Nursing care for patients with dermatological problems
Teresa J. Kelechi
July 19, 2002
Review
•	Anatomy of skin, hair, nails, glands
•	Functions of the skin
•	Age changes
•	Assessment: primary and secondary skin lesions
–	pages 1437 - 1451
Goals of nursing care
•	protect the skin/maintain skin integrity
•	prevent infection
•	reverse the inflammatory process
•	apply dressings
•	teach patients/families self care
•	relieve discomfort

•	Address body image
Common skin disorders
•	Psoriasis - noninfectious inflammatory dermatoses (abnormal skin conditions)
–	epidermal cells (keratin) are produced at a rate that is six to nine times faster than normal and become evident as profuse scales or plaques
–	protective layers of skin in involved areas do not form
–	stem from a hereditary defect
Clinical manifestations
•	silvery-white scales
•	red, scaling papules
•	oval, well-define plaques
•	occur on elbows, knees, scalp, gluteal fold, fingers and toenails

•	Goals of management are to slow the rapid turnover of epidermis, promote resolution of the lesions, and to control natural cycle of disease
–	reduce stress
–	apply topical therapy: corticosteroids (Table 52-7), nonsteroidals, coal tar products, medicated shampoos, intralesional
Therapy for psoriasis
•	Systemic: corticosteroids, methotrexate (cytotoxic preparation), cyclosporine A and hydroxyurea, oral retinoids
•	Photochemotherapy: combination of photosensitizing medication while exposed to long-wave ultraviolet light (risks are skin cancer, cataracts, premature aging of skin)
Nursing considerations
•	body image
•	potential complications:
–	psoriatic arthritis (complaint of discomfort in the sacroiliac and distal joints of the fingers)
–	overuse of topical steroids can result in cataract development, skin atrophy, striae (streaks)
–	instruct on therapeutic bath (balneotherapy) - used to remove crusts, scales and old meds
Exfoliative dermatitis
•	Progressive inflammation in which erythema and scaling occur in a generalized distribution
–	associated with chills, fever, itchy scaling of the skin
–	loss of stratum corneum resulting in capillary leakage, hypoproteinuremia, body heat loss

•	Caused by skin or systematic diseases: lymphoma, psoriasis, atopic dermatitis, contact dermatitis, severe reaction to medications including PCN; etiology is unknown in 25% of cases 
Clinical manifestations
•	May begin as patchy or generalized erythematous eruptions
–	accompanied by GI symptoms, fever, malaise, chills
–	skin color changes from pink to dark red
–	scales form (exfoliation) - thin flakes fall off leaving skin red, with new flakes forming as new ones fall off

•	hair loss
•	CHF, hyperuricemia, temperature disturbances
–	goal is to maintain fluid/electrolytes and prevent infection
–	patient may be hospitalized and on bedrest, medications stopped, room temperature kept warm, monitor vital signs
Nursing management
•	Assist patient with topical therapy, soothing baths, compresses, emollients, oral or parenteral corticosteroids
•	monitor vital signs
–	watch for hypothermia due to water loss through skin and cooling
Common blistering diseases
•	Origins: infections (bacterial, fungal, viral)
–	allergic contact reactions
–	metabolic disorders
–	immunologically-mediated reactions

•	Pemphigus
–	characterized by bullae (blisters) of various sizes on “normal” appearing skin and mucous membranes
–	autoimmune disease involving IgG, an immunoglobulin
–	blisters large, widespread, erupt, crust, drain, odor
Complications
•	bacterial infection
•	fluid and electrolyte imbalance
–	protein loss (hypoalbuminemia) common when bullae rupture is widespread 
Goals of therapy
•	Prevent fluid loss
•	prevent infection
•	dress wounds to absorb drainage
–	denuded skin drains
•	administer corticosteroids in high doses until remission and in many cases, lower doses for maintenance
•	immunosuppressive agents (gold, azathioprine)
Patients on steroids

