVASCULAR; nourishment from DERMIS Thickest on palms of hands, soles of feetThickest on palms of hands, soles of feet Innermost layer is STRATUM Innermost layer is STRATUM

GERMANITIVUMGERMANITIVUM Mitosis occurs to produce NEW epidermal Mitosis occurs to produce NEW epidermal

cells. Usually occurs at constant rate, but cells. Usually occurs at constant rate, but increased pressure produces increased increased pressure produces increased production to form calluses.production to form calluses.

New cells in the EPIDERMIS produce KERATINNew cells in the EPIDERMIS produce KERATIN Keratin is a waterproofing protein, prevents Keratin is a waterproofing protein, prevents

loss of water as well as prevents entry of loss of water as well as prevents entry of excess H2O. When die and slough off, also excess H2O. When die and slough off, also removes pathogensremoves pathogens

As new cells get pushed to surface of As new cells get pushed to surface of epidermis, they die, become the STRATUM epidermis, they die, become the STRATUM CORNEUM, OUTERMOST LAYERCORNEUM, OUTERMOST LAYER

Loss of large portions of this layer greatly Loss of large portions of this layer greatly increase risks for infection and dehydrationincrease risks for infection and dehydration

MELANOCYTES,cells in the lower EPIDERMIS, MELANOCYTES,cells in the lower EPIDERMIS, produce the protein MELANIN. Amounts produced produce the protein MELANIN. Amounts produced are genetically determined. Melanin is what gives are genetically determined. Melanin is what gives color to skin and hair.color to skin and hair.

Exposing melanin to UV rays causes an increase Exposing melanin to UV rays causes an increase in production. Melanin is incorporated in to the in production. Melanin is incorporated in to the epidermal cells, making them darker before they epidermal cells, making them darker before they die. Tanning is a direct result of this process.die. Tanning is a direct result of this process.

Melanin is important in that it acts as a pigment Melanin is important in that it acts as a pigment barrier to exposure from UV rays and thereby, barrier to exposure from UV rays and thereby, protects the str. germanitivum from mutational protects the str. germanitivum from mutational changes that can lead to extensive skin damage changes that can lead to extensive skin damage and cancerous lesions.and cancerous lesions.

Langerhans cells, a type of Langerhans cells, a type of MACROPHAGE, are located in BOTH MACROPHAGE, are located in BOTH the epidermis and the dermis. They the epidermis and the dermis. They act to present ANTIGENS to the act to present ANTIGENS to the HELPER T CELLS; a first line barrier to HELPER T CELLS; a first line barrier to invasion through the skin by invasion through the skin by pathogenspathogens

DERMISDERMIS

Made up of fibrous connective tissueMade up of fibrous connective tissue Cells are called FIBROBLASTSCells are called FIBROBLASTS They produce THE PROTEIN FIBERS OF They produce THE PROTEIN FIBERS OF

COLLAGEN and ELASTIN,which support the COLLAGEN and ELASTIN,which support the skin and allow for some skin stretching skin and allow for some skin stretching and recoiland recoil

THE DERMIS ALSO CONTAINS the hair and THE DERMIS ALSO CONTAINS the hair and nail follicles, GLANDS, NERVE ENDINGS nail follicles, GLANDS, NERVE ENDINGS AND BLOOD SUPPLY. THE blood AND BLOOD SUPPLY. THE blood CAPILLARIES are found in the PAPILLARY CAPILLARIES are found in the PAPILLARY layer of the dermislayer of the dermis

HAIRHAIR

Developes in FOLLICLES located in the Developes in FOLLICLES located in the EPIDERMAL structures.EPIDERMAL structures.

The hair root is a group of cells that The hair root is a group of cells that undergo mitosis to produce the hair shaftundergo mitosis to produce the hair shaft

Cells die AFTER producing KERATIN and Cells die AFTER producing KERATIN and incorporating MELANINincorporating MELANIN

Eyelashes,eyebrows,keep dust and sweat Eyelashes,eyebrows,keep dust and sweat out of eyes. Nostril hair filters air entering out of eyes. Nostril hair filters air entering nasal cavities.Hair on head, not sparse nasal cavities.Hair on head, not sparse body hair, provides for thermal regulation body hair, provides for thermal regulation

NAILSNAILS

Follicles found at ends of fingers and Follicles found at ends of fingers and toestoes

Growth similar to growth of hair, starts Growth similar to growth of hair, starts in the layer of DERMISin the layer of DERMIS

Mitosis in nail root, produces new cells Mitosis in nail root, produces new cells containing keratin.containing keratin.

Dead cells form the visible nailDead cells form the visible nail Protect ends of digits from mechanical Protect ends of digits from mechanical

injuryinjury

RECEPTORSRECEPTORS

SENSORY RECPTORS for the SENSORY RECPTORS for the cutaneous senses are located in the cutaneous senses are located in the DERMIS.DERMIS.

FREE nerve endings are receptors for FREE nerve endings are receptors for heat, cold and painheat, cold and pain

ENCAPSULATED nerve endings are for ENCAPSULATED nerve endings are for touch and pressuretouch and pressure

Sensitivity is = to # of nerve endings Sensitivity is = to # of nerve endings presentpresent

Sebaceous glands andSebaceous glands andsudoriferous glandssudoriferous glands

Sebaceous gland ducts open into hair Sebaceous gland ducts open into hair follicles or directly onto surface of skinfollicles or directly onto surface of skin

Sebum (a lipid substance) is secretedSebum (a lipid substance) is secreted Inhibits growth of some bacteria and drying Inhibits growth of some bacteria and drying

of skin and hairof skin and hair Sudoriferous glands are SWEAT GLANDSSudoriferous glands are SWEAT GLANDS 2 kinds: APOCRINE (modified scent 2 kinds: APOCRINE (modified scent

glands),and ECCRINE (sweat is secreted glands),and ECCRINE (sweat is secreted onto skin surface)onto skin surface)

APOCRINE found in axilla and genital areas. APOCRINE found in axilla and genital areas. Activated by stress and emotions.Activated by stress and emotions.

ECCRINE throughout dermis, but more ECCRINE throughout dermis, but more numerous on face, palms, soles; numerous on face, palms, soles; activated by high temperatures or activated by high temperatures or exercise.exercise.

Effective cooling mechanismEffective cooling mechanism MODIFIED sweat glands or MODIFIED sweat glands or

CERUMINOUS glands are located in CERUMINOUS glands are located in the dermis of ear canalsthe dermis of ear canals

Prevents drying of outer surfaces of Prevents drying of outer surfaces of ear canalear canal

BLOOD VESSELSBLOOD VESSELS

In the dermis, they serve to provide In the dermis, they serve to provide nourishment.nourishment.

ARTERIOLES are involved in body temp. ARTERIOLES are involved in body temp. maintenancemaintenance

Increased body heat results in Increased body heat results in vasodilatation, increased blood flow and vasodilatation, increased blood flow and loss of body heat to air or clothingloss of body heat to air or clothing

Decreased body temp results in Decreased body temp results in vasoconstriction with <blood flow and vasoconstriction with <blood flow and <loss of body heat<loss of body heat

SUBCUTANEOUS TISSUESUBCUTANEOUS TISSUE

Located BETWEEN dermis and Located BETWEEN dermis and musclesmuscles

Made up of areolar connective tissue Made up of areolar connective tissue and adipose tissueand adipose tissue

Contains numerous WBCs (fights Contains numerous WBCs (fights pathogens invading through the skin)pathogens invading through the skin)

Adipose tissue cushions some bones, Adipose tissue cushions some bones, provides for some insulation,but MOST provides for some insulation,but MOST IMPORTANTLY, provides for STORAGE IMPORTANTLY, provides for STORAGE OF FATS for energy needsOF FATS for energy needs

AGINGAGING

EFFECTS OF AGING ON THE SKIN IS EFFECTS OF AGING ON THE SKIN IS QUITE VISIBLEQUITE VISIBLE

Cell division in the epidermis slows.Cell division in the epidermis slows. Fibroblasts in the dermis die, don’t Fibroblasts in the dermis die, don’t

regenerateregenerate Hair and skin much thinnerHair and skin much thinner Collagen/elastin fibers deteriorateCollagen/elastin fibers deteriorate Sebaceous and sweat glands Sebaceous and sweat glands

decrease activitydecrease activity

Skin frail and drySkin frail and dry Less subcutaneous fatLess subcutaneous fat Temperature regulation labile in hot Temperature regulation labile in hot

or cold weather; more sensitive to or cold weather; more sensitive to changeschanges

Melanocytes die, hair goes to grayMelanocytes die, hair goes to gray

NURSING ASSESSMENTNURSING ASSESSMENT

May be only complaint or may be a May be only complaint or may be a manifestation of underlying systemic manifestation of underlying systemic condition/psychological stresscondition/psychological stress

Visibly communicates the clients’ healthVisibly communicates the clients’ health WHATSUP questionsWHATSUP questions INSPECTION AND PALPATIONINSPECTION AND PALPATION Phys. Assessment includes skin,hair Phys. Assessment includes skin,hair

nails,scalp, and mucus membranes.Client nails,scalp, and mucus membranes.Client must be fully disrobed but draped for must be fully disrobed but draped for privacyprivacy

Skin problems are common complaints

Well lit and warm roomWell lit and warm room Nl skin is intact, warm, smooth, dry, Nl skin is intact, warm, smooth, dry,

well hydrated, with firm skin turgor. well hydrated, with firm skin turgor. Surface is flexible and softSurface is flexible and soft

Know color rangesKnow color ranges Know developmental changesKnow developmental changes Inspect for color, Inspect for color,

moisture,lesions,edema, breaks in skin moisture,lesions,edema, breaks in skin integrity, vascular markings, turgor, integrity, vascular markings, turgor, and cleanlinessand cleanliness

COLORCOLORobj. #6obj. #6

Factors include temp of client, O2 Factors include temp of client, O2 level, blood flow, exposure to UV level, blood flow, exposure to UV rays, positioning, genetic differencesrays, positioning, genetic differences

Pallor; a decrease in color due to Pallor; a decrease in color due to vasoconstriction, decreased blood vasoconstriction, decreased blood flow or < HgB flow or < HgB

BEST ASSESSED ON FACE, BEST ASSESSED ON FACE, CONJUNCTIVA, NAILBEDS AND LIPSCONJUNCTIVA, NAILBEDS AND LIPS

Erythema; reddish discoloration, also may Erythema; reddish discoloration, also may indicate circulatory changes due to indicate circulatory changes due to vasodilation, incr. blood flow to skin from vasodilation, incr. blood flow to skin from fever or inflammationfever or inflammation

BEST ASSESSED ON FACE OR AREA OF BEST ASSESSED ON FACE OR AREA OF TRAUMA/RASHTRAUMA/RASH

Jaundice (yellow-orange) may occur as Jaundice (yellow-orange) may occur as result of liver disease.result of liver disease.

BEST ASSESSED IN SCLERA OF THE EYEBEST ASSESSED IN SCLERA OF THE EYE

Cyanosis; bluish discolorationCyanosis; bluish discoloration Cardiac, pulmonary or perfusion problemCardiac, pulmonary or perfusion problem BEST ASSESSED LIPS, NAILBEDS, BEST ASSESSED LIPS, NAILBEDS,

CONJUNCTIVA, PALMSCONJUNCTIVA, PALMS People of mediterranean descent, may People of mediterranean descent, may

have nl bluish on lips colorationhave nl bluish on lips coloration Brown coloration due to increased melanin Brown coloration due to increased melanin

prod. Could be from chr. exposure to sun prod. Could be from chr. exposure to sun or due to pregnancy or PVDor due to pregnancy or PVD

BEST ASSESSED FACE, AREOLA, NIPPLES, BEST ASSESSED FACE, AREOLA, NIPPLES, AND AREAS EXPOSED TO SUNAND AREAS EXPOSED TO SUN

LESIONSLESIONSobj. #7obj. #7

Any change or injury to tissueAny change or injury to tissue Assessment may help determine cause of Assessment may help determine cause of

skin disorderskin disorder Class. As primary; secondaryClass. As primary; secondary PRIMARY represent initial reaction to a PRIMARY represent initial reaction to a

disease processdisease process SECONDARY lesions are the changes that SECONDARY lesions are the changes that

take place in the primary lesion from take place in the primary lesion from infection, scratching, trauma or various infection, scratching, trauma or various disease stagesdisease stages

PRIMARY LESIONSPRIMARY LESIONS

Macule; flat, non-palpable, usually Macule; flat, non-palpable, usually smaller than 1cm; frecklesmaller than 1cm; freckle

Papule; palpable, solid raised lesion; Papule; palpable, solid raised lesion; wart, ringworm;1cm or lesswart, ringworm;1cm or less

Nodule; solid raised lesion, larger and Nodule; solid raised lesion, larger and deep; fibromadeep; fibroma

Vesicle; small fluid filled blister type Vesicle; small fluid filled blister type lesion; 1cm; chicken poxlesion; 1cm; chicken pox

Bulla; larger fluid filled blister;>1cm, burnsBulla; larger fluid filled blister;>1cm, burns Pustule; sm. elevation of skin, vesicle or bulla that contains Pustule; sm. elevation of skin, vesicle or bulla that contains

lymph or pus; impetigo/acnelymph or pus; impetigo/acne Wheal; round transient elevation of the skin caused by Wheal; round transient elevation of the skin caused by

dermal edema; white in the center and red in the periphery; dermal edema; white in the center and red in the periphery; hives, insect biteshives, insect bites

Plaque; PATCH, solid or raised lesion on skin OR mucus Plaque; PATCH, solid or raised lesion on skin OR mucus membrane >1cm in diameter; psoriasismembrane >1cm in diameter; psoriasis

Cyst; CLOSED SACK OR POUCH; contains solid, semi-solid or Cyst; CLOSED SACK OR POUCH; contains solid, semi-solid or liquid material; sebaceous cystliquid material; sebaceous cyst

SECONDARY LESIONSSECONDARY LESIONS

ScalesScales CrustsCrusts ExcoriationsExcoriations FissuresFissures UlcersUlcers LichenificationLichenification scarscar

configurationsconfigurations

DiscreteDiscrete GroupedGrouped ConfluentConfluent LinearLinear AnnularAnnular PolycyclicPolycyclic ArciformArciform reticularreticular

NOTE:NOTE: ColorColor Size in cmSize in cm LocationLocation DistributionDistribution Configuration (pattern)Configuration (pattern) Exudate (amt., color, odor, any other s/s)Exudate (amt., color, odor, any other s/s) Read how lesions may present in peoples Read how lesions may present in peoples

of colorof color

Check levels of hydrationCheck levels of hydration Dryness, moisture, scales and flakesDryness, moisture, scales and flakes Moisture within skin foldsMoisture within skin folds Should normally be smooth and dryShould normally be smooth and dry

PALPATIONPALPATIONOBJ.#8OBJ.#8

Utilized in conjunction with INSPECTIONUtilized in conjunction with INSPECTION Dorsum of hand for temp.Dorsum of hand for temp. Palpate lesions with fingertips to deter. Palpate lesions with fingertips to deter.

Size, contour, consistencySize, contour, consistency Note level of discomfort with palpationNote level of discomfort with palpation Wear glovesWear gloves Turgor/textureTurgor/texture Back of forearm, over sternum (best for Back of forearm, over sternum (best for

elderly)elderly) Tenting with gradual return= poss. Tenting with gradual return= poss.

