Lions and Tigers and Pustules, Oh My!

(Skin Disorders, Ch 54)

Pressure ulcers3 things cause em. Pressure (lying on same place), friction (rug burn) , and shear (patient slides down in bed). Those at risk IMMOBILE patients, decreased CIRCULATION, and decreased SENSORY function. How to prevent pressure ulcers: 1. Examine/document/clean skin daily. 2. Pat, dont rub skin. Use moisturizers. 3. Dry the skin-to-skin bits. Under breasts, skinfolds, groin. 4. Turn every 2 hours. 5. Avoid HOB more than 30 degrees (theyll slide!) 6. Use a draw sheet (and trapeze, if patients can use it) 7. Hydrate! At least 2500 ml fluid, unless contraindicated. 8. Pad the bony bits. 9. Activity! Get out of bed. Go to the toilet often. 10. If skin becomes reddened, turn more often. MOST IMPORTANT identify patients at risk! Use the Braden Scale! Braden Scale SIX areas, rated 1 (bad) to 4 (great!). a. Sensory perception. Are the lights on? Is anyone home? b. Moisture. Basically, are they continent? c. Activity. Are they in the bed, or active? d. Mobility. Can they change positions? e. Nutrition. Good appetite? Lots of protein? f. Friction. Do they slide down in bed often? HOW TO GRADE: 15 -18 (At Risk). 13-14 (Moderate Risk). 10-12 (HIGH Risk.) Under 9. DANGER! VERY HIGH RISK!

S/S of Pressure Ulcers. Reddened area that DOES NOT blanch. Capillary refill less than 3 seconds. Common sites: Sacrum (bottom back/butt), heels, elbows, hips, back of the head, and ears. If it touches the bed, its at risk. Lets talk about Colors and Stages. Black death (necrosis). Yellow icky (infection). Red healing. Stage I Red and Intact. Stage II Break in the skin (looks like blister) Stage III Deep crater. Cant see bone or muscle yet. Stage IV Can see bone, muscle, tendons. May have tunneling. Unstageable -- Covered by slough. Must be removed to evaluate wound. Wound infection is a COMMON complication! Not all wounds are infected, though! Treatment 4 types of debridement (removal of dead/bad tissue), dressings, and NPWT. Debridement 1. Mechanical trim it out with scissors. Also whirlpool baths. Wet to dry dressings. 2. Enzymatic topical enzymes are applied. Only to wound! Avoid healthy tissue! 3. Autolytic Synthetic dressing used. Bodys own enzymes heal wound. Not for infected wounds. 4. Surgical Scalpel it out. May be done in patients room, OR, or treatment room. How to clean a wound. Use a whirlpool, handheld shower, or irrigating system. 30 ml syringe with 18 G needle works well. Pressure needs to be between 4 psi and 15 psi. Dilution is the solution to wound pollution! There are many dressings. Appropriate dressing promotes the BEST healing. KEEP PRESSURE OFF! Negative Pressure Wound Therapy (NPWT) Pack it with a sponge. Cover with dressing. Apply vacuum. Apply gentle negative pressure. Keeps it moist (wounds like being moist to heal) Lets talk about wound exudate! 1. Serosanguineous. Blood and serum. Kinda amber colored.

2. Purulent. It has pus. Yellow for Staph. Fishy beige for Proteus. Fruity blue-green for Pseudomonas.

How about those INFLAMMATORY SKIN DISORDERS? Dermatitis inflammation of the skin. Itchy, red skin lesions. 3 types contact (like poison ivy, or soap), atopic (hereditary, associated with allergies, asthma, and hay fever), and seborrheic (on the oily scalp). Take short baths. Avoid deodorant soap. Dont scratch it! Can make it worse! Diagnosed by history, s/s, and clinical findings. Cultures are taken if it is infected. Treatment Control itching, alleviate discomfort and pain, prevent infection and skin damage. Pruritus means itching. Relieved by antihistamines, analgesics, and antipruritics. Oatmeal baths. Steroids are used. Also wet dressings. Pat skin dry, avoid friction and hot water, and wear sunscreen. Nursing Process Check skin often to see if treatment is working. Gently clean area. Pat, dont rub. High-protein diet. Relaxation for distressing symptoms. Verbalize concerns. Teach patient. Understand what triggers flare-ups. Psoriasis -- Chronic inflammatory disorder. Skin cells are produced rapidly (every 4-5 days, instead of monthly). Cause not known; hereditary AND autoimmune. Preventative measures avoid upper resp. infections, stress, trauma, sunburns, and certain medications. S/SRed papules that join to form plaques. SILVERY SCALES! Forms on elbows, knees, scalp, umbilicus, and genitals. Can lead to secondary infections and arthritis. Diagnoses by assessment. Therapy Steroids, Tar Preparations, UV light, retinoids. The cancer drug methotrexate in severe cases. Nursing Care- - Use medicines. Alcohol can interfere with treatments. Avoid triggers. How about those INFECTIOUS SKIN DISORDERS? Herpes Simplex (HSV) type 1 (cold sore) and type 2 (genital sore). Infection is through direct contact. NEVER GOES AWAY! NO CURE! HIGHLY CONTAGEOUS! Triggered by fever, sunburn, illness, menses, fatigue, or injury. Pregnant mommas with herpes can pass it along to the baby. Cultures provide definitive diagnosis. Antivirals (acyclovir, or other virs may help to heal, but wont cure. Herpes Zoster (shingles) -- You get chickenpox. Stays dormant in system. Then later, WHAMMO! Shingles. Most common in elderly or in immune compromised patients (AIDS, etc). HIGHLY CONTAGEOUS! Can lead to persistant pain for months, or eye herpes (ophthalmic herpes zoster really bad) Treatment is to control it, and relieve pain. Antivirals MOST effective within 72 HOURS of outbreak. Gabapentin and antidepressants used for nerve pain.

