Download Care of the Patient with an Integumentary Disorder

Efren N. Aquino M.D.
Jan. 6, 2009
May 19, 2009
1
Fungal infections are caused by microscopic
organisms (fungi) that can live on the skin. They can
live on the dead tissues of the hair, nails, and outer
skin layers.
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

Superficial fungal infections are known as
dermatophytoses.
The most common are:
 tinea capitis,
 tinea corporis,
 tinea cruris, and
 tinea pedis.
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

Tinea refers to the common disorder
known as “ringworm.”
The name comes from its characteristic
ring-shaped lesion and the location of
infection.
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
Etiology/pathophysiology
 Microsporum audouinii major fungal
pathogen
 Tinea capitis - Ringworm of the scalp
 Tinea corporis - Ringworm of the
body
 Tinea cruris - Jock itch
 Tinea pedis (most common) Athlete’s foot
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 Tinea
capitis
 Erythematous around lesion with
pustules around the edges and
alopecia at the site
 The hair can break off at the scalp, and
hair loss is typically not permanent.
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(From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)
Tinea capitis.
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
Clinical manifestations/assessment
 Tinea corporis
 Tinea corporis refers to ringworm of
the body.
 Flat lesions—clear center with red
border, scaliness, and pruritus
 Outbreaks are typically in hairless
areas.
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Tinea Corporis
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
Clinical manifestations/assessment
 Tinea cruris
 Brownish-red lesions in groin area,
severe pruritus with skin excoriation
due to intense scratching
 These lesions migrate outward from
the groin region.
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
Tinea cruris, also known informally as
crotch itch or jock itch in American
English and dhobi itch or scrot rot in
British English, is a dermatophyte fungal
infection of the groin region in either sex,
though more often seen in males.
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
The type of fungus that most commonly
causes tinea cruris is called Trichophyton
rubrum.
 Some other contributing fungi are
 Candida albicans,
 Trichophyton mentagrophytes and
 Epidermophyton floccosum.
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
Clinical manifestations/assessment
 Tinea pedis
 Fissures and vesicles around and
below toes
 Tinea pedis is also known as
“athlete’s foot.”
 This infection is associated with
more skin maceration than the other
types of tinea.
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
Diagnostic tests
 Visual inspection
 Ultraviolet light for tinea capitis
 Infected hair becomes fluorescent
(blue-green) under the light
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
Medical management
 Griseofulvin—oral
 Antifungal soaps and shampoos
 Tinactin or Desenex
 Burrow’s solution (tinea pedis)
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
Nursing Interventions
 The feet should be cleaned and dried
thoroughly, paying special attention to the
toes.
 Proper application of medications and
warm compresses
 Excellent foot care is stressed.
 Wearing sandal-type shoes or going
barefoot helps decrease foot moisture.
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Superficial inflammation of the skin is known as
dermatitis.
It can be caused by numerous agents, such as
drugs, plants, chemicals, metals, and food.
The nurse first observes erythema and edema,
followed by the eruption of vesicles that rupture
and encrust.
Pruritus is always present, which promotes
further skin excoriation.
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1. Contact dermatitis
2. Dermatitis venenata, exfoliative dermatitis, and
dermatitis medicamentosa
3. Urticaria
4. Angioedema
5. Eczema (atopic dermtitis)
6. Acne vulgaris
7. Psoriasis
8. Systemic lupus erythematosus
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Contact dermatitis – The epidermis is
inflammed and damaged
 Etiology/pathophysiology
 Direct contact with agents of
hypersensitivity
Detergents, soaps, industrial
chemicals, plants
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
Clinical manifestations/assessment
 Burning
 Pain
 Pruritus
 Edema
 Papules and vesicles
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
Diagnostic tests
 Health history –
 (1) tried a new soap,
 (2) been traveling and using different
personal items, or
 (3) been working with plants or
flowers
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
Diagnostic tests
 Intradermal skin testing
 Elimination diets
 Elevated serum IgE levels and
eosinophilla support the diagnosis.
 It is thought that both tests relate to
abnormalities of T-cell function.
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
Medical management/nursing
interventions
 Remove cause
 Burrow’s solution
 Corticosteroids to lesions
 Cold compresses
 Antihistamines (Benadryl)
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
Nursing Interventions
The primary goal is to identify the offensive
agent so as to rest the involved skin and protect
it from further damage.
 Wet dressings, using Burow’s solution, help
promote the healing process.
 A cool environment with increased humidity
decrease the pruritus.
 Cold compresses may be applied to decrease
circulation to the area (vasoconstriction).