•	Vital signs
•	body weight
•	glucose levels
•	fluid balance
•	monitor for serious side effects
–	bone loss, cataracts, ulcers, psychotic reactions, potential for adrenal suppression
Other blistering diseases
•	Bullous pemphigoid -
–	acquired, seen in elderly, small flaccid lesions
•	dermatitis herpetiformis
•	herpes gestationis 
Specific nursing interventions
•	Lesions in the mouth
–	humidified air, cool mist sprays to mouth, swishing with cool water, avoid commercial (alcohol-laden) mouthwashes, keep lips moist
•	skin integrity
–	cool moist dressings, baths, medicate for pain, avoid tape on skin, keep patient warm
•	reduce anxiety - provide for psychological needs

Toxic epidermal necrolysis
•	TEN
•	Stevens-Johnson Syndrome
–	fatal and often triggered by a reaction to medications or secondary to a viral infection
•	antibiotics, anticonvulsants, sulfonamides
Clinical manifestations
•	Starts out as conjunctival burning or itching, cutaneous tenderness, fever, cough, sore throat, headache, extreme malaise
•	then rapid onset of erythema of skin and mucous membranes
•	large flaccid bullae develop 
•	large sheets of epidermis are shed

•	Fingernails, toenails, hair, eyelashes are shed
•	excruciating tenderness 
•	denuded skin much like that of second degree burns (also called scalded skin syndrome)
–	elderly, immunocompromised
Complications

•	Sepsis
•	corneal lesions, scars - impaired vision
•	skin infections
–	hydrotherapy
–	keep patient warm
–	monitor VS, urine output, caloric needs
–	relieve pain, reduce anxiety
–	monitor lab values
Parasitic skin infestation
•	Pediculosis (lice)
–	capitis (head), corporis (body), pubis (pubic or crab louse)
–	cause severe itching because their digestive juices and excrement are deposited on the skin
•	head louse - back of head and eggs noted along hair line and behind ears
Lice
•	Condition spreads rapidly through physical contact, shared bedding, combs, hats
–	shampoo, wash linens, towels, clothing in 130 degree F water, comb hair with special combs, clean upholstered furniture, vacuum carpets and rugs frequently, treat all family members and close contacts
–	instruct regarding toxicity of medicated shampoos
Scabies
•	Skin infestation by the itch mite Sarcoptes scabiei
–	substandard hygienic conditions, elderly, sexually active
–	symptoms appear 4 weeks after contact
–	severe itching 
–	delayed type of immunologic reaction
–	burrows (raised areas)

•	Inspect areas with flashlight
–	scratches, straight or wavy, brown or black, threadlike, wrists, arms, axillary folds, under breasts, gluteal crease, groin, penis
–	red, pruritic eruptions appear between adjacent skin areas
–	increased itching at night due to increased warmth of skin

•	Secondary lesions common

•	nursing care
–	scabicide applied to skin left on topically for 12 to 24 hours, 2 treatments, one week apart
–	observe for hypersensitivity
–	encourage clean sheets daily

•	Watch for reactions to oral antihistamines for itching (Benadryl, Atarax)