Dehydr., agingDehydr., aging

Vascular markingVascular marking

NormalNormal Abnormal (petechiae, ecchymosis)Abnormal (petechiae, ecchymosis) Petechiae sm. Purplish hemorrhagic Petechiae sm. Purplish hemorrhagic

spots <0.5cmspots <0.5cm Seen best on dark skinned persons Seen best on dark skinned persons

on conjunctiva and oral mucosaon conjunctiva and oral mucosa Ecchymosis is a bruise; coloration Ecchymosis is a bruise; coloration

changeschanges

edemaedema

Dependent edema; part of body at Dependent edema; part of body at lowest point; feet , ankles, sacrumlowest point; feet , ankles, sacrum

Often relieved with elevation and Often relieved with elevation and repositioning, elastic stockings, repositioning, elastic stockings, medicationsmedications

Brawny edemaBrawny edema Pre-tibial edemaPre-tibial edema

EdemaEdema Occurs due to build up of fluid in the Occurs due to build up of fluid in the

tissuestissues Skin becomes stretched, taut and Skin becomes stretched, taut and

shineyshiney Location, distribution and color are Location, distribution and color are

determined and documenteddetermined and documented If unilateral, compare to other sideIf unilateral, compare to other side Measure to track progression or Measure to track progression or

regressionregression

When suspect edema, palpate for When suspect edema, palpate for tenderness, mobility, and consistencytenderness, mobility, and consistency

Pressure from finger/thumb 5sec. leaves Pressure from finger/thumb 5sec. leaves indentation (pitting edema)indentation (pitting edema)

Classified by depthClassified by depth 1+=1mm depth or “trace” edema1+=1mm depth or “trace” edema 2+= 2mm or small amt. edema2+= 2mm or small amt. edema 3+=moderate edema3+=moderate edema 4+ large amount of edema4+ large amount of edema

hairhair

Hair distribution is palpatedHair distribution is palpated Quantity, thickness, and textureQuantity, thickness, and texture Note any areas of ALOPECIANote any areas of ALOPECIA Terminal hair is hair of scalp, eyebrows, Terminal hair is hair of scalp, eyebrows,

axillae, pubic areas in both sexes and axillae, pubic areas in both sexes and facial and chest hair with menfacial and chest hair with men

VELLUS hairs are soft downey covering VELLUS hairs are soft downey covering bodybody

Normally has uniform distributionNormally has uniform distribution

Scalp hair can be thick, thin, coarse, Scalp hair can be thick, thin, coarse, shiney, curly, straightshiney, curly, straight

Describe distribution and cleanlinessDescribe distribution and cleanliness

NAILSNAILS

Reflect general healthReflect general health Color, shape, texture, thickness, any Color, shape, texture, thickness, any

abnormalitiesabnormalities Normally pink, smooth, hard, slightly Normally pink, smooth, hard, slightly

convex (160 degree) with firm baseconvex (160 degree) with firm base Elderly: yellowish-gray, thickening, Elderly: yellowish-gray, thickening,

ridgesridges Brown or black pigm. between nail and Brown or black pigm. between nail and

nail base In persons of color is nlnail base In persons of color is nl

Abnl findings include clubbing (poss. Abnl findings include clubbing (poss. Hypoxia)Hypoxia)

Spoon nails (concave)(koilonchia); poss. Spoon nails (concave)(koilonchia); poss. AnemiaAnemia

Thick nails; (poss. Fungal infection)Thick nails; (poss. Fungal infection) Observe for redness, swelling, tendernessObserve for redness, swelling, tenderness Beaus’ linesBeaus’ lines Splinter hemorrhagesSplinter hemorrhages paronychiaparonychia

Diagnostic testsDiagnostic testsobj.#9obj.#9

Cultures to show presence of bacteria, Cultures to show presence of bacteria, fungi, virusesfungi, viruses

fungi: specimen in 10% KOH; remains fungi: specimen in 10% KOH; remains at room temp until sent to labat room temp until sent to lab

viral: fluid gently expressed from intact viral: fluid gently expressed from intact vesicle with sterile swab, special vesicle with sterile swab, special culture tube MUST BE KEPT ON ICE until culture tube MUST BE KEPT ON ICE until sent to lab ASAPsent to lab ASAP

See box 50-2 for instr. On wound See box 50-2 for instr. On wound culturescultures

Skin biopsySkin biopsy

Indicated for deeper infectionIndicated for deeper infection Eval. For dx and/or efficacy of current txEval. For dx and/or efficacy of current tx Excision of small piece of tissueExcision of small piece of tissue Punch bx: plug of tissue for full thickness Punch bx: plug of tissue for full thickness

specimenspecimen Incisional bx: deep incision with scalpelIncisional bx: deep incision with scalpel ALWAYS REQUIRES CLOSURE WITH ALWAYS REQUIRES CLOSURE WITH

SUTURESUTURE Shave bx removes area of skin just above Shave bx removes area of skin just above

rest of skinrest of skin

All bx require sterile field/techniqueAll bx require sterile field/technique Prepare clientPrepare client Most painful part is ususally injection Most painful part is ususally injection

of local anestheticof local anesthetic

WOODS’ LIGHT is use of UV rays to WOODS’ LIGHT is use of UV rays to detect fluorescent substances in hair detect fluorescent substances in hair and skin that are present during and skin that are present during certain diseases such as tinea capitis certain diseases such as tinea capitis (ringworm)(ringworm)

Hand held black light in darkened Hand held black light in darkened roomroom

Skin testingSkin testing

Patch and scratch when allergic Patch and scratch when allergic dermatitis is suspecteddermatitis is suspected

Done by dermatolgist on uninvolved Done by dermatolgist on uninvolved skin/upper back, arms, must be skin/upper back, arms, must be shavedshaved

SCRATCH; superficial scratch or prick SCRATCH; superficial scratch or prick with allergen; IMMEDIATE REACTIONwith allergen; IMMEDIATE REACTION

Wheal= + reactionWheal= + reaction MUST HAVE RESUSCITATION EQUIP MUST HAVE RESUSCITATION EQUIP

AVAIL.AVAIL.

PATCH test: delayed hypersensitivityPATCH test: delayed hypersensitivity Develops in 48-96hDevelops in 48-96h Allergens applied under occlusive Allergens applied under occlusive

tape patchestape patches Review procedureReview procedure Final reading in 2-5 daysFinal reading in 2-5 days

Therapeutic measuresTherapeutic measuresobj.#10obj.#10

Wet compresses for acute, weeping, crusted, Wet compresses for acute, weeping, crusted, inflammatory, ulcerative lesionsinflammatory, ulcerative lesions

Decrease inflammation, cleanse and dry the Decrease inflammation, cleanse and dry the woundwound

To continue drainage from the areaTo continue drainage from the area Can be ordered as sterile or clean procedures Can be ordered as sterile or clean procedures Cool tap H2O, Burrows, normal saline, Cool tap H2O, Burrows, normal saline,

magnesium sulfatemagnesium sulfate applied q3-4 h for 15-20minapplied q3-4 h for 15-20min Not prescribed for more than 72h/skin too dry or Not prescribed for more than 72h/skin too dry or

macerated.macerated. For cool compr. Reapply q 5-10minFor cool compr. Reapply q 5-10min

Balneotherapy: therapeutic bathsBalneotherapy: therapeutic baths Medicate large areas of skin, remove Medicate large areas of skin, remove

old medications, debridement, old medications, debridement, relieve itching and inflammationrelieve itching and inflammation

Lasts for 15-30min.Lasts for 15-30min. Bathmats are importantBathmats are important Water/saline for weeping, oozing, Water/saline for weeping, oozing,

and erythematous lesionsand erythematous lesions

Colloidal baths for wide area of lesions, to Colloidal baths for wide area of lesions, to dry and relieve itchingdry and relieve itching

Medicated tar baths for chronic eczema Medicated tar baths for chronic eczema and psoriasisand psoriasis

Need WELL VENTILATED ROOMNeed WELL VENTILATED ROOM To increase hydration of skin after bath, To increase hydration of skin after bath,

use lubricating agent applied to damp skinuse lubricating agent applied to damp skin An EMOLLIENT is used for LUBRICATION An EMOLLIENT is used for LUBRICATION

AND TO RELIEVE ITCHINGAND TO RELIEVE ITCHING

Topical medicationsTopical medications

Include lotions, ointments, creams, Include lotions, ointments, creams, gels, pastes, intralesional therapygels, pastes, intralesional therapy

May need systemic medications as May need systemic medications as wellwell

Review how and why each type of Review how and why each type of medication is used and how applied.medication is used and how applied.

Powders should not be used with Powders should not be used with clients with respiratory or trachesclients with respiratory or traches

DRESSINGSDRESSINGS Used to enhance absorption of topical meds, Used to enhance absorption of topical meds,

promote retention of moisture, prevent promote retention of moisture, prevent evaporation of medication, reduce pain and evaporation of medication, reduce pain and itchingitching

Occlusive drsg; to seal wound; airtight plastic film Occlusive drsg; to seal wound; airtight plastic film placed over topical agentplaced over topical agent

Tube gauze, cotton socks, gloves, etc.Tube gauze, cotton socks, gloves, etc. Medication may be impregnated within drsg Medication may be impregnated within drsg

(chordran tape(chordran tape Review nursing care plan for client with occlusive Review nursing care plan for client with occlusive

drsg (50-3)pg 946drsg (50-3)pg 946 Applied ONLY to wound area, not healthy skinApplied ONLY to wound area, not healthy skin

Transparent dressings, Transparent dressings, (Opsite,Tegaderm)(Opsite,Tegaderm)

Hydrocolloid protect areas exposed Hydrocolloid protect areas exposed to pressure, and treat ulcers in to pressure, and treat ulcers in beginning stagesbeginning stages

Gels, pastes, granules to fill in deep Gels, pastes, granules to fill in deep wounds/ulcers to promote wounds/ulcers to promote granulation and healinggranulation and healing

TYPES OF TREATMENTS AND TYPES OF TREATMENTS AND REMOVAL OF LESIONSREMOVAL OF LESIONS

Moh’s chemosurgery technique; Moh’s chemosurgery technique; method of excising tumors of the method of excising tumors of the skin, done in layers until entire tumor skin, done in layers until entire tumor removed. Insures complete removal removed. Insures complete removal of the tumor. Helpful in tx of basal of the tumor. Helpful in tx of basal cell cancers (pg 1375 Tabers)cell cancers (pg 1375 Tabers)

Cryosurgery; use of extremely cold Cryosurgery; use of extremely cold probes to destroy unwanted, or probes to destroy unwanted, or cancerous or infected tissues (508,T.)cancerous or infected tissues (508,T.)

Photochemotherapy; use of light and Photochemotherapy; use of light and chemical together to treat certain chemical together to treat certain conditions such as psoriasis or conditions such as psoriasis or cutaneous T-cell lymphomacutaneous T-cell lymphoma

WOUND HEALINGWOUND HEALINGOBJ#11OBJ#11

HEAL BY :HEAL BY : FIRST INTENTION; SECOND INTENTION FIRST INTENTION; SECOND INTENTION

AND THIRD INTENTIONAND THIRD INTENTION Edges approximated and closed with Edges approximated and closed with

sutures= 1sutures= 1stst intent; minimal scarring. intent; minimal scarring. 22ndnd intent=wound left open to heal by intent=wound left open to heal by

granulation; scarring may be extensivegranulation; scarring may be extensive 33rdrd intent=infected site may be left intent=infected site may be left

open/reopened until all signs of infection open/reopened until all signs of infection are gone, then surgically closedare gone, then surgically closed

NSG CARE FOR OPEN LESIONNSG CARE FOR OPEN LESION

Assess site minimum 3x day (4h x3)Assess site minimum 3x day (4h x3) Assess for dead tissue, maceration, Assess for dead tissue, maceration,

exudates,exudates, Cleanse, pat dryCleanse, pat dry Apply agent and occlusive drsgApply agent and occlusive drsg REMOVE for 12h out of 24hREMOVE for 12h out of 24h Assess/eval Assess/eval

forprogression/regressionforprogression/regression

REVIEW ALL LEARNING TIP BOXESREVIEW ALL LEARNING TIP BOXES REVIEW ANY BOXES WITH REVIEW ANY BOXES WITH

INFORMATION IN THEMINFORMATION IN THEM

PRESSURE ULCERSPRESSURE ULCERSOBJ.#12-14OBJ.#12-14

SORE CAUSED BY PROLONGED SORE CAUSED BY PROLONGED PRESSURE AGAINST SKIN in one PRESSURE AGAINST SKIN in one positionposition

Weight of body compresses Weight of body compresses capillaries against a solid object, capillaries against a solid object, especially over bony prominencesespecially over bony prominences

Results in tissue anoxiaResults in tissue anoxia Start to develop in 20-40min.if Start to develop in 20-40min.if

pressure not relievedpressure not relieved

Assess at risk clientAssess at risk client Use Braden scale or similar scaleUse Braden scale or similar scale Assess labs for low serum albumin, Assess labs for low serum albumin,

anemia, level of immobility and anemia, level of immobility and incontinenceincontinence

Other causes include tight splints, casts, tractionOther causes include tight splints, casts, traction At risk are the immobile, decreased sensation, At risk are the immobile, decreased sensation,

decreased circulation, decreased neurological decreased circulation, decreased neurological functionfunction

Mechanical forces are friction, shear and Mechanical forces are friction, shear and pressure.pressure.

When pressure to the skin is greater than the When pressure to the skin is greater than the capillary bed pressure, there is impairment of capillary bed pressure, there is impairment of cellular metabolism with decreased blood supply cellular metabolism with decreased blood supply to cells causing tissue ischemia.to cells causing tissue ischemia.

The reduction in blood flow causes BLANCHING.The reduction in blood flow causes BLANCHING.(LOSS OF COLOR)(LOSS OF COLOR)

““FRICTION” rubbing of skin surface with an FRICTION” rubbing of skin surface with an external mechanical force.giving the effect external mechanical force.giving the effect of sheet burns.of sheet burns.