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
Nursing Interventions
Daily baths to cleanse the skin should be taken
with an application of oil.
 Fingernails should be cut at the level of the
fingertips to decrease excoriation from
scratching.
 Clothing should be lightweight and loose to
decrease trauma of the involved area.

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
Prognosis
 Removal of the offensive agent results in
full recovery.
 Desensitizing the individual may be
necessary if recurrences are frequent.
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
Dermatitis venenata, exfoliative
dermatitis, and dermatitis medicamentosa

Etiology/pathophysiology
 Dermatitis venenata: Contact with certain
plants
 Exfoliative dermatitis: Infestation of heavy
metals, antibiotics, aspirin, codeine, gold, or
iodine
 Dermatitis medicamentosa: Hypersensitivity
to a medication
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
Clinical manifestations/assessment
 Mild to severe erythema and pruritus
 Vesicles
 Respiratory distress (especially with
medicamentosa)
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Exfoliative
Dermatitis
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
Medical management/nursing
interventions
 All dermatitis
 Colloid solution, lotions, and ointments
 Cordicosteroids
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
Medical management/nursing
interventions
 Dermatitis venenata
 Thoroughly wash affected area
 Cool, wet compresses
 Calamine lotion
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
Medical management/nursing
interventions
 Dermatitis medicamentosa
 Discontinue use of drug
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
Etiology/pathophysiology
Presence of wheals or hives in an allergic
reaction commonly caused by drugs, food,
insect bites, inhalants, emotional stress, or
exposure to heat or cold.
 The wheals (round elevation of the skin; white
in the center with a pale red periphery) of
urticaria appear suddenly.
 Urticaria or hives is caused by the release of
histamine in an antigen-antibody reaction.

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
Etiology/pathophysiology

Clinical manifestations/assessment
 Pruritus
 Burning pain
 Wheals
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
Diagnostic tests
 Health history
 Allergy skin test
 Serum examination for immunoglobulin
E (IgE)

Medical management
 Identify cause and alleviate symptoms
 Antihistamine (Benadryl)
 Epinephrine
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
Nursing Interventions
 Identify and alleviate cause
 Therapeutic bath
 Teach patient possible causes and
prevention
 The signs and symptoms of an
anaphylactic reaction should be
reviewed to include shortness of
breath, wheezing, and cyanosis.
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
Prognosis
 Patient recover fully when the
offensive agent is determined and
avoided.
 Compliance with the therapeutic
treatment regimen influences the
outcome.
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
Etiology/pathophysiology
 Form of urticaria
 Occurs only in subcutaneous tissue
 Same offenders as urticaria
 Common sites: eyelids, hands, feet,
tongue, larynx, GI, genitalia, or lips
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
Clinical manifestations/assessment
 Burning and pruritus
 Acute pain (GI tract)
 Respiratory distress (larynx)
 Edema of an entire area (eyelid, feet,
lips, etc.)
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Angioedema
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
Medical management
 Antihistamines (Benadryl®)
 Epinephrine
 Corticosteroids (Solu-Medrol®)
 Cold compresses
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
Nursing interventions
 Cold compresses
 Respiratory assessment, continuous
 Medical alert
 Education and teaching for prevention
Prognosis
 With early treatment, the prognosis is
good
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
Etiology/pathophysiology
 Allergen causes histamine to be
released and an antigen-antibody
reaction occurs
 Primarily occurs in infants
 The common allergies are to chocolate,
eggs, wheat, and orange juice.
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
Clinical manifestations/assessment
 Pruritus
 Papules and vesicles on scalp,
forehead, cheeks, neck, and extremities
 The vesicles generally rupture,
discharging a yellow, tenacious
exudates that dries and encrusts.
 the skin may depigment and become
shiny with dry scales.
 Erythema and dryness of area
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
Eczema (atopic dermatitis) (continued)
 Diagnostic tests
 Health history (heredity)
 Diet elimination
 Skin testing
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
Medical management/nursing
interventions
 Reduce exposure to allergen
 Hydration of skin
 Topical steroids
 Lotions—Eucerin, Alpha-Keri,
Lubriderm, or Curel 3-4 times/day
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Etiology/pathophysiology
 Occluded oil glands


Androgens increase the size of the oil gland
Influencing factors
Diet
 Stress
 Heredity
 Overactive hormones