Contact dermatitis
•	Inflammatory reaction of the skin to physical, chemical, thermal, and biologic agents
–	can be allergic or non-allergic
•	non-allergic - chemical irritants such as soaps, detergents, scouring compounds, industrial chemicals, wool
S&S
•	Severe itching or burning
•	erythema
•	edema, papules, vesicles, denuded skin
•	crusting, drying, fissuring, peeling
•	lichenification and hyperpigmentation
Nursing care
•	Remove irritant
•	avoid soap on skin
•	cool, wet compresses
•	nonmedicated lotions (Aveeno)
•	hydrocortisone gels
•	medicated baths
•	short-course prednisone
Skin cancer
•	Most common cancer in U.S.
–	caused by exposure to sun, chemical pollutants, age, history of x-ray therapy for acne or benign lesions, immunosuppression, genetic factors
•	Most common types
–	basal cell (BCC)
–	squamous cell (SCC)
•	Other: melanoma, Karposi’s sarcoma
Basal cell
•	Appears most often on face: begins as waxy nodules with pearly edges, central ulcerations, crusting, may be shiny, flat
–	usually does not metastasize, recurrence is common
Squamous cell
•	Malignant proliferation arising from epidermis 
–	 can arise on sun-exposed area (face, loer lip, ears, nose, forehead, upper extremities), on “normal” skin, or from preexisting skin lesions
•	invasive carcinoma that can metastasize to blood and lymphatic system
•	metastases account for 75% of deaths from SCC
Goals of care
•	Remove the tumor (surgically)
–	adequacy of surgical excision verified by microscopic evaluation of sections of specimen
•	may use electrosurgery (cautery), chemosurgery, Moh’s micrographic surgery (shaving of layers), cryosurgery (deep-freezing with liquid nitrogen)
•	radiation (used for eyelid, type of nose and areas in or near vital structures such as facial nerve) - skin can become red and blistered
Nursing management
•	Most patients treated in outpatient settings
–	role of nurse is to teach patient about post-op self care
•	may have wound care with dressing changes
•	watch for excessive bleeding
•	avoid tight constrictive clothing over area (baseball caps)
•	apply emollients after sutures removed and especially a sun screen to scar
Malignant melanoma
•	Atypical melanocytes (pigment cells) in both the epidermis and dermis
•	most lethal of all skin cancers
•	often appear simultaneously with cancer of other organs
–	risk factors: ultraviolet light exposure, dysplastic moles or nevi
–	occur anywhere on the body
Melanoma
•	Superficial spreading melanoma
–	Occurs most frequently on trunk and lower extremities
–	lesions circular with irregular outer portions, margins may be flat or elevated and palpable
–	various colors of tan, brown and black with with gray, bluish-black or white

•	Lentigo-maligna melanomas
–	slowly evolving
–	pigmented on exposed areas of skin
•	dorsum of hand, head, neck
–	may be present for many years as tan, flat lesions and in time undergo changes in size and color

•	Nodular melanoma
–	spherical, blueberry-like nodule
–	smooth surface and uniform with blue-black color
–	dome shaped (can be described as a blood blister)
–	invades directly into adjacent dermis
–	poor prognosis

•	Acral-lentiginous melanoma
–	occurs in areas not excessively exposed to sun and where hair follicles are absent (palms of hand, plantar surface of foot, nail beds, mucous membranes)
–	irregular borers, pigmented, macules, nodules
–	become invasive early

•	Intervention is surgical: primary lesion, lymph nodes and vessels
–	nursing measures related to providing comfort postoperatively, care of incision sites, grafts, manage pain, reduce anxiety
–	prognosis depends on extent of metastasis: the deeper and thicker (> 4 mm), the greater the likelihood of metastasis
Nursing knowledge
•	Most effective current therapies
•	supportive care
•	provide and clarify information about the therapy
•	side effects
•	expected outcomes of treatment
•	monitor for symptoms of metastasis
S & S of metastasis
•	lung
•	bone
•	liver
–	role is to allow patient time to express fears, provide palliative care, arrange hospice, help patient with hope and realistic expectations
Kaposi’s Sarcoma
•	Associated with epidermic KS from AIDS, acquired KS from immunosuppression, African KS (of eastern half of Africa near equator), classic KS in men of Mediterranean or Jewish ancestry
–	local skin lesions, mucocutaneous lesions 
–	disease involves endothelial layer of blood and lymphatic vessels

•	Lesions of the AIDS-related Kaposi’s sarcoma
–	may remain flat,
–	extensively disseminated raised with edema
–	diagnosis confirmed by biopsy
–	prognosis depends on extent of tumor, CDC+ count and constitutional symptoms
–	life-threatening when pulmonary or GI involvement
Nursing care
•	Reduce symptoms by decreasing size of lesions
•	reduce discomfort 
•	control symptoms associated with mucosal or visceral involvement
–	surgical excision, cryosurgery, injection of chemotherapeutic agents into lesions, systemic chemotherapy, radiation as a palliative measure