““SHEARING”occurs when pt slides down SHEARING”occurs when pt slides down or is pulled up without lifting buttocks. or is pulled up without lifting buttocks. Skin and subcut. tissues remain stationary; Skin and subcut. tissues remain stationary; fat, muscle and bone shift in direction of fat, muscle and bone shift in direction of body’s movementbody’s movement

Damage occurs deep in tissuesDamage occurs deep in tissues

Prolonged pressure occurs in the Prolonged pressure occurs in the elderly due to nl skin changeselderly due to nl skin changes

The obese, because fat cells are The obese, because fat cells are poorly vascularized, the thin, poorly vascularized, the thin, because there is little padding over because there is little padding over prominences, and those with prominences, and those with impaired peripheral circulationimpaired peripheral circulation

Signs and symptomsSigns and symptoms

Pain at ulcer sitePain at ulcer site Freq. assess at common sites: sacrum, Freq. assess at common sites: sacrum,

heels, elbows, lateral malleoli, greater heels, elbows, lateral malleoli, greater trochanters, ischial tuberositiestrochanters, ischial tuberosities

Describe according to “3” color system Describe according to “3” color system “ “blackened” tissue=necrosisblackened” tissue=necrosis ‘ ‘yellow” color and with yellow” color and with

exudates=infection presentexudates=infection present “ “red”wounds are pink/red and are in the red”wounds are pink/red and are in the

healing stages healing stages

Treat worst color firstTreat worst color first Dead tissue must be removed first or Dead tissue must be removed first or

healing will not take placehealing will not take place

InterventionsInterventionsobj.#13obj.#13

Box 51-1avoid use of soap and water Box 51-1avoid use of soap and water on dry skinon dry skin

Clean and dry between toesClean and dry between toes Perineal cleansersPerineal cleansers Moisturizing agents without alcoholMoisturizing agents without alcohol Avoid areas of pressure,don’t Avoid areas of pressure,don’t

massage areas of rednessmassage areas of redness Assess for areas of redness, if stage Assess for areas of redness, if stage

1, initiate turn/position schedules1, initiate turn/position schedules

Short fingernailsShort fingernails Use of pillows, pads to maintain good body Use of pillows, pads to maintain good body

alignment. Use of specialty mattresses, pads to alignment. Use of specialty mattresses, pads to decrease pressuredecrease pressure

Encourage activity. Continue to assess skin and Encourage activity. Continue to assess skin and positionposition

Teach patient to shift weight q15min. When lying Teach patient to shift weight q15min. When lying or sittingor sitting

If immobile, needs freq. active/passive ROMIf immobile, needs freq. active/passive ROM Provide high protein, vitamin rich dietProvide high protein, vitamin rich diet Braden scale to assess for riskBraden scale to assess for risk

Heels should not rest on bedHeels should not rest on bed Avoid source of any pressure behind Avoid source of any pressure behind

calves if using pillows to elevate heelscalves if using pillows to elevate heels Use protectors to alleviate pressure on Use protectors to alleviate pressure on

vulnerable sitesvulnerable sites NEVER USE A “DONUT”NEVER USE A “DONUT” Avoid allowing skin surfaces to rub Avoid allowing skin surfaces to rub

togethertogether Use trapeze, draw sheets to move pt in Use trapeze, draw sheets to move pt in

bedbed

Complications are wound infections, Complications are wound infections, progression to a deeper, larger progression to a deeper, larger woundwound

DIAGNOSTIC TESTSDIAGNOSTIC TESTS All considered to be colonized with All considered to be colonized with

bacteria( bacteria present); wound not bacteria( bacteria present); wound not necessarily “infected”necessarily “infected”

Cleansing and mech. debridement can prevent Cleansing and mech. debridement can prevent progression to infectionprogression to infection

Swab cultures; cultures for sensitivity done to Swab cultures; cultures for sensitivity done to identify causative agent from suspected infected identify causative agent from suspected infected sitessites

Must determine between infection and bacterial Must determine between infection and bacterial colonization. If wound is healing by 2colonization. If wound is healing by 2ndnd intention, intention, will be colonized by flora on skin and in will be colonized by flora on skin and in environment. If growth exceeds local tissue environment. If growth exceeds local tissue defenses, then becomes a true infactiondefenses, then becomes a true infaction

When ulcer not healing, invasive/non-When ulcer not healing, invasive/non-invasive blood supply studies are invasive blood supply studies are recommendedrecommended

Wound biopsies may be obtained in the Wound biopsies may be obtained in the case of large, extensive woundscase of large, extensive wounds

Medical treatment varies with size, depth Medical treatment varies with size, depth and stage of ulcer, pt condition.and stage of ulcer, pt condition.

ALL PRESSURE MUST BE REMOVED FOR ALL PRESSURE MUST BE REMOVED FOR HEALING TO OCCUR, cleanliness HEALING TO OCCUR, cleanliness maintainedmaintained

Debridement, cleansing and wound drsg. Debridement, cleansing and wound drsg. To provide moist, healing environmentTo provide moist, healing environment

Debridement: removal of non-viable Debridement: removal of non-viable tissue from the woundtissue from the wound

Non-surgical means: mechanical, Non-surgical means: mechanical, enzymatic, autolyticenzymatic, autolytic

Mech.; scissors/forceps; dextranomer Mech.; scissors/forceps; dextranomer beads; whirlpool baths; wet to dry beads; whirlpool baths; wet to dry saline gauzesaline gauze

Results in non-selective debridementResults in non-selective debridement Usually very painful; pt needs premedUsually very painful; pt needs premed Enzymatic proteolytic agent; selectively Enzymatic proteolytic agent; selectively

digests necrotic tissue. Requires very digests necrotic tissue. Requires very careful application. Will digest living tissue careful application. Will digest living tissue alsoalso

Autolytic; use of synthetic dressing; a Autolytic; use of synthetic dressing; a moisture retentive drsg. Eschar is moisture retentive drsg. Eschar is

self digested due to enzyme action. NOT self digested due to enzyme action. NOT USED FOR INFECTED WOUNDSUSED FOR INFECTED WOUNDS

SURGICAL debridement removal by SURGICAL debridement removal by scalpel, of devitalized tissue, thick scalpel, of devitalized tissue, thick adherent eschar.adherent eschar.

May need a graft to close wound, May need a graft to close wound, espec. For full thickness ulcer or loss espec. For full thickness ulcer or loss of joint funct involves a donor siteof joint funct involves a donor site

Needs continual assess for pain Needs continual assess for pain during procedureduring procedure

Wound cleansingWound cleansing

Should be cleansed with whirlpool or Should be cleansed with whirlpool or shower head/irrigation with between 4-shower head/irrigation with between 4-15lbs per sq. inch(psi)15lbs per sq. inch(psi)

Less than 4psi does not effectively Less than 4psi does not effectively cleanse. Greater than 15psi may damage cleanse. Greater than 15psi may damage good tissuegood tissue

If wound debris or light layer of eschar If wound debris or light layer of eschar present, use 30ml syringe with 18g present, use 30ml syringe with 18g needle/250ml of NSneedle/250ml of NS

This pressure will also remove bacteriaThis pressure will also remove bacteria

If wound healing and tissue is red ( sign of If wound healing and tissue is red ( sign of new granulation tissue), use 30-60ml new granulation tissue), use 30-60ml NEEDLELESS syringe to prevent trauma to NEEDLELESS syringe to prevent trauma to new fragile tissue. After cleansing/dbr. new fragile tissue. After cleansing/dbr. Apply occlusive drgApply occlusive drg

Wounds need moist env, minimal bacterial Wounds need moist env, minimal bacterial colonization and a healing temp; takes 12h colonization and a healing temp; takes 12h to occur.if freq removed, may not reach to occur.if freq removed, may not reach healing temphealing temp

Infected wounds are NOT covered with Infected wounds are NOT covered with occlusiveocclusive

Wound dressingsWound dressings

Vary according to size, location, Vary according to size, location, depth, stage of ulcerdepth, stage of ulcer

Commonly used materials; hydrogel, Commonly used materials; hydrogel, polyurethane, hydocolloid wafers, polyurethane, hydocolloid wafers, biologic agents, alginates and cotton biologic agents, alginates and cotton gauzegauze

Use hypoallergenic tape to secure Use hypoallergenic tape to secure PRESSURE MUST BE KEPT OFF OF PRESSURE MUST BE KEPT OFF OF

ULCERULCER

Nursing assessmentNursing assessment

Ongoing assessmentOngoing assessment Recognize causative factors and any Recognize causative factors and any

impediments to healingimpediments to healing Wound measurements including Wound measurements including

depthdepth Probe gently with q-tip to detect and Probe gently with q-tip to detect and

measure tunnelingmeasure tunneling

Wound stagingWound staging

1; skin intact but red and does NOT 1; skin intact but red and does NOT blanch; may have warmth, hardness blanch; may have warmth, hardness and deeper tissue damageand deeper tissue damage

2; break in skin with PARTIAL 2; break in skin with PARTIAL THICKNESS LOSS OF THICKNESS LOSS OF EPIDERMIS/DERMIS. Appears as a EPIDERMIS/DERMIS. Appears as a shallow crater, abrasion, or a blistershallow crater, abrasion, or a blister

3; full thickness skin loss that extends to 3; full thickness skin loss that extends to the subcutaneous tissue, BUT NOT THE the subcutaneous tissue, BUT NOT THE FASCIA. There may be undermining of FASCIA. There may be undermining of adjacent tissue. Looks like a deep crater, adjacent tissue. Looks like a deep crater, may have escharmay have eschar

4; full thickness loss with damage into the 4; full thickness loss with damage into the muscle, bone, other support structures. muscle, bone, other support structures. May have undermining and sinus tractsMay have undermining and sinus tracts

Assess the wound exudateAssess the wound exudate Will be serosanguiness or may be purulentWill be serosanguiness or may be purulent Purulent may have color and odor Purulent may have color and odor

depending on the infecting agentdepending on the infecting agent Yellow = staphYellow = staph Beige and fishy=proteusBeige and fishy=proteus Green-blue /fruity=pseudomonasGreen-blue /fruity=pseudomonas Brown/fecal=bacteroidesBrown/fecal=bacteroides

Assess for granulationAssess for granulation Should be pink/red and slightly Should be pink/red and slightly

spongeyspongey Assess ulcer min. q24h; color , size, Assess ulcer min. q24h; color , size,

exudateexudate Assess pt tempAssess pt temp Provide wound care/sterile techniqueProvide wound care/sterile technique Assess pt for pain/can pt sleep, eatAssess pt for pain/can pt sleep, eat

Inflammatory skin problemsInflammatory skin problemsdermatitisdermatitisobj15-17obj15-17

Char. by itching, redness, lesions of Char. by itching, redness, lesions of varying sizes and distributionvarying sizes and distribution

Often caused by exposure to Often caused by exposure to allergens, irritants,: can be allergens, irritants,: can be precipitated by emotional stress and precipitated by emotional stress and genetic factorsgenetic factors

Eczema ( non-specific term) and Eczema ( non-specific term) and dermatitis used interchangeablydermatitis used interchangeably

Contact dermatitis: acute/chronicContact dermatitis: acute/chronic Caused by DIRECT CONTACT WITH Caused by DIRECT CONTACT WITH

IRRITATING SUBSTANCE; SOAP, MEDICINEIRRITATING SUBSTANCE; SOAP, MEDICINE Allergic: contact with an allergen resulting Allergic: contact with an allergen resulting

in A CELL MEDIATED IMMUNE RESPONSEin A CELL MEDIATED IMMUNE RESPONSE Atopic: chronic, inherited, assoc with Atopic: chronic, inherited, assoc with

asthma. Lesions often become lichenified asthma. Lesions often become lichenified and hyperpigmentedand hyperpigmented

Seborrheic: chronic inflammatory, Seborrheic: chronic inflammatory, see seborrhea,excessive production see seborrhea,excessive production of sebaceous secretions ( scalp face, of sebaceous secretions ( scalp face, axilla, genitocrural areas), greasy axilla, genitocrural areas), greasy scales,yellow or pink-yellow crustsscales,yellow or pink-yellow crusts

Assoc. with emot. Stress, often a Assoc. with emot. Stress, often a genetic pre-dispositiongenetic pre-disposition

3 types are common3 types are common Atopic, contact, seborreicAtopic, contact, seborreic Chronic, usually respond to tx, but Chronic, usually respond to tx, but

recurrecur See preventive measuresSee preventive measures Present as dry flakey scales, yellow Present as dry flakey scales, yellow

crusts, fissures, macules, papulescrusts, fissures, macules, papules Worsen with continued irritation and Worsen with continued irritation and

exposure to offending agentsexposure to offending agents

Dx based on hx, s/s, clinical findings.Dx based on hx, s/s, clinical findings. Review table 51-1Review table 51-1 Tx based upon s/sTx based upon s/s Control itching, pain, decrease Control itching, pain, decrease

inflammation, control or prevent inflammation, control or prevent crust formations, prevent further skin crust formations, prevent further skin damage, infectiondamage, infection

Measures to control s/s are:Measures to control s/s are: Use of antihistamines, anti-puretics and Use of antihistamines, anti-puretics and

analgesics to control itching and painanalgesics to control itching and pain Use of steroids topically, intralesionally or Use of steroids topically, intralesionally or

systemically to control inflammationsystemically to control inflammation Topical is preferred as systemic use over Topical is preferred as systemic use over

the long term can cause side effects and the long term can cause side effects and adrenal suppressionadrenal suppression

Read page 325 in Davis 10Read page 325 in Davis 10thth edit. For s/e to edit. For s/e to corticosteroidscorticosteroids

Use “whatsup for nsg assess. Be sure to Use “whatsup for nsg assess. Be sure to include assessment for altered body imageinclude assessment for altered body image

Review your NANDA dx; impaired skin Review your NANDA dx; impaired skin integrity, disturbed body image, and defic. integrity, disturbed body image, and defic. Knowledge related to disease and txKnowledge related to disease and tx

Goals of tx to keep skin intact, or improve, Goals of tx to keep skin intact, or improve, prevent infect., maintain comfortprevent infect., maintain comfort

Give me at least 10 questions with Give me at least 10 questions with rationales from whatsup, 50-1rationales from whatsup, 50-1

Display an accepting attitudeDisplay an accepting attitude Teaching for how to apply medications, Teaching for how to apply medications,

robinrobin How are you able to measure your goals How are you able to measure your goals

for effectiveness of txfor effectiveness of tx Controlled or in remission, itching or Controlled or in remission, itching or

discomfort minimal, able to socialize, pt discomfort minimal, able to socialize, pt able to describe and demonstrate self careable to describe and demonstrate self care

PsoriasisPsoriasis

Chr. Inflammatory disorder in which Chr. Inflammatory disorder in which the EPIDERMAL CELLS proliferate the EPIDERMAL CELLS proliferate abnormally fast. Ordinarily takes 27 abnormally fast. Ordinarily takes 27 days. With psoriasis, takes only 4-5days. With psoriasis, takes only 4-5

The abnl keratin forms loosly The abnl keratin forms loosly adherent scales on reddened baseadherent scales on reddened base

Exacerbations/remissionsExacerbations/remissions Cause unknown, but has large Cause unknown, but has large

familial componentfamilial component

Onset can be any age with 27y being Onset can be any age with 27y being the averagethe average

Severe if starts in childhoodSevere if starts in childhood Sun /humidity may suppressSun /humidity may suppress Strep pharyngitis, stress, hormonal Strep pharyngitis, stress, hormonal

changes, weather, skin trauma and changes, weather, skin trauma and meds ( antimalarials, beta blockers meds ( antimalarials, beta blockers and lithium) may exacerbateand lithium) may exacerbate

No known true prevention, but avoid No known true prevention, but avoid stress, meds, trauma, resp. infections if stress, meds, trauma, resp. infections if poss.poss.

s/s vary with type of psoriasiss/s vary with type of psoriasis Lesions usually are red papules that join to Lesions usually are red papules that join to

form plaques with DISTINCT BORDERS form plaques with DISTINCT BORDERS silvery scales form on untreated lesionssilvery scales form on untreated lesions

Most affected areas are: ELBOWS, KNEES, Most affected areas are: ELBOWS, KNEES, SCALP, UMBILICUS, GENITALSSCALP, UMBILICUS, GENITALS

May see nail involvement, dry, brittle hairMay see nail involvement, dry, brittle hair

Complications may include Complications may include secondary infections, psoriatic secondary infections, psoriatic arthritisarthritis

Systemic s/s and lymphadenopathySystemic s/s and lymphadenopathy Tests would depend on severityTests would depend on severity Usually done on phys. FindingsUsually done on phys. Findings Testing done to dx a concurrent Testing done to dx a concurrent

disease or secondary infect.disease or secondary infect.

Anthralin, a strong irritant, may be used Anthralin, a strong irritant, may be used with salicylic acid as a paste.with salicylic acid as a paste.