ZOSTAVAX (the vaccine) is recommended for ALL patients OVER 60. Reduces risk and duration. Impetigo. Caused by Staph or Strep. Highly contagious, infectious, and inflammatory. Often on little kids faces. Develops honey crust. Must remain home until ALL lesions are healed. Takes about 1-2 weeks to heal, if allowed to dry. Practice good hygiene.

Theres a fungus among us! 2 major types tinea (foot, crotch, scalp, or toenails) and candidiasis (Thrush. Anywhere warm and moist). Patients given OTC antifungals. Occurs through DIRECT CONTACT. Cellulitis inflammation of skin and just under the skin, usually Staph or Strep. Result of trauma, pressure ulcer, or wound. Often in lower extremities. Practice good hygiene! S/S warmth, redness, localized edema, pain, tenderness, fever, swollen lymph nodes. Culture it, use antibiotics. Report HYPOTENSION and TACHYCARDIA (systemic infection). Acne Zits. Common in teenagers, when the hormones go wacko. Comedo = zit. Dont pick at it! Avoid excessive washing, irritants, and abrasives. Acne is NOT related to diet, chocolate, sexual activity (you might go blind, though), or uncleanliness. Treatment Benzoyl peroxide (topical), tetracycline (oral and systemic), and Retin-A (topical). Use clean hands. Avoid eyes, nose. Accutane (causes photosensitivity) and systemic antibiotics are for severe cases. Birth control pills can help (sorry, women only) there are risks. Infectious Skin Nursing Process Monitor/document the size and location. Take temp every 8 hours (increasing temp means infection). Watch for s/s of SYSTEMIC INFECTION SPREAD (hypotension, tachycardia, and increasing temp). Standard precautions. With shingles: cool, moist compresses. With cellulitis: elevate extremity. The parasites in sight! Pediculosis Its lice. On the head, or the genitals (FYI also in beards and eyelashes. Yikes!) Avoid infected people. Do not share personal items. S/S it itches. Really bad. Also, you can find lice poop in yer underwear (Im not making this up!) Secondary bacterial infections common. IMPORTANT lice can carry OTHER diseases. Oh, and possible STDs (How well did you know your date?) Treatment OTC meds, usually pyrethins (RID) or permethrin (Nix).

Education --Remember kids, lice can happen to anyone (not a sign of uncleanliness). Bathe with soap and water. Wash clothes in hot water and detergent, or seal in bag for 10 days. Examine family members and intimate partners for lice. For head lice, it takes 15 minutes of head soaking to work. Scabies Its a mite. Burrows into your skin. Comes from intimate contact (time to become a hermit). Appears as short, wavy brown lines. Asymtomatic at this time, but MOST CONTAGIOUS! Takes 4 weeks for symptoms to appear. They die in 24 hours of no human contact. S/S itching and rash. Treatment is a layer of scabicide over the ENTIRE body for 8-12 hours (overnight).Treat animals so you wont get it. Skin lesions (Is it Cancer?) Two types benign (not cancer) or malignant (yep cancer) Malignant Skin Lesions include basal cell carcinoma (most common), squamous cell carcinoma (fragile, likes to bleed), and malignant melanoma (spreads rapidly). MAJOR cause of skin cancer is TOO MUCH SUN! Avoid sunlight between 10 am-4 pm. Wear sunscreen of SPF 15. Wear a hat and long sleeves. Other factors are fair skin, blue eyes, too many x-rays. Definitive diagnosis is biopsy (same with ALL cancers). Usually, surgery is done on lesions. Maybe chemo. Remember the ABCD of melanoma detection: A for asymmetrical (not same) shape. B for border (irregular). C for color (not the same). D for diameter (larger than pencil eraser)