•	Interferon treatment (IV, IM, SQ)
–	provide skin care, nondrying soaps, oral care, medicated lotions, dressings, avoid tape, administer antipruritics, antibiotics, analgesics
Facial  reconstructive surgery
•	Plastic surgery (to form) performed to reconstruct or alter congenital or acquired defects, restore or improve the body’s form or function
–	major goals of care for patient’s posoperatively:
•	maintenance of adequate airway
–	signs of hypoxia - restlessness, anxious behavior, mental confusion, combativeness
–	oral and pharyngeal edema

•	Manage facial edema
–	keep head slightly elevated (if BP stable)
–	suction as needed
•	Manage pain - may have minimal to extreme pain (bone grafts, head and neck cancer)
•	Maintain adequate nutrition

•	TPN, oral or gastrostomy tube feedings)
–	measure body weight
–	serum protein (pre-albumin, albumin levels)
–	electrolytes
•	Enhance communication
–	may have loss of oral speech is extensive surgery involving larynx, tongue and mandible

•	Address body image and self concept issues especially if severe disfigurement involved
•	promote family coping - involvement in treatment
•	monitor and manage potential complications
–	secondary infection - inspect mouth, suture line, change dressings, note drainage

•	Assess circulation of flaps, grafts, implants
–	note formation of hematomas, note color, temperature, increased drainage, odor

•	Other procedures:
–	face lift (rhytidectomy)
•	rest, fluids, check for excessive bleeding, avoid lifting bending, note sudden pain

•	Laser treatment of lesions
–	port-wine stains, telangiectases, vascular tumors, pigmented lesions
•	argon, carbon dioxide, pulse-dye lasers
–	patient’s often require special glasses/eye protection, may apply cold compresses to treatment area to minimize edema, exudate and loss of capillary permeability

•	Instruct patient that there may be:
–	swelling 
–	crust development
–	avoid sun exposure and wear sun screen
–	avoid makeup for a period of time
–	may apply bacterial ointment to area
–	may apply nonstick dressings Telfa
Websites
•	http://tray.dermatology.uiowa.edu
•	http://skincarephysicians.com/agingskinnet/photos
Burns
•	Types: 	superficial partial, partial, full-thickness (first, second, third) (minor, moderate, severe)  (major) - Table 53-1 (p. 1503)
•	rule of nines - Table 53-2 (p. 1504)
•	treatment of minor burns - Table 53-3
•	treatment of moderate and severe
–	AIRWAY, volume depletion, stabilization principles, baseline lab studies and monitoring

•	Pain relief
•	surgical debridement of eschar
•	chermical burns
•	physical/occupation therapy
Review
•	Local and systemic responses to burns
–	cardiovascular 
–	fluid, electrolyes, blood volume
–	pulmonary
–	renal, immunologic, thermoregulation GI
Questions
•	What is the most common IV fluid used in the 1st 24 hours post burn to manage volume depletion?
•	Why would the temperature/humidity be carefully controlled in a burn unit?
•	What is the most common drug used to manage pain in minor burns?  In severe burns and what is the route of administration?

•	How would a topical antibacterial agent be removed before reapplication?
•	What are three methods for removing eschar?
•	List three types of grafting (wound coverage) for full-thickness burns.
•	How is the donor site cared for in an autograft?

•	Why are elastic pressure garments used and for how long each day should the patient wear them?
•	Name three potential complications for which you would monitor the patient (p. 1528).
•	Why is it important to promote early mobilization?

•	Describe six psychosocial responses to burns.
•	What is the nurses role in support patient and family processes?
•	The temperature of water during hydrotherapy should be maintained at ______ degrees and limited to _______ minutes.