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
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Clinical manifestations/assessment
 Tenderness and edema
 Oily, shiny skin
 Pustules
 Comedones (blackheads)
 Scarring from traumatized lesions
Diagnostic tests
 Inspection of lesion
 Blood samples for androgen level
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Comedones with a
few inflammatory
pustules
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Papulo-pustular acne
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
Medical management/nursing
interventions
 Keep skin clean
 Keep hands and hair away from area
 Wash hair daily
 Water-based makeup
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
Medical management/nursing
interventions
 Topical therapy
 Benzoyl peroxide, vitamin A acids,
antibiotics, sulfur-zinc lotions
 Systemic therapy
 Tetracycline, isotretinoin (Accutane)
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
Etiology/pathophysiology
 Noninfectious, hereditary, chronic,
proliferative epidermal disorder
 Skin cells divide more rapidly than
normal
Clinical manifestations/assessment
 Raised, erythematous, circumscribed,
silvery, scaling plaques
 Located on scalp, elbows, knees, chin,
and trunk
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(Courtesy of the
Department of
Dermatology, School of
Medicine, University of
Utah.)
Psoriasis.
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
Objective of treatment:
decrease inflammation
 Reduces shedding of the outer layer of skin
 Slow down the proliferation of skin epithelium


Topical steroids

e.g: betamethasone, hydrocortisone
 decrease inflammation
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
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Keratolytic agents
 Tar preparations
 Salicylic acid
 Reduces shedding of the outer layer of skin
Photochemotherapy
 PUVA ( Oral psoralen + Ultraviolet light)
Methotrexate and vit D
 reduce epidermal proliferation
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
Prognosis:
Psoriasis is a chronic disease.
 The clinical course is variable, but less than
half of the patients followed for a prolonged
period will have a prolonged remission;
severity may range from a minimal cosmetic
problem to a life-threatening emergency.

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
Etiology/pathophysiology
 Also referred to as systemic red wolf skin
 Autoimmune disorder
 Inflammation of almost any body part
 Skin, joints, kidneys, and serous
membranes
 Affects women more than men
 Chronic, incurable, and multicausal disease
 Contributing factors
 Immunological, hormonal, genetic, and
viral
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
Clinical manifestations/assessment
 Erythema butterfly rash over nose and cheeks
 Alopecia
 Photosensitivity
 Oral ulcers
 Polyarthralgias and polyarthritis
 Pleuritic pain, pleural effusion, pericarditis,
and vasculitis
 Renal disorders
 Neurological signs (seizures)
 Hematological disorders
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Systemic
Lupus
Erythematosus
(SLE) – The
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
Diagnostic tests
 Antinuclear antibody
 DNA antibody
 Complement
 CBC
 Erythrocyte
sedimentation rate
 Coagulation profile
 Rheumatoid factor
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Rapid plasma reagin
Skin and renal biopsy
C-reactive protein
Coomb’s test
LE cell prep
Urinalysis
Chest x-ray
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
Medical management/nursing
interventions
 Medications
 Nonsteroidal antiinflammatory agents
 Ibuprofen, ASA
 antimalarial drugs - hydroxychloroquine
(Plaquenil®) or chloroquine
 Corticosteroids - methylprednisolone
 antineoplastic drugs – azathioprine (Imuran)
 antiinfective agents - Ciprofloxacin
 Analgesics
 diuretics
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
Medical management/nursing
interventions
 No cure
 treat symptoms
 induce remission
 aleviate exacerbations
 Avoid direct sunlight
 Balance rest and exercise
 Balanced diet
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Prognosis


There is no known cure for SLE.
Management of the disease depends on the
nature and severity of the manifestations and the
organs affected.
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
Etiology/pathophysiology
 Lice infestation
 Three types of lice
 Head lice (capitis)
 Attaches to hair shaft and lays eggs
 Body lice (corporis)
 Found around the neck, waist, and thighs
 Found in seams of clothing
 Pubic lice (crabs)
 Looks like crab with pincers
 Found in pubic area
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
Clinical manifestations/assessment
 Nits and/or lice on involved area
 Pinpoint raised, red macules
 Pinpoint hemorrhages
 Severe pruritus
 Excoriation