Can cause a chemical burn, not on for >2hCan cause a chemical burn, not on for >2h Used with tar and UV light under close Used with tar and UV light under close

medical supervisionmedical supervision UVB (short wave) and UVA (long wave) UVB (short wave) and UVA (long wave)

amount of exposure dtermined by pts amount of exposure dtermined by pts condit., pigmentation and susceptibilitycondit., pigmentation and susceptibility

Occlusive drsgs enhance penetration Occlusive drsgs enhance penetration of medsof meds

Keratolytics enhance effects of Keratolytics enhance effects of salicylic acid to loosen, remove salicylic acid to loosen, remove scalesscales

Tars are usually prescribed along Tars are usually prescribed along with steroids. Tars act to slow cell with steroids. Tars act to slow cell division in the epidermal layersdivision in the epidermal layers

Never use occlusive drsgs with tarsNever use occlusive drsgs with tars

Must WEAR EYE GUARDS during txMust WEAR EYE GUARDS during tx PUVA tx is oral Psoralen used in conjunct PUVA tx is oral Psoralen used in conjunct

with UVA tx. This tx temporarily inhibits with UVA tx. This tx temporarily inhibits DNA synthesisDNA synthesis

Pt MUST WEAR DARK GLASSES DURING TX Pt MUST WEAR DARK GLASSES DURING TX AND FOR ENTIRE DAY AFTER TX. Longterm AND FOR ENTIRE DAY AFTER TX. Longterm effects are unknown. Possible incr. risk of effects are unknown. Possible incr. risk of skin cancers, premature aging and actinic skin cancers, premature aging and actinic keratosiskeratosis

Observe pt closely for redness, Observe pt closely for redness, tenderness, edema and eye changestenderness, edema and eye changes

Depending upon pt condition, initial and Depending upon pt condition, initial and f/u eye exams, skin bx, urinalysis and f/u eye exams, skin bx, urinalysis and blood work may be orderedblood work may be ordered

Antimetabolites..a last resortAntimetabolites..a last resort Methotrexate most common agent, can Methotrexate most common agent, can

lead to hepatotoxicity. Liver bx and labs lead to hepatotoxicity. Liver bx and labs are routinely done prior to tx. are routinely done prior to tx. Contraindicated in persons with any liver, Contraindicated in persons with any liver, renal or bone marrow diseaserenal or bone marrow disease

Nursing care would be the same as Nursing care would be the same as for any pt with a dermatitis, but be for any pt with a dermatitis, but be sure to emphasize freq. periods of sure to emphasize freq. periods of rest to enhance the antimitotic rest to enhance the antimitotic effects of the medicationseffects of the medications

Usually females pred. In males, often Usually females pred. In males, often have Rhinophyma (enlarged, have Rhinophyma (enlarged, redenned/purplish noseredenned/purplish nose

Heat/cold, spicey foodsHeat/cold, spicey foods Avoid temp. extremes/alcohol/stressAvoid temp. extremes/alcohol/stress

RosaceaRosacea

Chronic acneform disorder of faceChronic acneform disorder of face Increased reactions of capillaries to Increased reactions of capillaries to

heatheat Often exists with acneOften exists with acne Often cause of significant facial Often cause of significant facial

cosmetic disfigurementcosmetic disfigurement Age 30-50yAge 30-50y

INFECTIOUS SKIN DISORDERSINFECTIOUS SKIN DISORDERS

Impetigo contagiosaImpetigo contagiosa Common , infectious, inflammatory Common , infectious, inflammatory

skin disorderskin disorder Strep or staphStrep or staph Pools, pets, dirt fingernails, Pools, pets, dirt fingernails,

contaminated materials, or contaminated materials, or secondary to scrapes, cuts, etc.secondary to scrapes, cuts, etc.

Primary infection appears on Primary infection appears on exposed areas, extrem., hands, exposed areas, extrem., hands, face , neck, skin foldsface , neck, skin folds

OOZING, THIN ROOFED VESICLE that OOZING, THIN ROOFED VESICLE that grows rapidly and produces a HONEY grows rapidly and produces a HONEY COLORED CRUST; EASILY REMOVED, COLORED CRUST; EASILY REMOVED, replaced with new onesreplaced with new ones

Heal in 1-2wks if allowed to dryHeal in 1-2wks if allowed to dry

COMPLICATIONSCOMPLICATIONS

GLOMERULONEPHRITIS FROM A GLOMERULONEPHRITIS FROM A PARTICULAR STRAIN OF STREP(PG 599)PARTICULAR STRAIN OF STREP(PG 599)

EASILY SPREAD TO OTHER PARTS OF BODYEASILY SPREAD TO OTHER PARTS OF BODY Will persist if lesions not allowed to dryWill persist if lesions not allowed to dry Secondary PYODERMA..ACUTE , Secondary PYODERMA..ACUTE ,

INLAMMATORY PURULENT DERMATITIS, if INLAMMATORY PURULENT DERMATITIS, if lesions not responsive to txlesions not responsive to tx

TREATMENTTREATMENT SYSTEMIC ANTIBIOTICSSYSTEMIC ANTIBIOTICS TOPICALANTIBIOTICS AFTER REMOVAL OF TOPICALANTIBIOTICS AFTER REMOVAL OF

CRUSTSCRUSTS Gentle washing with mild soap and warm Gentle washing with mild soap and warm

water to remove crustswater to remove crusts AntipyreticsAntipyretics Clean hands/nails, mitts, GOOD HYGIENEClean hands/nails, mitts, GOOD HYGIENE REMAIN HOME UNTIL ALL LESIONS ARE REMAIN HOME UNTIL ALL LESIONS ARE

HEALEDHEALED Observe for 6-7 weeks for s/s glomerular Observe for 6-7 weeks for s/s glomerular

nephritisnephritis

HERPES SIMPLEXHERPES SIMPLEXcommon viral infection common viral infection

Hsv1 and hsv2Hsv1 and hsv2 HSV-1 occurs above the waist, typical HSV-1 occurs above the waist, typical

cold sore on mouthcold sore on mouth HSV-2 occurs below the waist and HSV-2 occurs below the waist and

causes genital herpescauses genital herpes Primary infection occurs thru direct Primary infection occurs thru direct

contact, respiratory droplet or contact, respiratory droplet or exposure to fluid filled vesiclesexposure to fluid filled vesicles

Lies dormant in nerve ganglia near the Lies dormant in nerve ganglia near the spinal cord…immune system can’t destroy spinal cord…immune system can’t destroy it. At this time, pt has no s/s, may first it. At this time, pt has no s/s, may first present with pain , itching, burning at site present with pain , itching, burning at site of breakoutof breakout

Recurrence is spontaneous; stress, Recurrence is spontaneous; stress, lowered immune, fatigue, injurylowered immune, fatigue, injury

Secondary lesion may be single or as a Secondary lesion may be single or as a group of vesicles or pustueles on an group of vesicles or pustueles on an erythematous baseerythematous base

Crusts form, dry, heal in approx. 1 wkCrusts form, dry, heal in approx. 1 wk

LESIONS ARE CONTAGIOUS for 2-4 LESIONS ARE CONTAGIOUS for 2-4 days before dry crusts formdays before dry crusts form

Can be red lesions without vesiclesCan be red lesions without vesicles Virus shedsVirus sheds Avoid contact with a known infected Avoid contact with a known infected

lesion during the blistering phase can lesion during the blistering phase can prevent the primary infectionprevent the primary infection

Attacks diminish with Attacks diminish with age..contagious until scabs formage..contagious until scabs form

If herpes simples is present in the If herpes simples is present in the vagina at childbirth, the newborn vagina at childbirth, the newborn may be infected and develop may be infected and develop meningoencephalitis or panvisceral meningoencephalitis or panvisceral infectioninfection

If rub lesion and rub eyes, can If rub lesion and rub eyes, can develop HSV infection in eyes, develop HSV infection in eyes, possible blindness, brain infectionpossible blindness, brain infection

Culture provides definite dxCulture provides definite dx Usual dx based on s/s, hxUsual dx based on s/s, hx NO COMPLETE CURENO COMPLETE CURE Topical acyclovir drug of choice to tx primary Topical acyclovir drug of choice to tx primary

lesions to suppress multiplication of lesions to suppress multiplication of vesicles.DOES NOT WORK ON SECONDARY vesicles.DOES NOT WORK ON SECONDARY LESIONS. LESIONS.

Oral acyclovir may be recommended for severe or Oral acyclovir may be recommended for severe or freq. attacks.; people who are immunocompr. freq. attacks.; people who are immunocompr. Creams. Ointments may be prescribed to speed Creams. Ointments may be prescribed to speed drying, healing..may need addit. Of oral drying, healing..may need addit. Of oral antibioticsantibiotics

Nursing education of pt is PRIMARY Nursing education of pt is PRIMARY IMPORTANCE; INSTRUCTION ON HOW IMPORTANCE; INSTRUCTION ON HOW TO AVOID INFECTION, WHEN IT IS TO AVOID INFECTION, WHEN IT IS CONTAGIOUS, AND how to prevent CONTAGIOUS, AND how to prevent spreading to other body partsspreading to other body parts

Furuncles and carbunclesFuruncles and carbuncles

Furncle; small tender boil; occurs deep in Furncle; small tender boil; occurs deep in one or more hair follicles, spreads to one or more hair follicles, spreads to dermisdermis

Usually caused by StaphUsually caused by Staph Areas of excessive perspiration, friction Areas of excessive perspiration, friction

and irritationand irritation Yellow, black or whiteheadYellow, black or whitehead Pain, tenderness, erythema, surrounding Pain, tenderness, erythema, surrounding

cellulitis, poss. lymphadenopathycellulitis, poss. lymphadenopathy

Carbuncle; extension of furuncleCarbuncle; extension of furuncle Abscess of skin and subcutan. TissueAbscess of skin and subcutan. Tissue Where skin is thick, non-elastic, Where skin is thick, non-elastic,

fibrousfibrous Upper back, back of neck, buttocksUpper back, back of neck, buttocks Fevers , pain, leukocytosis, collapseFevers , pain, leukocytosis, collapse Debilitated clients and diabeticsDebilitated clients and diabetics

Furuncles can progress to carbunclesFuruncles can progress to carbuncles Systemic infectionSystemic infection Can spread infection to others Can spread infection to others

(staph)(staph) Scarring can occur, may require I&D, Scarring can occur, may require I&D,

and systemic antibioticsand systemic antibiotics

DO NOT SQUEEZE AND IRRITATEDO NOT SQUEEZE AND IRRITATEUse antibacterial soaps to cleanse/ointmentUse antibacterial soaps to cleanse/ointmentSurg. I&dSurg. I&dCover lesion with DSDCover lesion with DSDDOUBLE BAG ALL SOILED DRESSINGSDOUBLE BAG ALL SOILED DRESSINGSAnalgesia/antipyreticsAnalgesia/antipyreticsBed rest advised with carbuncles/or furuncles Bed rest advised with carbuncles/or furuncles

located in the perineal/anal areas (Forniers’ located in the perineal/anal areas (Forniers’ gangrene)gangrene)

Cleans living area and equipment daily, laundry Cleans living area and equipment daily, laundry after each useafter each use

Strict hand washingStrict hand washing

HERPES ZOSTERHERPES ZOSTER(SHINGLES)(SHINGLES)

Different virus than HSVDifferent virus than HSV This is caused by Varicella zoster, thought This is caused by Varicella zoster, thought

to be identical to virus causing chickenpoxto be identical to virus causing chickenpox Presents as acute, inflammatory and Presents as acute, inflammatory and

infectious outbreak of painful vesicles on infectious outbreak of painful vesicles on erythematous base. Out break occurs erythematous base. Out break occurs along the dermatone(s) of one or more along the dermatone(s) of one or more cutaneous sensory nervescutaneous sensory nerves

Usually unilateralUsually unilateral

Thought to be a reactivation of latent Thought to be a reactivation of latent zoster viruszoster virus

Incubation 7-21 daysIncubation 7-21 days Vesicles appear in 3-4 daysVesicles appear in 3-4 days Eruption generally occurs posteriorly Eruption generally occurs posteriorly

and progresses anteriorly and and progresses anteriorly and peripherally along the dermatoneperipherally along the dermatone

Duration can vary from 10days to 5+ Duration can vary from 10days to 5+ weeksweeks

Occurs most commonly in elderlyOccurs most commonly in elderly Or immune suppressed, immun-Or immune suppressed, immun-

suppr. Agents or with malignancies, suppr. Agents or with malignancies, injuries to spine or cranial nervesinjuries to spine or cranial nerves

Avoid contagion by avoiding contact Avoid contagion by avoiding contact with person with this disease.with person with this disease.

Contagion possible a few days before Contagion possible a few days before eruption of vesicles and until dryeruption of vesicles and until dry

May present with vesicles and plaquesMay present with vesicles and plaques Irritation, itching, fever, malaiseIrritation, itching, fever, malaise May be very painful, pain likely to increase May be very painful, pain likely to increase

with age of pt and remain after healing in with age of pt and remain after healing in the elderlythe elderly

Condition referred to as hyperesthesia; Condition referred to as hyperesthesia; any measures to increase comfort should any measures to increase comfort should be used; cold compressesbe used; cold compresses

Dx by clinical presentation and Dx by clinical presentation and assoc. s/s. may do cultures for assoc. s/s. may do cultures for suspected secondary infectionsuspected secondary infection

If in more than two dermatones, pt If in more than two dermatones, pt will need isolation room in hospitalwill need isolation room in hospital

Some evidence can be airbornSome evidence can be airborn

complicationscomplications

Post herpetic neuralgiaPost herpetic neuralgia Persistent dermatomal pain, can last for Persistent dermatomal pain, can last for

months and years. Can have severe months and years. Can have severe negative impact on quality of lifenegative impact on quality of life

Opthalmic herpes zoster affects 5Opthalmic herpes zoster affects 5thth cranial cranial nerve; serious complication, can lose nerve; serious complication, can lose sight, hearing loss, facial paralysis, vertigosight, hearing loss, facial paralysis, vertigo

Full thickness skin necrosis and systemic Full thickness skin necrosis and systemic viremiaviremia

Can cause chickenpox in othersCan cause chickenpox in others

TreatmentTreatment Aimed towards controlling s/s and preventing Aimed towards controlling s/s and preventing

complications. Should start within 72hcomplications. Should start within 72h Acyclovir, topical, oral, IV may be used at initial Acyclovir, topical, oral, IV may be used at initial

outbreak, early stages as well as Famciclovir and outbreak, early stages as well as Famciclovir and ValacyclovirValacyclovir

Doesn’t cure, but helps suppress the viral Doesn’t cure, but helps suppress the viral outbreakoutbreak

Analgesics for pain; of limited value, Analgesics for pain; of limited value, corticosteroids to reduce pain, but NOT with corticosteroids to reduce pain, but NOT with opthalmic involvement. Topicals, tricyclics, opthalmic involvement. Topicals, tricyclics, anticonvulsantsanticonvulsants

Antihistamines, antibiotics, medicated bathsAntihistamines, antibiotics, medicated baths

Only reliable way to differentiate Only reliable way to differentiate from HSV is culture, serum PCR/IFAfrom HSV is culture, serum PCR/IFA

Use of new vaccine, Zostavax in Use of new vaccine, Zostavax in people age 60 and youngerpeople age 60 and younger

FUNGAL INFECTIONSFUNGAL INFECTIONS

DERMATOPHYTOSIS a fungal infection of DERMATOPHYTOSIS a fungal infection of the skin that occurs when there is a break the skin that occurs when there is a break in skin integrity in the presence of warmth in skin integrity in the presence of warmth and moisture.and moisture.

