Chapter 56 Management of Patients With Dermatologic Problems

Copyright © 2008 Lippincott Williams & Wilkins.

Chapter 56

Management of Patients With Dermatologic Problems


Care of Patients With Skin Conditions

• Objectives of therapy are to prevent additional damage, prevent secondary infection, reverse inflammatory processes, and relieve symptoms

• Nursing care includes administration of topical and systemic medications and providing wound care, dressings, and patient hygiene

• Nursing care also needs to address the educational, emotional, and psychosocial needs of the patient


Psoriasis• A chronic, noninfectious inflammatory disease of the

skin in which epidermal cells are produced at an abnormally rapid rate

• Affects about 2% of the population, primarily those of European ancestry

• Improves and recurs; a life-long condition • May be aggravated by stress, trauma, and seasonal

and hormonal changes• Treatment: baths to remove scales and medications;

see PUVA therapy (Table 56-6 )


Psoriasis (cont.)


Nursing Process—Assessment of the Patient With Psoriasis

• Appearance of the skin

• Coping of the patient with condition

• Note impact of the disease on the patient activities and interactions


Nursing Process—Diagnosis of the Patient with Psoriasis

• Deficient knowledge

• Impaired skin integrity

• Disturbed body image


Collaborative Problems/Potential Complications

• Infection

• Psoriatic arthritis


Nursing Process—Planning the Care of the Patient With Psoriasis

• Major goals may include: – Increased understanding of psoriasis and the

treatment regimen – Achievement of smoother skin with control of

lesions – Development of self-acceptance– Absence of complications


Interventions• Patient teaching regarding the disease, skin

care, and treatment regimen; see Chart 56-5• Measures to prevent skin injury: avoid picking

or scratching• Measures to prevent skin dryness: use

emollients, avoid excessive washing, use warm (not hot) water, and pat dry

• Use of the therapeutic relationship for support and to aid coping


Infectious Diseases of the Skin• Bacterial infections

– Impetigo – Folliculitis, furuncles, and carbuncles

• Viral infections– Herpes zoster– Herpes simplex: orolabial and genital

• Fungal infections: tinea pedis, tinea corporis, tinea capitis, tinea cruris, tinea unguium; see Table 56-5


Impetigo


Herpes Zoster (Shingles)


Tinea Corporis (Ringworm) of the Face


Patient Teaching—Bacterial Infections

• Impetigo is contagious and may spread to other parts of a patient’s body or to other persons

• Patient teaching regarding antibiotics, hygiene, and skin and lesion care

• Do not share towels, combs, etc.• Bathe daily with antibacterial soap• Furuncles, boils, or pimples should never be

squeezed


Patient Teaching—Viral Infections

• Herpes zoster: provide instruction regarding prescribed antiviral medications, lesion care, dressings, and hand hygiene

• Herpes simplex: provide instruction regarding prescribed use of antiviral and prophylactic medications, information about the spread of herpes, and measures to reduce contagion of partner or of neonates born to mothers with genital herpes


Patient Teaching—Fungal Infections• Instruction regarding medications, use of oral and topical

agents, and shampoos • Instructions regarding hygiene; use clean towels and

washcloths every day • Do not share towels, combs, etc.• Keep skin folds and feet dry• Wear clean, dry, cotton clothing including underwear and

socks; avoid synthetic underwear, tight-fitting garments, wet bathing suits, and plastic shoes

• Avoid excessive heat and humidity • Hair loss associated with tinea capitus is temporary


Parasitic Skin Infestations

• Pediculosis (lice): pediculosis capitus, pediculosis corporus, and phthirius pubis

• Scabies (mites): Sarcoptes scabiei


Patient Teaching—Pediculosis Capitis• Head lice may infest anyone and are not a sign of

uncleanliness• Provide instruction in use of shampoo (lindane: Kwell;

pyrethrin: RID) and combing of hair with fine-tooth comb dipped in vinegar to remove all nits

• Note lindane may have toxic effects and must be used only as directed

• All articles of clothing and bedding must be disinfected, washed in hot water, or dry cleaned; furniture and floors should be frequently vacuumed

• Do not share combs, hats, etc. • All family members and close contacts must be treated


Patient Teaching—Pediculosis Corporis and Pubis

• Pediculosis corporis is a disease related to poor hygiene and occurs in those who live in close quarters

• Pediculosis pubis is common and spread chiefly by sexual contact

• Bathe in soap and water; apply prescription scabicide or an OTC permethrin, such as NIX; mechanically remove any nits; if eyelashes are involved, Vaseline may be applied twice a day for 8 days


Patient Teaching—Pediculosis Corporis and Pubis (cont.)