Diagnostic tests
 Physical exam
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(From Baran R., Dawber, R.R., & Levene, G.M. [1991]. Color atlas of the hair, scalp, and nails. St. Louis: Mosby.)
Eggs of Pediculus attached to shafts of hair.
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Medical management/nursing
interventions
 Lindane (Kwell); pyrethrins (RID)
 Cool compresses
 Corticosteroid ointment
 Assess all contacts
 Wash bed linens and clothes in hot water
 Properly clean furniture or nonwashable
materials
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
Etiology/pathophysiology
 Sarcoptes scabiei (itch mite)
 Mite lays eggs under the skin
 Transmitted by prolonged contact with
infected area

Clinical manifestations/assessment
 Wavy, brown, threadlike lines on the body
 Pruritus
 Excoriation
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
Diagnostic tests
 Microscopic examination of infected skin

Medical management/nursing
interventions
 Lindane (Kwell), pyrethrins (RID),
crotamiton (Eurax), 4-8% solution of sulfur in
petrolatum
 Treat all family members
 Wash linens and clothing in hot water
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Keloids
Angiomas
Verruca (wart)
Nevi (moles)
Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
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

Keloids
 Overgrowth of collagenous scar tissue; raised,
hard, and shiny
 May be surgically removed, but may recur
 Steroids and radiation may be used
Angiomas
 A group of blood vessels dilate and form a
tumor-like mass
 Port-wine birthmark
 Treatment: electrolysis; radiation
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(From Zitelli, B.J., Davis, H.W. [2002]. Atlas of pediatric physical diagnosis. [4th ed.]. St. Louis: Mosby.)
Keloids.
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
Verruca (wart)
Benign, viral warty skin lesion
 Common locations: hands, arms, and fingers
 Treatment: cauterization, solid carbon
dioxide, liquid nitrogen, salicylic acid


Nevi (moles)
Congenital skin blemish
 Usually benign, but may become malignant
 Assess for any change in color, size, or texture
 Assess for bleeding or pruritus

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
Basal cell carcinoma
Skin cancer
 Caused by frequent contact with
chemicals, overexposure to the sun,
radiation treatment
 Most common on face and upper trunk
 Favorable outcome with early detection
and removal

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
Squamous cell carcinoma
Firm, nodular lesion; ulceration and
indurated margins
 Rapid invasion with metastasis via
lymphatic system
 Sun-exposed areas; sites of chronic
irritation
 Early detection and treatment are
important

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(From Belcher, A. E. [1992]. Cancer nursing. St. Louis: Mosby.)
Basal cell carcinoma.
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(Courtesy of the Department of Dermatology, School of Medicine, University of Utah.)
Squamous cell carcinoma.
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
Malignant melanoma
Cancerous neoplasm
 Melanocytes invade the epidermis, dermis,
and subcutaneous tissue
 Greatest risk
 Fair complexion, blue eyes, red or blond hair,
and freckles
 Treatment
 Surgical excision
 Chemotherapy
 Cisplatin, methotrexate, dacarbazine

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(From Habif, T.P. [2004]. Clinical dermatology: a color guide to diagnosis and therapy. [4th ed.]. St. Louis: Mosby.)
The ABCDs of melanoma.
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

Prevention of Skin Cancer
The American Academy of Dermatology (AAD)
has recommended these three preventive steps
for prevention of skin cancer:
 Wear protective clothing, including a hat with
a 4-inch brim.
 Apply sunscreen all over the body and avoid
sun from 10 am to 3 pm.
 Regularly use a broad-spectrum sunscreen
with a skin protection factor (SPF) of 15 or
higher, even on cloudy days.
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Prevention of Skin Cancer
The following six steps have been recommended
by the AAD and the Skin Cancer Foundation to
help reduce the risk of sunburn and skin
cancer:
1. Minimize exposure to the sun at midday-between 10
AM and 3 PM.
2. Apply sunscreen, with at least an SPF 15 or higher
that protects against both ultraviolet A (UVA) and
ultraviolet B (UVB) rays, to all areas of the body that
are exposed to the sun.
3. Reapply sunscreen every 2 hours, even on cloudy
days. Reapply after swimming or perspiring.
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
Prevention of Skin Cancer
4. Wear clothing that covers the body and shades
the face.
Hats should provide shade for both the face and
back of the neck.
Wearing sunglasses reduces the amount of rays
reaching the eyes by filtering as much as 80% of
the rays, and protecting the eyelids as well as the
lenses.
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
Prevention of Skin Cancer
5. Avoid exposure to UV radiation from sunlamps
and tanning parlors.
6. Protect children. Keep them from excessive sun
exposure when the sun is stronger (10 AM to 3
PM), and apply sunscreen liberally and
frequently to children ages 6 months and older.
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•
•
END
DONE
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