Occurs with direct contact with infected Occurs with direct contact with infected humans ,animals or objectshumans ,animals or objects

TINEA IS THE OPERATIVE NOUN.TINEA IS THE OPERATIVE NOUN. The second name stands for the body site The second name stands for the body site

affectedaffected

TINEA pedis(athletes foot), common.TINEA pedis(athletes foot), common. Chronic plantar scaling, acute vesicular, Chronic plantar scaling, acute vesicular,

and interdigitaland interdigital Chronic plantar scaling in fold lines, itching Chronic plantar scaling in fold lines, itching

not usually presentnot usually present Acute vesic. Eruption of tiny painful itching Acute vesic. Eruption of tiny painful itching

blistersblisters Interdigital, common form, erosion, Interdigital, common form, erosion,

scaling, fissuring in toe webs, painful, scaling, fissuring in toe webs, painful, burning, itchy with offensive odorburning, itchy with offensive odor

Chronic planatr treated with Chronic planatr treated with keratolytics, topical antifungals. NOT keratolytics, topical antifungals. NOT CURATIVECURATIVE

ACUTE SOAKS OR BATHS 2-3X DAY ACUTE SOAKS OR BATHS 2-3X DAY TO DRY BLISTERS astringent paint TO DRY BLISTERS astringent paint applied to unroofed blistersapplied to unroofed blisters

Interdigital treated with combinations Interdigital treated with combinations antifungals, antibiotics and foot antifungals, antibiotics and foot soaks with Burrowssoaks with Burrows

Pt teaching importantPt teaching important Feet dry, avoid plastic/rubbersoled Feet dry, avoid plastic/rubbersoled

shoesshoes Water shoes in public showersWater shoes in public showers Cotton socks to absorb perspirationCotton socks to absorb perspiration

Tinea capitas; ringworm of scalpTinea capitas; ringworm of scalp Contagious; loss of hair in childrenContagious; loss of hair in children Presents as scattered round red scaly Presents as scattered round red scaly

patches, may have small pustulespatches, may have small pustules Brittle hair at site, breaks off, mild Brittle hair at site, breaks off, mild

itching and kerion inflammationitching and kerion inflammation

Treat with systemic antifungals Treat with systemic antifungals because of high relapse rate with just because of high relapse rate with just topicalstopicals

Highly contagiousHighly contagious Teach med side effects, never share Teach med side effects, never share

combs, headgear, pillows, brushescombs, headgear, pillows, brushes Check pets for s/s of infectionCheck pets for s/s of infection

Tinea corporis; ringworm of bodyTinea corporis; ringworm of body Erythematous macule that Erythematous macule that

progresses to rings of vesicles, alone progresses to rings of vesicles, alone or in groups, on exposed areas of or in groups, on exposed areas of body, may be intensely itchybody, may be intensely itchy

Infected pets are freq. sourceInfected pets are freq. source Topical/oral antifungals, topical Topical/oral antifungals, topical

steroidssteroids Keep skin dry, wear cottonKeep skin dry, wear cotton

Tinea cruris (jock itch)Tinea cruris (jock itch) Ringworm of groin may extend to Ringworm of groin may extend to

inner thighs and buttocks. Often inner thighs and buttocks. Often present along with tinea pedispresent along with tinea pedis

Small scaly patch, then sharply Small scaly patch, then sharply demarcated plaque with elevated demarcated plaque with elevated scaly or vesicular bordersscaly or vesicular borders

May be intensely itchyMay be intensely itchy

Teach to avoid heat, moisture, Teach to avoid heat, moisture, frictionfriction

Topical anitfungals; spread beyond Topical anitfungals; spread beyond lesion borderslesion borders

Oral antifungals/steroids may be Oral antifungals/steroids may be needed to control/cureneeded to control/cure

Remember to discuss possible med Remember to discuss possible med side effects, short and long term with side effects, short and long term with clientclient

Tinea unguium (onychomycosis) Tinea unguium (onychomycosis) fungal infection of fingernails and fungal infection of fingernails and toenailstoenails

Usually lifelongUsually lifelong Yellow thickening of nailplate, Yellow thickening of nailplate,

crumbly debris; nail plates become crumbly debris; nail plates become separated, eventually nail is separated, eventually nail is destroyeddestroyed

Topicals usually not effectiveTopicals usually not effective May need nail avulsion (removal)May need nail avulsion (removal) High rate of relapseHigh rate of relapse

CELLULITISCELLULITIS

Inflammation of skin cells and or cellular or Inflammation of skin cells and or cellular or connective tissue from a generalized connective tissue from a generalized infection with Staph or Strepinfection with Staph or Strep

Result of skin trauma or secondary Result of skin trauma or secondary infection of an ope wound, or may have no infection of an ope wound, or may have no immediately known causeimmediately known cause

Most freq. occurs in lower extremitiesMost freq. occurs in lower extremities Good hygiene and prevention of cross Good hygiene and prevention of cross

contaminationcontamination

Presents with warmth, pain, edema, Presents with warmth, pain, edema, erythema, tenderness, fever locally erythema, tenderness, fever locally and progresses rapidlyif not treatedand progresses rapidlyif not treated

C&S of pustule or lesions to identify C&S of pustule or lesions to identify organism. May need blood cultures if organism. May need blood cultures if bacteremia suspectedbacteremia suspected

Always be aware of your patient’s Always be aware of your patient’s immune statusimmune status

Topical and oral or IV antibioticsTopical and oral or IV antibiotics Get good hx; recent trauma?, abnl Get good hx; recent trauma?, abnl

temp, v/stemp, v/s Use of good hand hygiene at all Use of good hand hygiene at all

times for you and the patient, wash times for you and the patient, wash linens and clotheslinens and clothes

Much CA-MRSA nowMuch CA-MRSA now

ACNE VULGARISACNE VULGARIS

COMMON SKIN DISORDER OF THE COMMON SKIN DISORDER OF THE SEBACEOUS GLANDSSEBACEOUS GLANDS

Occurs freq. on upper back, face, Occurs freq. on upper back, face, shoulders, whereever there are shoulders, whereever there are numerous hair folliclesnumerous hair follicles

Multifocal causes, often hormonalMultifocal causes, often hormonal Sebaceous glands under endocrine Sebaceous glands under endocrine

system control; androgenssystem control; androgens

Stimulation of glands causes more Stimulation of glands causes more sebum to be producedsebum to be produced

This with grad. Obstr. Of This with grad. Obstr. Of pilosebaceous ducts with debris, pilosebaceous ducts with debris, leads to inflammation and rupture of leads to inflammation and rupture of seb. Gl.seb. Gl.

This leads to greater infl., formation This leads to greater infl., formation of pustules, nodules and cystsof pustules, nodules and cysts

Hereditary factors, stress, strong Hereditary factors, stress, strong soaps contributesoaps contribute

NOT RELATED TO CHOCOLATE, DIET, NOT RELATED TO CHOCOLATE, DIET, CLEANLINESSCLEANLINESS

Can occur regardless of interventionsCan occur regardless of interventions Initial lesions are comeodones, Initial lesions are comeodones,

closed whiteheads, lead to open closed whiteheads, lead to open lesions with blackheads, lipids and lesions with blackheads, lipids and melanin pigmentsmelanin pigments

Effective topical agents; benzol peroxide, Effective topical agents; benzol peroxide, an anticiotic, erythromycin and an anticiotic, erythromycin and tetracycline(teeth)to kill bacteria in tetracycline(teeth)to kill bacteria in folliclesfollicles

Vitamin A acid (retin-A to loosen pore Vitamin A acid (retin-A to loosen pore plugs and prevent new form.plugs and prevent new form.

Antibiotics usually reserved for severe Antibiotics usually reserved for severe cases, espec Retin-A must be closely cases, espec Retin-A must be closely monitoredmonitored

Must be tested to be sure not pregnant, Must be tested to be sure not pregnant, use 2 forms of birthcontrol 1 mo before, use 2 forms of birthcontrol 1 mo before, during and afterduring and after

Parasitic disordersParasitic disordersinfestationsinfestations

Infestation by liceInfestation by lice Pediculosis capitas,corporis, pubisPediculosis capitas,corporis, pubis Bite skin and feed on human bloodBite skin and feed on human blood Leave eggs and excrementLeave eggs and excrement Causes intense itchingCauses intense itching Lice are oval and 2mm in lengthLice are oval and 2mm in length

P. capitas, female lays eggs(nits) P. capitas, female lays eggs(nits) close to scalp hair and behind earsclose to scalp hair and behind ears

Silvery whiteSilvery white Transmitted dy direct contact with Transmitted dy direct contact with

infested organisms or infested organisms or objects(fomites)objects(fomites)

Most common in children and people Most common in children and people with long hairwith long hair

May not be itchyMay not be itchy

P.corporis; body lice that lay eggs in P.corporis; body lice that lay eggs in seams of clothing, then pierce skinseams of clothing, then pierce skin

Neck, trunk thighsNeck, trunk thighs Intense itching, excoriationsIntense itching, excoriations P. pubic(crabs) usually in genital area, but P. pubic(crabs) usually in genital area, but

can be hairs of chest, axilla,eyelashes, can be hairs of chest, axilla,eyelashes, beardbeard

Often thru sexual contact,less often Often thru sexual contact,less often infested bed lineninfested bed linen

Intensely itchyIntensely itchy

Prevent by avoiding contact with Prevent by avoiding contact with infested persons/objectsinfested persons/objects

Don’t share equip.,routine washing of Don’t share equip.,routine washing of clothingclothing

Secondary infections/impetigo, boilsSecondary infections/impetigo, boils MrsaMrsa Parallel linear scratches,Hyperemia, Parallel linear scratches,Hyperemia,

hyperpigmentationhyperpigmentation Can be vectors for rickettsial diseasesCan be vectors for rickettsial diseases Through hx and exam, may also want to Through hx and exam, may also want to

test for STDstest for STDs Pediculocides/nixPediculocides/nix Complications with other medsComplications with other meds

Goal to kill the parasites and Goal to kill the parasites and mechanically remove nitsmechanically remove nits

Use of pediculocides ie permethrin or Use of pediculocides ie permethrin or pyrethrum are commonly usedpyrethrum are commonly used

Some lice may exhibit resistanceSome lice may exhibit resistance ““NIX” or permethrin active for NIX” or permethrin active for

approx. 1wk, kills adult lice approx. 1wk, kills adult lice immediately and nits as they hatchimmediately and nits as they hatch

Rid, A-200 pyrinate must be re-Rid, A-200 pyrinate must be re-applied in one weekapplied in one week

Physostigmine opthal. Oint to Physostigmine opthal. Oint to eyebrows, lashes, no other medseyebrows, lashes, no other meds

Nursing care; give full instructions on Nursing care; give full instructions on the medications used, possible side the medications used, possible side effects, how, when and where the effects, how, when and where the medication is used and for how long.medication is used and for how long.

How to remove nitsHow to remove nits How to remove lice from body, hair How to remove lice from body, hair

and linensand linens Children out of school until Children out of school until

adequately treatedadequately treated

SCABIESSCABIES

Contagious and caused by Sarcoptes Contagious and caused by Sarcoptes scabieiscabiei

Intimate or prolonged contact with Intimate or prolonged contact with infected clothing, bedding, animalsinfected clothing, bedding, animals

Mites burrow into superficial layers of Mites burrow into superficial layers of skin; show as short, wavy brown or skin; show as short, wavy brown or blacklines.blacklines.

Most contagious at this time, but pt Most contagious at this time, but pt may be asymptomaticmay be asymptomatic

s/s may not appear for 4 wkss/s may not appear for 4 wks Mites live for 24h only without Mites live for 24h only without

human contacthuman contact All infected Persons and animals All infected Persons and animals

need to have tx at same timeneed to have tx at same time Linen and clothing washed, but Linen and clothing washed, but

furniture does not require cleaningfurniture does not require cleaning

s/s = itching and rash, espec. At s/s = itching and rash, espec. At night. Itching starts 1mo after night. Itching starts 1mo after infestation and may continue for infestation and may continue for days and weeks after txdays and weeks after tx

Signs may be concentrated in webs Signs may be concentrated in webs of fingers, axilla, wrist folds, groin, of fingers, axilla, wrist folds, groin, genitals, excoriations from scratchinggenitals, excoriations from scratching

On penis, groinOn penis, groin

Hypersensitivity to mite can result in Hypersensitivity to mite can result in crusted lesions, infectioncrusted lesions, infection

Dx confirmed by superficial shaving Dx confirmed by superficial shaving of a lesion and microscopic eval. For of a lesion and microscopic eval. For mites, eggs or fecesmites, eggs or feces

Topical scabicides are used for disinfectionTopical scabicides are used for disinfection Entire body, neck to feet and folds, left on Entire body, neck to feet and folds, left on

for 8-12h, then washed off. One tx usually for 8-12h, then washed off. One tx usually suffic. If not re-infectedsuffic. If not re-infected

Caution pt that itching may return after tx Caution pt that itching may return after tx until the allergic reaction subsidesuntil the allergic reaction subsides

Dead mites remain in theepidermis until Dead mites remain in theepidermis until exfoliatedexfoliated

PEMPHIGUSPEMPHIGUS

Acute or chronic serious skin disease Acute or chronic serious skin disease characterized by the development of large characterized by the development of large bullae on normal skin and mucus bullae on normal skin and mucus membranes, usually affects older membranes, usually affects older poulationpoulation

When they rupture, leave open, raw, When they rupture, leave open, raw, painful, eroded, oozing partial thickness painful, eroded, oozing partial thickness wounds, that form crustswounds, that form crusts

Originates in the oral mucosa and spreads Originates in the oral mucosa and spreads to the trunk, involving large areas of bodyto the trunk, involving large areas of body

May also experience pain, burning, May also experience pain, burning, itching and may develop foul smellitching and may develop foul smell

Interferes with chewing, talking, Interferes with chewing, talking, swallowing, pt miserableswallowing, pt miserable

Likely to develop a secondary Likely to develop a secondary bacterial infection..high mortality bacterial infection..high mortality rate with this diseaserate with this disease

Dx by +Nikolski’s sign (sloughing or Dx by +Nikolski’s sign (sloughing or blistering of nl skin when pressure blistering of nl skin when pressure applied)applied)

Bx will reveal acantholysis Bx will reveal acantholysis (separation of epidermal cells from (separation of epidermal cells from each othereach other

Medical Tx consists of trying to Medical Tx consists of trying to control s/s and infection, body fluid control s/s and infection, body fluid and protein losses, promote healingand protein losses, promote healing

Corticosteroids in large doses, Corticosteroids in large doses, cytotoxic agents, analgesics, cytotoxic agents, analgesics, antipyreticsantipyretics

Needs high protein/high calorie diets Needs high protein/high calorie diets to maintain nutrition and fluid to maintain nutrition and fluid replacementreplacement

Nursing careNursing care

Educate pt on effects and side Educate pt on effects and side effects of medicationseffects of medications

Maintain I&O, body wt, b/pMaintain I&O, body wt, b/p Potassium permanganate baths to Potassium permanganate baths to

cleanse, disinfect and remove odors. cleanse, disinfect and remove odors. Thoroughly dissolve these crystalsThoroughly dissolve these crystals

Offer fluids, provide appropriate Offer fluids, provide appropriate psycho-social supportpsycho-social support

At risk for alterations in self imageAt risk for alterations in self image At risk for nutritional deficitsAt risk for nutritional deficits At risk for infectionsAt risk for infections At risk for alterations in fluid/electrolyte At risk for alterations in fluid/electrolyte

balancebalance At risk for medication side effects of At risk for medication side effects of

steroidssteroids At risk for alterations in comfortAt risk for alterations in comfort At risk for grief reaction/mortalityAt risk for grief reaction/mortality

BURNSBURNSpages967-976 ; 278-288 in PEDSpages967-976 ; 278-288 in PEDS

Wounds caused by energy transfer from a Wounds caused by energy transfer from a heat source to body tissue, causing tissue heat source to body tissue, causing tissue damagedamage

Infants under age 2 and adults over age Infants under age 2 and adults over age 60 have highest mortality rates60 have highest mortality rates

Heat denatures proteins and interrupts Heat denatures proteins and interrupts blood supplyblood supply

3 zones of tissue damage3 zones of tissue damage EPIDERMIS; hyperemia; no interruption of EPIDERMIS; hyperemia; no interruption of

blood supply; no cell death; area least blood supply; no cell death; area least affected by heataffected by heat

DERMIS; stasis injury; temp. incr. on DERMIS; stasis injury; temp. incr. on tissue edema; vasoconstriction, tissue edema; vasoconstriction, sludging of red blood cells; red, + sludging of red blood cells; red, + blanching; fragile area prone to blanching; fragile area prone to necrosis/infectionnecrosis/infection