• All family members and sexual contacts must be treated and instructed regarding personal hygiene

• All clothing and bedding must be washed in hot water or dry cleaned

• Patient and partner should be scheduled for a medical checkup to assess for coexisting sexually transmitted disease


Patient Teaching—Scabies• Mites frequently involve fingers and hands; contact may

spread infection; health care personnel should wear gloves when providing care until infection is ruled out

• Instruct patient to take a warm, soapy bath; allow skin to cool; apply the prescription scabicide lindane, crotamiton, or 5% permethrin to entire body, not including the face or scalp; leave on for 12 to 24 hours

• Wash clothing and bedding in hot water and dry in a hot dryer

• Treat all contacts at the same time• Pruritus may continue for several weeks and does not

mean retreatment is required


Nursing Process—Assessment of the Patient With Blistering Diseases

• Appearance of the skin• Monitor VS frequently and assess for signs and

symptoms of infection• Pain, pruritus, and discomfort• Coping skill of the patient with the condition• Note impact of the disease on the patient’s

activities and interactions


Nursing Process--Diagnosis of the Patient With Blistering Diseases

• Acute pain: skin and oral cavity

• Impaired skin integrity

• Anxiety

• Ineffective coping




• Infection and sepsis

• Fluid volume deficit and electrolyte imbalance


Nursing Process—Planning the Care of the Patient With Blistering Diseases

• Major goals may include: – Relief of pain and discomfort of lesion – Skin healing – Reduced anxiety – Improved coping– Absence of complications


Interventions• Provide meticulous oral hygiene• Avoid commercial mouthwashes• Keep lips moist with lip balm, petroleum, or lanolin• Provide cool humidified air• Apply cool, wet dressing or baths; initiate hygiene

measures • Apply powder liberally to keep skin from adhering

to sheets


Interventions (cont.)

• Monitor for and prevent hypothermia

• Skin care may be similar to that of the patient with extensive burns

• Initiate measures to prevent secondary infections

• Encourage adequate fluid and nutritional intake


Skin Cancer • Frequently related to sun exposure; prevention involves

use of sunscreen and avoidance of sun exposure • Incidence is increasing• Prevention of all types of skin cancer involves protection

from excessive sun exposure• Basal cell carcinoma

– Most common type and most successfully treated because tumors remain localized

• Squamous cell carcinoma– Prognosis depends upon presence of metastasis

• Treatment involves eradication of the tumor


Basal Cell Carcinoma and Squamous Cell Carcinoma


Skin Cancer• Malignant melanoma

– Risk factors: see Chart 56-8– Worldwide incidence and mortality rate are

increasing– Peak incidence occurs between ages 20 to 45– Types: superficial spreading, lentigo-maligna

melanoma, and nodular melanomas– Treatment: surgical excision and other therapies


Malignant Melanoma


Nursing Process—Assessment of the Patient With Malignant Melanoma

• Inspect the skin carefully

• Ask specific questions about pruritus, tenderness, pain, changes in moles, and new pigmented lesions

• Assess knowledge level and risk factors

• Assess coping and anxiety


Nursing Process—Diagnosis of the Patient With Malignant Melanoma

• Acute pain

• Anxiety

• Depression




• Metastasis

• Infection of surgical site


Nursing Process—Planning the Care of the Patient With Malignant Melanoma

• Major goals may include:

– Relief of pain and discomfort

– Reduced anxiety and depression

– Increased knowledge of early signs of melanoma

– Absence of complications


Interventions

• Pain: provide appropriate analgesics and measures to promote comfort

• Provide emotional support; allow patient to express feelings, clarify misconceptions, and supply information; support coping; and involve family in the discussion


Kaposi’s Sarcoma (KS)• A malignancy of endothelial cells that line the blood

vessels: dark reddish-purple lesions of the skin, oral cavity, GI tract, and lungs

• Categories– Classic KS– Endemic (African) KS– Immunosuppression: associated KS

Occurs in transplant recipients and people with AIDS

Much more aggressive form that involves multiple body organs


AIDS-Related Kaposi’s Sarcoma


Dermatologic and Reconstructive Surgeries

• Skin grafts– Autografts, allografts, and xenografts – Split thickness or full thickness

• Pedicle flaps and free flaps• Chemical peels• Dermabrasion• Facial reconstruction surgery• Rhytidectomy (face lift)


Laser Treatment of Lesions

• Argon laser

• Carbon dioxide laser

• Pulse-dye laser


Layers of Skin Appropriate for Split-Thickness and Full-Thickness Grafts


Common Donor Graft Sites


Nursing Process—Assessment of the Patient With Facial Reconstructive

Surgery

• Emotional responses

• Coping mechanisms and support

• Patient knowledge and understanding

• Assess family coping, knowledge, and support


Nursing Process—Diagnosis of the Patient With Facial Reconstructive Surgery• Ineffective airway clearance• Pain• Deficient knowledge• Imbalanced nutrition• Impaired verbal communication• Disturbed body image/self-esteem/self-concept• Anxiety• Coping impairments



• Infection

• Bleeding and hematoma formation

• Compromised circulation of flap and tissue necrosis


Interventions

• Provide patient and family teaching and support

• Monitor airway and for signs of hypoxia

• Keep head slightly elevated to minimize edema

• Provide analgesics as prescribed

• Maintain aseptic technique

• Provide frequent, gentle oral hygiene


Interventions (cont.)• Monitor nutritional status: I&O, weight, serum

protein, and electrolyte levels• Provide individualized nutritional care• Address communication needs preoperatively;

use pencil and paper, pictograph board, or other methods as needed; refer patient to speech therapy

• Provide emotional reassurance and support• Encourage socialization as appropriate

Documents

Chapter 56 Management of Patients With Dermatologic Problems