SUBCUTANEOUS TISSUE; coagulation SUBCUTANEOUS TISSUE; coagulation injury; irreversible cell death; injury; irreversible cell death; white/gray; no blanchingwhite/gray; no blanching

Damage related to: temperature of agent, Damage related to: temperature of agent, type of agent, length of exposure, type of agent, length of exposure, conductivity of tissue, thickness of tissue conductivity of tissue, thickness of tissue involvedinvolved

Loss of large areas of skin= loss of Loss of large areas of skin= loss of protective functions, impaired temp. protective functions, impaired temp. regulation, possible infection, loss of fluids, regulation, possible infection, loss of fluids, sensory deficits, impaired skin sensory deficits, impaired skin regeneration, impaired regeneration, impaired secretory/excretory functionsecretory/excretory function

Alterations in skin function affects most all Alterations in skin function affects most all body systemsbody systems

Increased capillary permeability leads to Increased capillary permeability leads to leakage of plasma and proteins into leakage of plasma and proteins into tissues; leads to edema and loss of tissues; leads to edema and loss of intravascular volume (HYPOVOLEMIA)intravascular volume (HYPOVOLEMIA)

Evaporative water loss, greater than 4-15x Evaporative water loss, greater than 4-15x nlnl

Incr. metabolism= incr. water loss thru Incr. metabolism= incr. water loss thru resp. systemresp. system

Cardiac funct.; decre.output, that worsens Cardiac funct.; decre.output, that worsens due to lower circ. Plasma vol. As plasma due to lower circ. Plasma vol. As plasma leaks into interstitial tissues,for first 48h, leaks into interstitial tissues,for first 48h, leads to severe hypovolemia; if untreated, leads to severe hypovolemia; if untreated, hypovolemic shock. At risk for 72h after hypovolemic shock. At risk for 72h after burn. Must have fluid replacement. There burn. Must have fluid replacement. There is an increase in Hct., and red blood cell is an increase in Hct., and red blood cell destruction; decreases platelet function destruction; decreases platelet function (pg 367)intravenous fluids as ordered, (pg 367)intravenous fluids as ordered, check urinary output, likely will require check urinary output, likely will require indwelling catheterindwelling catheter

Increased metabolic demands; body Increased metabolic demands; body maintains high metabolic rate for healingmaintains high metabolic rate for healing

Severe catabolism (breakdown of body Severe catabolism (breakdown of body tissues and cellular structures) results in tissues and cellular structures) results in neg. nitrogen balance, wt. loss, and decre. neg. nitrogen balance, wt. loss, and decre. Wound healingWound healing

Stress triggers elevated catecholamine Stress triggers elevated catecholamine levels (epinepherine, norepinepherine) levels (epinepherine, norepinepherine) which causes elevated glucagon levels and which causes elevated glucagon levels and hyperglycemiahyperglycemia

GI problems ie. Gastric dilation, GI problems ie. Gastric dilation, Curling’s ulcer (peptic ulcer from Curling’s ulcer (peptic ulcer from stress), paralytic ileus, and superior stress), paralytic ileus, and superior mesenteric artery syndrome mesenteric artery syndrome (intestinal angina from occlusion)(intestinal angina from occlusion)

Acute renal insufficiencyAcute renal insufficiency Electrical burns can result in tubular Electrical burns can result in tubular

necrosis as a result of myoglobin necrosis as a result of myoglobin casts (muscle damage)casts (muscle damage)

Pulmonary effects mostly related to smoke Pulmonary effects mostly related to smoke inhalation, and very common in burns to face and inhalation, and very common in burns to face and chest. Hyperventilation in proportion to severity chest. Hyperventilation in proportion to severity of burn Incr. O2 consumption. Rapid of burn Incr. O2 consumption. Rapid swelling/edema of the respiratory passages, swelling/edema of the respiratory passages, hoarse voice. Elevate head of bed to 30 degrees, hoarse voice. Elevate head of bed to 30 degrees, continuous assessment, provide O2, prepare pt continuous assessment, provide O2, prepare pt for intubation if nec.for intubation if nec.

Immune system severely compromised from loss Immune system severely compromised from loss of substantial portion of skin barrier and first line of substantial portion of skin barrier and first line defense macrophages. defense macrophages.

Common burnsCommon burns Thermal/steam/scaldsThermal/steam/scalds RadiationRadiation Chemical; acids or alkali, cancause skin and Chemical; acids or alkali, cancause skin and

pulmonary burns; dry chemicals must be brushed pulmonary burns; dry chemicals must be brushed offoff

FlamesFlames ContactContact Electrical; more serious than appears; lightening Electrical; more serious than appears; lightening

in excess of 50,000 degrees; may present with in excess of 50,000 degrees; may present with feathery, branching appearancefeathery, branching appearance

Burn classificationsBurn classifications

Partial thickness (1Partial thickness (1stst-2-2ndnd degree) degree) Superficial; comprised of epidermis, Superficial; comprised of epidermis,

poss. Papillae of dermisposs. Papillae of dermis Bright red to pink, blanches, fluid Bright red to pink, blanches, fluid

filled blisters, glistening, moistfilled blisters, glistening, moist Very sensitive to air , temp. and Very sensitive to air , temp. and

touchtouch Heals in 7-10 daysHeals in 7-10 days

MINOR BURNSMINOR BURNS 15% of TBSA NOT involving face , 15% of TBSA NOT involving face ,

hands, genitalia orhands, genitalia or Full thickness burn less than 2% of Full thickness burn less than 2% of

TBSATBSA

Partial thickness (deep; 2Partial thickness (deep; 2ndnd degr.); degr.); Appendage usually involvedAppendage usually involved ½-7/8 dermis½-7/8 dermis Blisters may be presentBlisters may be present Pink, light red, white, blanchablePink, light red, white, blanchable Exposed nerve endingsExposed nerve endings 14-21 days for healing14-21 days for healing May need grafting to prevent scarsMay need grafting to prevent scars

MODERATE BURNSMODERATE BURNS 15-25% of TBSA or15-25% of TBSA or Full thickness burns that are 10% of Full thickness burns that are 10% of

TBSATBSA

Full thickness (3-4Full thickness (3-4thth degree) degree) Epidermis down thru boneEpidermis down thru bone 33rdrd degr. Involves entire dermis and degr. Involves entire dermis and

portions of subcutaneous tissue, fatty portions of subcutaneous tissue, fatty tissue showingtissue showing

Red, Snow white , gray, brown, leathery, Red, Snow white , gray, brown, leathery, drydry

Nerve endings destroyed, no pain unless Nerve endings destroyed, no pain unless close to lesser degree burnsclose to lesser degree burns

Needs graftingNeeds grafting

MAJOR BURNSMAJOR BURNS Partial thickness burn greater than Partial thickness burn greater than

25% of TBSA or25% of TBSA or Full thickness burn involving greater Full thickness burn involving greater

than 10% of TBSA or involving face, than 10% of TBSA or involving face, hands, feet or genitaliahands, feet or genitalia

sizingsizing

Done by rule of “nines” or Lund and Done by rule of “nines” or Lund and Browder chartBrowder chart

Figure 51-11, see difference in adult Figure 51-11, see difference in adult and child configurations on “nines”and child configurations on “nines”

This formula NOT accurate in This formula NOT accurate in formulating burn percentages for formulating burn percentages for children, so note differenceschildren, so note differences

Common labs orderedCommon labs ordered Dx thru clinical manifestations and hxDx thru clinical manifestations and hx labs: CBC,BUN, fasting glucose, labs: CBC,BUN, fasting glucose,

electrolytes,electrolytes, ABGs, pulse oximetryABGs, pulse oximetry Blood protein; albuminBlood protein; albumin Urinalysis; specific gravityUrinalysis; specific gravity EkgEkg BronchoscopyBronchoscopy Pulm. Funct, (spirometer, lung vol, Pulm. Funct, (spirometer, lung vol,

diffusion capacity(body’s ability to extract diffusion capacity(body’s ability to extract O2 from lungs)O2 from lungs)

Emergent phaseEmergent phaseonset of injury to completion of fluid onset of injury to completion of fluid

resuscitationresuscitation BURNING PROCESS MUST BE STOPPED/REMOVE BURNING PROCESS MUST BE STOPPED/REMOVE

VICTOM FROM SOURCE OF BURN. and airway VICTOM FROM SOURCE OF BURN. and airway patency ,breathing, and circulation assuredpatency ,breathing, and circulation assured

Assess percentage and depth of burns (#2)Assess percentage and depth of burns (#2) Clothing must be removed and jewelry (#1)Clothing must be removed and jewelry (#1) Wound is cooled with tepid water only if TBSA is Wound is cooled with tepid water only if TBSA is

10% or less, however,lavage for 20min. Needed 10% or less, however,lavage for 20min. Needed for chemical burns.dry chemicals must be for chemical burns.dry chemicals must be brushed off. Use precautionsbrushed off. Use precautions

Person covered with sterile or clean sheet to Person covered with sterile or clean sheet to decrease shivering/contaminationdecrease shivering/contamination

DO NOT APPLY ICEDO NOT APPLY ICE Assist in wound Assist in wound

debridement/medicate for pain prior debridement/medicate for pain prior to txsto txs

Assess for hypovolemia (decreased Assess for hypovolemia (decreased B/P, incr. HR, and respirations)B/P, incr. HR, and respirations)

Monitor ABGs, and Monitor ABGs, and carboxyhemoglobin levelscarboxyhemoglobin levels

Initiate intravenous access, USUALLY Initiate intravenous access, USUALLY LACTATED Ringers, 0.9% saline or plasmaLACTATED Ringers, 0.9% saline or plasma

Possible need for TPNPossible need for TPN Monitor v/s; CLOSE, ACCURATE I&OMonitor v/s; CLOSE, ACCURATE I&O Maintain NPOMaintain NPO Insert indwelling catheterInsert indwelling catheter Administer pain medication as prescribedAdminister pain medication as prescribed Administer Tetanus toxoid as prescribedAdminister Tetanus toxoid as prescribed Monitor extr for any circumferential burnsMonitor extr for any circumferential burns

Check extremities for any Check extremities for any circumferential burns. Will act like a circumferential burns. Will act like a tourniquet, causing compartment tourniquet, causing compartment syndrome/respiratory insufficiency. syndrome/respiratory insufficiency. Pt will need an escharotomy; incision Pt will need an escharotomy; incision thru eschar and superficial fat.thru eschar and superficial fat.

Common sites are extremities, trunk Common sites are extremities, trunk and chestand chest

Patients, especially children, may Patients, especially children, may quickly become hypervolemic (within quickly become hypervolemic (within 24-96h) even to having pulmonary 24-96h) even to having pulmonary edemaedema

Sterile technique/hand washingSterile technique/hand washing Prevent infection/sepsisPrevent infection/sepsis

Stage 2 (acute)Stage 2 (acute)from start of diuresis to near from start of diuresis to near completion of wound closurecompletion of wound closure

Goals are wound closureGoals are wound closure No infectionsNo infections Minimum scarring/lack of contractureMinimum scarring/lack of contracture Maintainance of comfortMaintainance of comfort Adequate nutrit supportAdequate nutrit support

Dialy wound cleansing and Dialy wound cleansing and debridementdebridement

MEDICATE FOR PAINMEDICATE FOR PAIN Hubbard tank or showering for Hubbard tank or showering for

cleansingcleansing Debridement; mech. Chemical, Debridement; mech. Chemical,

surgical or combinationsurgical or combination

DressingsDressings

Open or closed, biologic or synthetic Open or closed, biologic or synthetic or comboor combo

Open involves topical agent no Open involves topical agent no dressingdressing

Closed involves occlusive drsg over Closed involves occlusive drsg over the woundthe wound

Limit bulkLimit bulk No skin surface to surface; donut gauze No skin surface to surface; donut gauze

around eararound ear Base drsgs on wound size, absorption Base drsgs on wound size, absorption

needs, protection and type of debridement needs, protection and type of debridement being donebeing done

Wrap extremities DISTAL TO PROXIMALWrap extremities DISTAL TO PROXIMAL ELEVATE ALL AFFECTED EXTREMITIES ELEVATE ALL AFFECTED EXTREMITIES

ABOVE LEVEL OF HEARTABOVE LEVEL OF HEART

BIOLOGIC DRESSINGSBIOLOGIC DRESSINGS

TISSUE FROM LIVING OR DECEASED TISSUE FROM LIVING OR DECEASED HUMANS OR ANIMALSHUMANS OR ANIMALS

These dressings may be used as These dressings may be used as donor site dressings; to manage a donor site dressings; to manage a partial thickness burn and cover a partial thickness burn and cover a clean, excised wound before clean, excised wound before autograftingautografting

Assist with wound healing and Assist with wound healing and stimulate epithelializationstimulate epithelialization

Synthetic dressingsSynthetic dressings Are used in management of partial Are used in management of partial

thickness burns and donor sitesthickness burns and donor sites More available, less costly, easier to More available, less costly, easier to

store than biologicsstore than biologics Variety of materials and sizesVariety of materials and sizes Rarely contain antimicrobial agentsRarely contain antimicrobial agents

Biologic and synthetic dressings are Biologic and synthetic dressings are TEMPORARY wound coverings for TEMPORARY wound coverings for clean partial- thickness AND full clean partial- thickness AND full thickness injuriesthickness injuries

Maintain wound surface until healing Maintain wound surface until healing occurs, a donor site is available or occurs, a donor site is available or wound is ready for autograftingwound is ready for autografting

SKIN GRAFTINGSKIN GRAFTING

Autograft is skin graft from the Autograft is skin graft from the PATIENT’S unburned skin to be PATIENT’S unburned skin to be placed on clean excised burn siteplaced on clean excised burn site

2 types; STSG (.006-.016) and FTSG 2 types; STSG (.006-.016) and FTSG (.035-.040) inches in thickness(.035-.040) inches in thickness

STSG includes epidermis and part of STSG includes epidermis and part of dermisdermis

FTSG includes epidermis and entire FTSG includes epidermis and entire DERMAL AREADERMAL AREA

STSG may be applied as a sheet graft or STSG may be applied as a sheet graft or meshed graftmeshed graft

Sheet graft used primarily for cosmetic Sheet graft used primarily for cosmetic effect; face, chest, breasts , or hands, effect; face, chest, breasts , or hands, placed on as a full sheetplaced on as a full sheet

Meshed graft, tiny splits, looks like fishnet; Meshed graft, tiny splits, looks like fishnet; allows skin to expand 1.5-9 times its allows skin to expand 1.5-9 times its original sizeoriginal size

Allows for coverage of large area with Allows for coverage of large area with small piece of skin. Good for extensive small piece of skin. Good for extensive burn areasburn areas

Graft take or revascularization in 3-5 daysGraft take or revascularization in 3-5 days

Disadvantages include:Disadvantages include: Prone to chronic breakdownProne to chronic breakdown More likely to hypertrophyMore likely to hypertrophy More likely to contractMore likely to contract

FTSG can be sheet grafts or pedicle FTSG can be sheet grafts or pedicle flapsflaps

Used over areas of muscle mass, soft Used over areas of muscle mass, soft tissue loss, hands feet, eyelidstissue loss, hands feet, eyelids

Pedicle attached to blood supply and Pedicle attached to blood supply and area to area in need of graftingarea to area in need of grafting

Pedicle not used for extensive Pedicle not used for extensive wounds; not as popular as free skin wounds; not as popular as free skin graftsgrafts

FTSGs allows more elasticity over jointsFTSGs allows more elasticity over joints Soft, pliableSoft, pliable May allow hair regrowthMay allow hair regrowth Provides good color matchProvides good color match Less hyperpigmentationLess hyperpigmentation Donor sites take longer to healDonor sites take longer to heal Requires split-thickness graft to heal or Requires split-thickness graft to heal or

closure from wound edgesclosure from wound edges

Promoting factorsPromoting factors

Adequate hemostasisAdequate hemostasis Anatomic location of graftAnatomic location of graft Smooth contourSmooth contour Non-jointsNon-joints Graft well securedGraft well secured Immobilization of graft areaImmobilization of graft area Good nutitional statusGood nutitional status

Inhibiting factorsInhibiting factors

InfectionInfection Necrotic skinNecrotic skin Location on perineum, axilla, buttocksLocation on perineum, axilla, buttocks Poor quality donor skinPoor quality donor skin Poor nutritional statusPoor nutritional status BleedingBleeding Mechanical traumaMechanical trauma Shock+Shock+

DONOR SITESDONOR SITES Donor sites are considered to be PARTIAL Donor sites are considered to be PARTIAL

THICKNESS WOUNDSTHICKNESS WOUNDS Try to get healed in 10-14 days, but many Try to get healed in 10-14 days, but many

variables affect this time-tablevariables affect this time-table Nursing considerations include promoting Nursing considerations include promoting

comfort, preventing trauma and infectioncomfort, preventing trauma and infection Outer dressing to apply pressure to Outer dressing to apply pressure to

maintain homeostasis remains in place 1-2 maintain homeostasis remains in place 1-2 days. Dry exposure may require avoidance days. Dry exposure may require avoidance of pressure, and a heat lamp 60-100wts, of pressure, and a heat lamp 60-100wts, KEPT 2 FEET AWAY FROM SITE. Loose KEPT 2 FEET AWAY FROM SITE. Loose separating gauze is trimmedseparating gauze is trimmed

MUST KNOWMUST KNOW

THE DONOR SITE IS VERY PAINFULTHE DONOR SITE IS VERY PAINFUL THE GRAFT SITE MUST BE KEPT IMMOBILE THE GRAFT SITE MUST BE KEPT IMMOBILE

UNTIL THE GRAFT TAKES.UNTIL THE GRAFT TAKES. SKIN GRAFT MUST NOT SLIPSKIN GRAFT MUST NOT SLIP GRAFT SITE DRESSINGS MAY BE BULKY GRAFT SITE DRESSINGS MAY BE BULKY

AND MUST NOT BE DISTURBEDAND MUST NOT BE DISTURBED MUST HAVE FREQ. CIRC. CHECKS AND ANY MUST HAVE FREQ. CIRC. CHECKS AND ANY

INVOLVED EXTREMITY MUST BE ELEVATEDINVOLVED EXTREMITY MUST BE ELEVATED

GOAL: GOOD ADHERENCE OF GRAFT GOAL: GOOD ADHERENCE OF GRAFT AND NO WOUND INFECTIONAND NO WOUND INFECTION

MEDICATIONS USEDMEDICATIONS USED

Silver sulfadiazine: buttered on, covered Silver sulfadiazine: buttered on, covered with a light dressing 1-2x daywith a light dressing 1-2x day

Broad spectrum, low toxicity, Can still Broad spectrum, low toxicity, Can still have burning sensation can be used have burning sensation can be used with/wo dressingswith/wo dressings

Intermediate penetration of escharIntermediate penetration of eschar Leukopenia (fever, sore throat, cough)Leukopenia (fever, sore throat, cough) Thrombocytopenia (easy bruising, unusual Thrombocytopenia (easy bruising, unusual

bleeding)bleeding)

Sulfamylon: buttered on 3-4x daySulfamylon: buttered on 3-4x day Broad spectrum, rapid deep penetration of Broad spectrum, rapid deep penetration of

eschar, excreted rapidlyeschar, excreted rapidly Causes pain with applicationCauses pain with application Pulmonary toxicity, metabolic acidosis, Pulmonary toxicity, metabolic acidosis,

may inhibit wound healingmay inhibit wound healing With any sulfa med, may have adverse With any sulfa med, may have adverse

reaction, Stevens- Johnson reaction, Stevens- Johnson syndrome,MUST MAINTAIN ADEQUATE syndrome,MUST MAINTAIN ADEQUATE FLUID INTAKEFLUID INTAKE

Silver Nitrate solution: wet dressing Silver Nitrate solution: wet dressing change BID, resoak q2h; broad change BID, resoak q2h; broad spectrum, nonallergenic, low toxicity, spectrum, nonallergenic, low toxicity, inexpensive, won’t interfere with inexpensive, won’t interfere with healinghealing

Poor penetration of eschar; Poor penetration of eschar; ineffective on established wound ineffective on established wound infectionsinfections

Bacitration: buttered on q4-6hBacitration: buttered on q4-6h No pain, odorless, softens eschar, No pain, odorless, softens eschar,

but..poor penetration of eschar. but..poor penetration of eschar. Ineffective on established wound Ineffective on established wound infectionsinfections

Gentamicin: apply gently 3-4x dayGentamicin: apply gently 3-4x day Broad spec., covered or left openBroad spec., covered or left open Ototoxic, nephrotoxic, pain with Ototoxic, nephrotoxic, pain with

applicationapplication

Nitofurazone: THIN LAYER dierectly Nitofurazone: THIN LAYER dierectly on wound or impregnate gauze. on wound or impregnate gauze. Change drsg. BID,Change drsg. BID,

Broad spec., bacteriocidalBroad spec., bacteriocidal PAINFUL APLLICATIONPAINFUL APLLICATION May support overgrowth of fungus May support overgrowth of fungus

and/or Pseudomonasand/or Pseudomonas

STAGE 3STAGE 3from wound closure to return of from wound closure to return of optimum function on all levelsoptimum function on all levels

RehabilitationRehabilitation therapy STARTS IN ACUTE PHASE therapy STARTS IN ACUTE PHASE

CONTINUES THRU REHABCONTINUES THRU REHAB Reconstructive can take many yearsReconstructive can take many years 2 major nsg considerations; the most 2 major nsg considerations; the most

comfortable position is the position comfortable position is the position of CONTRACTURE and the burn site of CONTRACTURE and the burn site will contin. to shorten until it meets will contin. to shorten until it meets an opposing forcean opposing force

MAJOR GOAL IS TO AVOID CONTRACTUREMAJOR GOAL IS TO AVOID CONTRACTURE Exercise program within 24-48hExercise program within 24-48h Use of splinting devices for positioning and Use of splinting devices for positioning and

stretching ie pressure garmentstretching ie pressure garment Great psychosocial effectGreat psychosocial effect Important to return to abilities of preburn Important to return to abilities of preburn

level. Requires work of many disciplines level. Requires work of many disciplines and the patientand the patient

Nursing processNursing process

Assessment includes: medical hx, Assessment includes: medical hx, known allergies, current medications known allergies, current medications if any,if any,

Extent, depth, burn agent, duration Extent, depth, burn agent, duration of contact, location of pain, level of of contact, location of pain, level of pain, associated injuriespain, associated injuries

Determine first aid needsDetermine first aid needs Additional losses, how burn ocurredAdditional losses, how burn ocurred

Nursing diagnosisNursing diagnosis Primary are:Primary are: Impaired skin integrityImpaired skin integrity Impaired gas exchangeImpaired gas exchange Deficient fluid volumeDeficient fluid volume Ineffective tissue perfusionIneffective tissue perfusion Imbalanced nutritionImbalanced nutrition Activity intoleranceActivity intolerance Selfcare deficitSelfcare deficit Disturbed body imageDisturbed body image Ineffective copingIneffective coping

Deficient fluid volumeDeficient fluid volume Check urine output/replacement 50ml/h in adults; Check urine output/replacement 50ml/h in adults;

HR AT NL TO 100BPM, stable body wtHR AT NL TO 100BPM, stable body wt Wt dailyWt daily Record I&O, insert indwelling catheterRecord I&O, insert indwelling catheter Assess for s/s Assess for s/s

hypovolemia(<b/p,tachycardic,tachypneic, hypovolemia(<b/p,tachycardic,tachypneic, thirsty, restless, disoriented)thirsty, restless, disoriented)

Monitor/review labs (electrolytes and CBC)Monitor/review labs (electrolytes and CBC) Assess urine specific gravity and for Assess urine specific gravity and for

hemochromogens(indicate renal tubular necrosis)hemochromogens(indicate renal tubular necrosis)

Administer osmotic diureticsAdminister osmotic diuretics Assess gi funct.for paralytic ileusAssess gi funct.for paralytic ileus Maintain nasogastric tube/tube Maintain nasogastric tube/tube

patencypatency

Impaired gas exchange relatedImpaired gas exchange related

To upper airway edema, carbon To upper airway edema, carbon monoxide poisoning, edema of monoxide poisoning, edema of capillary aveolar membranescapillary aveolar membranes

Goal: pt will have patent airway; CO Goal: pt will have patent airway; CO level< 10%, clear lung sounds, PAO2 level< 10%, clear lung sounds, PAO2 80-100mmhg; PACO2 35-45 mmHg, 80-100mmhg; PACO2 35-45 mmHg, alert and awarealert and aware

No s/s stridor, nasal flaring, No s/s stridor, nasal flaring, retractionsretractions

Pain related to burns or graft donor Pain related to burns or graft donor sitessites

Pt will have good pain control as Pt will have good pain control as evidenced by verbal and non-verbal evidenced by verbal and non-verbal cuescues

Does pt verbalize this, how many Does pt verbalize this, how many hours of sleep in 24h, does he/she hours of sleep in 24h, does he/she feel restedfeel rested

Risk for sepsis related to wound Risk for sepsis related to wound infectioninfection

Pt will not develop a wound infectionPt will not develop a wound infection Healthy granulation tissue?Healthy granulation tissue? Unhealed, open area with <10 Unhealed, open area with <10

colonies of bacteriacolonies of bacteria Donor sites free of infection?Donor sites free of infection? Did graft takeDid graft take Nl temp/nl WBC?Nl temp/nl WBC?

Skin lesionsSkin lesions

Non-cancerousNon-cancerous PremalignantPremalignant malignantmalignant

Benign include: cysts, seborrheic Benign include: cysts, seborrheic keratosis, keloids, pigmented keratosis, keloids, pigmented nevi,which must be watched for nevi,which must be watched for change in color or moles>1cm, size, change in color or moles>1cm, size, inflammation, itching, oozing, inflammation, itching, oozing, bleeding, varigated colors(bluish), bleeding, varigated colors(bluish), irregular borders, warts, irregular borders, warts, hemangiomashemangiomas

Malignant lesionsMalignant lesions

Basal cell carcinoma arises from Basal cell carcinoma arises from basal cell layer of epidermisbasal cell layer of epidermis

Most common typeMost common type Sun exposed areas on bodySun exposed areas on body Rolled waxy edge, depressed center, Rolled waxy edge, depressed center,

can be pearly, crusting and can be pearly, crusting and ulcerationulceration

Rarely metastatic, but can be locally Rarely metastatic, but can be locally invasive/disfiguringinvasive/disfiguring

Squamous cell ca., also from epidermis Squamous cell ca., also from epidermis and sun exposed areas of skin and the and sun exposed areas of skin and the mucus membranesmucus membranes

Lower lip, neck, tongue, head and dorsa of Lower lip, neck, tongue, head and dorsa of hands, poss. develops on preexisting hands, poss. develops on preexisting lesion (actinic keratosis)lesion (actinic keratosis)

Single crusted, scaled, eroded papule, Single crusted, scaled, eroded papule, nodule or plaque, fragile, prone to oozing, nodule or plaque, fragile, prone to oozing, bleedingbleeding

Highly invasive with metsHighly invasive with mets

Malignant melanomaMalignant melanoma Malignant growth of pigment cellsMalignant growth of pigment cells Highly metastatic/high mortality rateHighly metastatic/high mortality rate Can occur anywhere on bodyCan occur anywhere on body Many arise out of pre existing moles Many arise out of pre existing moles

or nevior nevi

Three types:Three types: Lentigo maligna; slow growing dark Lentigo maligna; slow growing dark

macule on exposed skin surfaces (face of macule on exposed skin surfaces (face of elderly pts) irreg. borders, brown, black, elderly pts) irreg. borders, brown, black, tan. Prognosis good if treated earlytan. Prognosis good if treated early

Superficial spreading; most common type, Superficial spreading; most common type, can occur anywhere on body espec of can occur anywhere on body espec of elderly; slightly elevated plaque with irreg elderly; slightly elevated plaque with irreg border, varies in color, may bleed or oozeborder, varies in color, may bleed or ooze

Eventually develops into a noduleEventually develops into a nodule Prognosis is poor at this stagePrognosis is poor at this stage Nodular melanoma appears suddenlyNodular melanoma appears suddenly Spherical papule or nodule on skin or in a Spherical papule or nodule on skin or in a

molemole Color blue-black, blue gray, reddish-blueColor blue-black, blue gray, reddish-blue Fragile, bleeds easilyFragile, bleeds easily Mets occurs rapidly, least favorable Mets occurs rapidly, least favorable

prognosisprognosis

preventionprevention Prevention is primaryPrevention is primary Limit or avoid direct exposure to UV rays, sun Limit or avoid direct exposure to UV rays, sun

(10a-2p), tanning booths(10a-2p), tanning booths Wear sunblock 15 or>Wear sunblock 15 or> Protective clothingProtective clothing Self examination weekly/monthlySelf examination weekly/monthly See md for suspicious lesions or changes. Have See md for suspicious lesions or changes. Have

moles or nevi in areas of constant friction moles or nevi in areas of constant friction removedremoved

Fair skinned people, and/or those with a lot of Fair skinned people, and/or those with a lot of moles, freckles be more cautious, less melanin moles, freckles be more cautious, less melanin protectionprotection

Preliminary based on presentation of Preliminary based on presentation of lesionlesion

Definitive from biopsy; further Definitive from biopsy; further testing done if +testing done if +

Miliaria rubraMiliaria rubra

Prickly heatPrickly heat Pinsized erythematous papulesPinsized erythematous papules Sweat glands, foldsSweat glands, folds ItchingItching PreventionPrevention No bundlingNo bundling Tepid bathsTepid baths

Diaper rashDiaper rash

Rash from ammoniaRash from ammonia Burning erythematous rashBurning erythematous rash Must consider yeastMust consider yeast Primary is preventionPrimary is prevention Expose to airExpose to air Avoid baby powdersAvoid baby powders Wash and dry thoroughlyWash and dry thoroughly

C. albicansC. albicans

Causative agent for thrush and some Causative agent for thrush and some “diaper rash”“diaper rash”

If mother has vaginitisIf mother has vaginitis Milk curdsMilk curds Antibiotic therapyAntibiotic therapy Mycostatin/nystatin q6h, thin layerMycostatin/nystatin q6h, thin layer Cleanliness/open to air as much as Cleanliness/open to air as much as

possiblepossible

impetigoimpetigo

Superficial bacterial infectionSuperficial bacterial infection In newborn/staph aureusIn newborn/staph aureus Older child group A beta-hemolytic Older child group A beta-hemolytic

strepstrep Newborn presents as bullous(blisters)Newborn presents as bullous(blisters) Older child non-bullousOlder child non-bullous Highly infectious Follow skin/contact Highly infectious Follow skin/contact

precautionsprecautions

Gown and glovesGown and gloves Infant needs to be segregated from othersInfant needs to be segregated from others Appears on face, spreads, crusts and Appears on face, spreads, crusts and

drainage are contagiousdrainage are contagious Soak off crusts, follow with Soak off crusts, follow with

Bacitracin/neosporinBacitracin/neosporin Careful handwashingCareful handwashing Older child treated in home with careful Older child treated in home with careful

teaching of caregiversteaching of caregivers

Very itchy, trim nails Medical Very itchy, trim nails Medical treatment can be Peniciilen or treatment can be Peniciilen or erythromycin for ten dayserythromycin for ten days

Daily wash off crusts,/bactrobanDaily wash off crusts,/bactroban ****If older child and organism is ****If older child and organism is

strep, infection can be rheumatic strep, infection can be rheumatic fever or acute glomeruloephritis*****fever or acute glomeruloephritis*****

Acute infantile eczemaAcute infantile eczema

Atopic dermatitis often as a result of Atopic dermatitis often as a result of reaction to an irritantreaction to an irritant

Common first year of life, after 3mosCommon first year of life, after 3mos Uncommon in breastfed babiesUncommon in breastfed babies Hereditary predispositionHereditary predisposition Hypersensitivity in deep skin layers Hypersensitivity in deep skin layers

to protein or protein like allergensto protein or protein like allergens

Allergens may be inhaled, ingested, Allergens may be inhaled, ingested, absorbed thru direct contactabsorbed thru direct contact

House dust,mites, egg white , woolHouse dust,mites, egg white , wool Infants may develop hay fever or Infants may develop hay fever or

asthma later in lifeasthma later in life

Starts on cheeks, spreads to Starts on cheeks, spreads to extensor surfaces of arms and legs, extensor surfaces of arms and legs, then entire trunkthen entire trunk

Initially red skin, then papule and Initially red skin, then papule and vesicle formationvesicle formation

INTENSE ITCHING causing weeping INTENSE ITCHING causing weeping and crusting, may quickly become and crusting, may quickly become infected by strep or staphinfected by strep or staph

Common allergens are foods; egg Common allergens are foods; egg whites, cows milk, wheats, orange whites, cows milk, wheats, orange juice, tomato juicejuice, tomato juice

Inhalants, dust , pollens, animal Inhalants, dust , pollens, animal danderdander

Materials; wools, nylons, plasticMaterials; wools, nylons, plastic

Dx, by process of eliminationDx, by process of elimination Elimination diet/ assess often for s/s Elimination diet/ assess often for s/s

malnutritionmalnutrition Serious condition eczema Serious condition eczema

vaccinatumvaccinatum High mortality rateHigh mortality rate Avoid herpes infection/exposureAvoid herpes infection/exposure Severe pain and illnessSevere pain and illness

Treatment may include oral Treatment may include oral antibiotics, antihistamines, sedativesantibiotics, antihistamines, sedatives

Cortisone creams only if there is no Cortisone creams only if there is no infection, wet soaks (colloidal), tepid infection, wet soaks (colloidal), tepid water, emollientswater, emollients

Parents are exhausted, frustratedParents are exhausted, frustrated Usually clears by age 2Usually clears by age 2

Nursing diagnosesNursing diagnoses

Impaired skin integrityImpaired skin integrity Disturbed sleep Disturbed sleep

patterns(itching/discomfort)patterns(itching/discomfort) Imbalanced nutrition (elimination Imbalanced nutrition (elimination

diet)diet) Risk for infectionRisk for infection Deficient knowledge of caregiversDeficient knowledge of caregivers

goalsgoals

Preserve skin integrityPreserve skin integrity Maintain comfortMaintain comfort Maintain good nutritionMaintain good nutrition Prevent infectionPrevent infection Increase family/caregiver knowledgeIncrease family/caregiver knowledge

What are the interventions available to What are the interventions available to implement goals?implement goals?

Cover skin, prevent scratching, wet Cover skin, prevent scratching, wet dressings, don’t allow to drydressings, don’t allow to dry

Weighing daily****Weighing daily**** Aseptic technique/avoid hospitalizationAseptic technique/avoid hospitalization Read labels carefullyRead labels carefully Instruct caregivers/ provide Instruct caregivers/ provide

support/referrals to community servicessupport/referrals to community services Small papule on scalp;spreadsSmall papule on scalp;spreads

Griseofulvin drug of choice. Griseofulvin drug of choice. Compliance difficult due to tx of Compliance difficult due to tx of 3mos3mos

Corporis lesions on bodyCorporis lesions on body Usually from infected dog or catUsually from infected dog or cat Miconazole, clotrimazoleMiconazole, clotrimazole T. pedis, hygiene, meds, white socksT. pedis, hygiene, meds, white socks T. crurisT. cruris

Fungal infections (pg 406)Fungal infections (pg 406)

Tinea, fungal infection living in outer Tinea, fungal infection living in outer layers of hair, skin, nailslayers of hair, skin, nails

Ringworm of scalp, tinea Ringworm of scalp, tinea capitis/tonsuranscapitis/tonsurans

Transmitted person to personTransmitted person to person Microsporum canis/animal to childMicrosporum canis/animal to child Hair brittle and breaks off easilyHair brittle and breaks off easily

Parasitic infectionsParasitic infections

Pediculosis and scabiesPediculosis and scabies Suck blood of hostsSuck blood of hosts Capitis, corporis, pubisCapitis, corporis, pubis Human to humanHuman to human Severe itchingSevere itching Kwell shampoo for at least 4min, rinse, Kwell shampoo for at least 4min, rinse,

dry, dip comb in warm white vinegardry, dip comb in warm white vinegar Wash all in hot wter and dry in hot dryerWash all in hot wter and dry in hot dryer

Dryclean non-washablesDryclean non-washables Seal in plastic bags for 2 weeks to Seal in plastic bags for 2 weeks to

break cyclebreak cycle All in contact 30-60 days, treatAll in contact 30-60 days, treat

Drugs affecting skinDrugs affecting skin

TERMSTERMS Antiseptic: chemicals applied to living Antiseptic: chemicals applied to living

tissue to kill pathogens that may harm the tissue to kill pathogens that may harm the hosthost

Disinfectants: chemicals used to kill Disinfectants: chemicals used to kill organisms present on objectsorganisms present on objects

Bacteriostatic: halts or slows growth Bacteriostatic: halts or slows growth without killing off entire populationwithout killing off entire population

Bactericidal: will kill bacteria, not fungus, Bactericidal: will kill bacteria, not fungus, spores or virusesspores or viruses

Types of drugsTypes of drugs I. Topical anti-infectivesI. Topical anti-infectives Topical antibioticsTopical antibiotics Topical antifungalsTopical antifungals Topical antiviralsTopical antivirals II.Topical antiseptics and germicidesII.Topical antiseptics and germicides III.Topical corticosteroidsIII.Topical corticosteroids IV.Topical antipsoriaticsIV.Topical antipsoriatics V.Topical enzymesV.Topical enzymes VI.KeratolyticsVI.Keratolytics VII.Topical local anestheticsVII.Topical local anesthetics

Topical antibioticsTopical antibiotics

Exert direct local effect on specific Exert direct local effect on specific organismsorganisms

Can be bacteriostatic/bactericidalCan be bacteriostatic/bactericidal Used to prevent superficial infections Used to prevent superficial infections

in minor breaks in skin integrityin minor breaks in skin integrity

Bacitracin; 1-5x dayBacitracin; 1-5x day G-myticin; 1-5xdayG-myticin; 1-5xday Emgel; 2x dayEmgel; 2x day Neomycin; 1-3x dayNeomycin; 1-3x day Thin layersThin layers All have significant side effectsAll have significant side effects

antifungalsantifungals

Interrupts the continued growth of a Interrupts the continued growth of a fungus after long period of usefungus after long period of use

Used for jock itch, athletes foot, Used for jock itch, athletes foot, ringworm, candidal infections of skin, ringworm, candidal infections of skin, vagina and mucus membranesvagina and mucus membranes

Fungizone (amphetericin B), Fungizone (amphetericin B), Miconozole (Micatin), ciclopirox Miconozole (Micatin), ciclopirox olamine (Loprox) olamine (Loprox) Econazole(spectazole)Econazole(spectazole)

Tolnaftate (tinactin), Nystatin (Nilsat Tolnaftate (tinactin), Nystatin (Nilsat and Mycostatin)and Mycostatin)

antiviralsantivirals

2 available are acyclovir (Zovirax) 2 available are acyclovir (Zovirax) and penciclovir (Denavir) inhibit viral and penciclovir (Denavir) inhibit viral replicationreplication

Acyclovir for initial outbreaks of Acyclovir for initial outbreaks of genital herpes and for Herpes genital herpes and for Herpes simplex viral infections in simplex viral infections in immunocompromised clientsimmunocompromised clients

Penciclovir only for HSV 1( Herpes Penciclovir only for HSV 1( Herpes labalis adultslabalis adults

Adverse reactions of topicalsAdverse reactions of topicals Can cause hypersensitivity reactionCan cause hypersensitivity reaction Superinfection (overgrowth of organisms Superinfection (overgrowth of organisms

not affected by med)not affected by med) Topical antibiotics are category C for Topical antibiotics are category C for

pregnant women..used cautiously during pregnant women..used cautiously during pregnancy and lactationpregnancy and lactation

Topical antivirals are Cat. B, still used with Topical antivirals are Cat. B, still used with cautioncaution

Topical antifungals unknown except for Topical antifungals unknown except for Spectazole (cat. C) and ciclopirox (penlac)Spectazole (cat. C) and ciclopirox (penlac)(cat. B)(cat. B)

Topical antiseptics/germicidesTopical antiseptics/germicides

Exact action not known; affect a Exact action not known; affect a variety of organismsvariety of organisms

Efficacy may depend on strength, Efficacy may depend on strength, concentration and length of exposure concentration and length of exposure with skin or mucus membranewith skin or mucus membrane

Used to reduce numbers of bacteria Used to reduce numbers of bacteria on skin surfaceson skin surfaces

Benzalkonium,chlorhexidine, IodineBenzalkonium,chlorhexidine, Iodine

Have few adverse reactions unless Have few adverse reactions unless individual has an allergyindividual has an allergy

Contraindicated if known hypersens Contraindicated if known hypersens otherwise, no significant reasons to otherwise, no significant reasons to avoid useavoid use

Topical corticosteroidsTopical corticosteroids

Vary in potency, vehicle for delivery, Vary in potency, vehicle for delivery, and area of skin to which it is appliedand area of skin to which it is applied

Exert a local anti-inflammatory effectExert a local anti-inflammatory effect Useful in relieving itching, redness Useful in relieving itching, redness

and swelling from psoriasis, and swelling from psoriasis, dermatitis, rashes, eczema, insect dermatitis, rashes, eczema, insect bites, first and second degree burnsbites, first and second degree burns

May cause same symptoms May cause same symptoms supposed to relievesupposed to relieve

Don’t give with known Don’t give with known hypersensitivityhypersensitivity

Not for use as monotherapy in Not for use as monotherapy in bacterial skin infections or viral bacterial skin infections or viral infectionsinfections

Limit or avoid use on face, eyesLimit or avoid use on face, eyes Preg. Category CPreg. Category C

Topical antipsoriaticsTopical antipsoriatics

Drugs help to remove plaquesDrugs help to remove plaques Anthralin (Anthra-derm) and Anthralin (Anthra-derm) and

calcipotriene ( Dovonex)calcipotriene ( Dovonex) Don’t give with known hypers.Don’t give with known hypers. Category CCategory C

Topical enzymesTopical enzymes

Aids in removal of necrotic tissue by Aids in removal of necrotic tissue by reducing proteins into simpler tissue reducing proteins into simpler tissue (proteolytic action)(proteolytic action)

Responders may be second/third degree Responders may be second/third degree burns, pressure ulcers and ulcers of PVDburns, pressure ulcers and ulcers of PVD

Collagenase/SantylCollagenase/Santyl Low incidence of adverse reactionsLow incidence of adverse reactions Not for use in wounds where nerves are Not for use in wounds where nerves are

exposed or wounds connect with a body exposed or wounds connect with a body cavity. Cat. B, may be inactivated by cavity. Cat. B, may be inactivated by detergents and antisepticsdetergents and antiseptics

keratolyticskeratolytics

Acts to remove excess growth of the Acts to remove excess growth of the epidermisepidermis

Warts, calluses, corns, and Warts, calluses, corns, and seborrheic keratosisseborrheic keratosis

Salicylic acid, diclofenac (solaraze) Salicylic acid, diclofenac (solaraze) and Actinex, salicylic acid often in and Actinex, salicylic acid often in OTC preparationsOTC preparations

Usually well toleratedUsually well tolerated

Don’t give with known hypersen.Don’t give with known hypersen. Not used on moles, warts with hair, Not used on moles, warts with hair,

genital or facial warts, warts on genital or facial warts, warts on mucus membranes or infected skinmucus membranes or infected skin

Not for longterm use in diabetics, Not for longterm use in diabetics, clients with impaired circulation or clients with impaired circulation or infantsinfants

Cat. CCat. C

Topical local anestheticsTopical local anesthetics

Temporarily inhibit conduction of Temporarily inhibit conduction of impulses from sensory nerve fibersimpulses from sensory nerve fibers

Relieve itching, burning and pain Relieve itching, burning and pain Can be used with caution on mucus Can be used with caution on mucus

membranesmembranes Lanacane, nupercainal, XylocaineLanacane, nupercainal, Xylocaine Occas. local irritation notedOccas. local irritation noted Contraind. With known hypers. And Contraind. With known hypers. And

with certain class 1 antiarrhy medswith certain class 1 antiarrhy meds

Nursing processNursing process

Pre-administration assessment consists of Pre-administration assessment consists of visual and palpation, describe using visual and palpation, describe using appropriate terminologyappropriate terminology

Ongoing assessment of site every Ongoing assessment of site every application; checking for changes or application; checking for changes or adverse reactionsadverse reactions

Apply nursing diagnoses Apply nursing diagnoses Planning for expected outcomesPlanning for expected outcomes

Implementation to promote an Implementation to promote an optimal response to therapyoptimal response to therapy

Allow for time to verbalize concerns Allow for time to verbalize concerns or ask questionsor ask questions

Assure condition improves, if trueAssure condition improves, if true

Topical antiinfectivesTopical antiinfectives Cleanse skin with soap and warm Cleanse skin with soap and warm

waterwater Apply medication thin layer, liberallyApply medication thin layer, liberally Either cover or leave exposedEither cover or leave exposed Avoid eye areaAvoid eye area

Topical antiseptics and germicidesTopical antiseptics and germicides Instill or apply as directedInstill or apply as directed Occlusive dressing only if orderedOcclusive dressing only if ordered All containers must be clearly labeled All containers must be clearly labeled

and dated, more advisable not to and dated, more advisable not to leave on bedside table, espec. With leave on bedside table, espec. With elderly or confused ptelderly or confused pt

Educate pt to any special effects of Educate pt to any special effects of med, iodine may stain, etcmed, iodine may stain, etc

Topical corticosteroidsTopical corticosteroids Wash site with soap/water unless Wash site with soap/water unless

otherwise directedotherwise directed Applied sparingly. If to have Applied sparingly. If to have

occlusive drsg, apply while skin still occlusive drsg, apply while skin still moist, cover with plastic wrapmoist, cover with plastic wrap

Topical enzymes to remove dead Topical enzymes to remove dead tissuetissue

Certain skin wounds may require Certain skin wounds may require special preparation,special preparation,

Area is washed or cleansedArea is washed or cleansed Med applied as dirMed applied as dir If bleeding occurs, d/c and reptIf bleeding occurs, d/c and rept Avoid application to healthy tissueAvoid application to healthy tissue

Topical antipsoriaticsTopical antipsoriatics Apply only to prescribed areasApply only to prescribed areas Assess for intensified irritationAssess for intensified irritation Educate pt on s/e and limitation to Educate pt on s/e and limitation to

sunlight exposuresunlight exposure

Topical anestheticsTopical anesthetics Advise pt of numbness which can last Advise pt of numbness which can last

an hour or soan hour or so If used on mucus membranes, advise If used on mucus membranes, advise

no food for at least I hr, may have no food for at least I hr, may have impaired swallowimpaired swallow