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INTEGUMENTARY DISORDERS By: JOHN MARK B.

POCSIDIO,RN, MSN SKIN BIOPSY A skin biopsy is the removal of a piece of skin for the purpose of further examination in the laboratory using a microscope. Skin biopsies are performed to diagnose a number of conditions. Skin biopsy is most frequently done to diagnose a skin growth such as a mole, or a skin condition such as a rash. A skin biopsy can also be used to diagnose a cancer of the skin.

A skin biopsy is also sometimes used to diagnose infections of the skin. SKIN BIOPSY Methods include: punch excisional shave Pre-procedure: Obtain informed consent Cleanse site as prescribed Inform client that local anesthetic can cause burning & stinging sensation SKIN BIOPSY Post procedure: Place specimen, when obtained by physician, in the appropriate container and send to pathology laboratory for analysis Use surgically aseptic technique for biopsy site dressings Assess the biopsy site for bleeding and infection Instruct the client to keep dressing in place for at least 8 hours Clean the site daily Use antibiotic as prescribed Sutures removed 7-10 days after surgery Woods Lamp Examination Skin is viewed under UV light through a special glass (woods glass) to identify superficial infections of the skin Woods Lamp Examination Normal Result Normally your skin will not shine, or fluoresce, under the ultraviolet light. Abnormal results mean Skin shine & fluoresce Under UV light Woods Lamp Examination Special considerations Do not wash before the test, because that may cause a false-negative result. A room that is not dark enough may also alter results. Other materials may also glow. For example, some deodorants, make-ups, soaps, may be visible with the Wood's lamp. Darken room prior to the examination Assist the client during adjustment from the darkened room

Patch Testing A patch test is a method used to determine if a specific substance causes inflammation of the skin. It is often used to test for allergens.

Patch Testing PROCESS: The first appointment will take about half an hour. Tiny quantities of 25 to 150 materials (allergens) in individual square plastic or round aluminium chambers are applied to the upper back. They are kept in place with special hypoallergenic adhesive tape. The patches stay in place undisturbed for at least 48 hours. PRE-PROCEDURE Discontinue systemic corticosteroids or antihistamine therapy 48 hours before the test Obtain informed consent Bring resuscitation equipment available POSTPROCEDURE Instruct the client to keep the skin-testing patch area dry Avoid activities that may produce sweating Record the site, date and time of the test Initial reading is after 2 days Inspect the site for results/ reactions like: RESULTS: WEAK POSITIVE: Redness, fine bumps, itching, MODERATELY POSITIVE: Fine blisters, papules, severe itching STRONG POSITIVE: Blister, pain, ulceration Skin Culture Used for microbial study Use sterile applicator & appropriate culture tube Viral culture is immediately placed on ice Obtain prior to antibiotic administration

INTEGUMENTARY DISORDERS Contact Dermatitis Inflammatory skin reaction which results because the skin has come in contact with a specific irritant) or allergen. CAUSES: Poison ivy and poison oak Fabric- wool, polyester Cosmetics Household products such as detergents, soap Hair dyes Industrial substances- paints, insecticides ,rubber compounds SIGNS & SYMPTOMS: Pruritus and discomfort Hive- like papules, vesicles, plaques Edema Sharply circumbscribed area and crust and ooze Diagnostic test Skin test ( to determine specific allergen) TREATMENT: Medical Topical steroids oral steroids

Antihistamines and antipruritic agent Aveeno ( oatmeal) baths and topical soaks

Nursing interventions Avoid exposure to skin irritants Apply cool, wet compress Elevate affected area Maintain a cool environment Administer antihistamine and topical corticosteroids or antibiotics Administer burrows solution for 20 mins Prevent or minimize scratching, keep nails short, use of mittens or socks Burows solution Nursing int. cont. Eliminate conditions that increases itching like heat, wool, stuff toys Wash cloth in mild soap and rinse thoroughly Monitor lesions for signs of infections Psoriasis Koebners phenomenon Development of psoriatic lesions at the site of injury, such as sunburned area or scratch. Shedding, silvery white scales on a raised reddened round plaques Affect scalp, knees, elbows QUESTION? Is there a cure? NURSING INTERVENTIONS Goal: slow the rapid turnover of epidermis. To promote resolution of the psoriatic lesion. REMEMBER: there is no known cure Precipitating factors should be removed Limit stress Daily soaks and tepid, wet compresses. Plus coal tar Assists the client to remove scales Drugs tar preparation, salicylic acid, steroids, Apply occlusive dressing Systemic therapy (methotrexate, Cyclosporin, Hydroxyurea) Photochemotherapy (PUVA) Provide client teaching and discharge Feeling about change in appearance of skin. (encourage to cover arms and legs with clothing if sensitive about appearance) Importance of adhering to treatment and avoid commercial products

Acute cellulitis Cellulitis is a bacterial infection of the deep layer of skin (dermis) and the layer of fat and soft tissues (the subcutaneous tissues) that lie underneath the skin.. : Causes: Trauma to the skin Poorly controlled diabetes. Skin disorders, such as eczema, psoriasis or severe acne. Obesity Poor immune system Circulatory problems

Athletes foot Infection due to surgery

SYMPTOMS Fever Redness and inflammation of the skin Pain Swelling Red streaking of the skin The affected area spreading and getting bigger Warmness to the touch Drainage of pus from the skin Swollen glands near the infected area

NURSING INTERVENTIONS Administer prescribed antibiotics Rest the affected area Elevate the extremity Provide meticulous skin & wound care with contact precaution Apply moist pack to the site Provide adequate nutrition Herpes Zoster (Shingles) is a nerve infection caused by the chicken-pox virus. Shingles results from reactivation of the chicken-pox virus that remained in your body since you had chicken pox--perhaps many years ago. SYMPTOMS Unilateral clustered skin vesicles along peripheral sensory nerves Fever Burning neuralgia Pruritus ( but more on pain) paresthesia

Diagnostic test Tzancks smear test Treatment: Acyclovir helps to control the skin eruption. It is not a cure, but helps to heal the rash, provided treatment is started early. Acyclovir is taken by mouth. Tylenol or mild painkiller as prescribed cortisone NURSING INTERVENTIONS Isolate the client ( contact precaution) Assess neurovascular status and 7th cranial nerve function Assess signs and symptoms of infection Reassign nurse personnel who have not been exposed to chicken pox Inform the client not to scratch the lesion Keep weeping lesion covered Apply cool & warm compresses ( relieve pain &itchiness) Impetigo

Impetigo is an infection of the surface of the skin, caused by staphylococcus ("staph") and streptococcus ("strep") bacteria. Impetigo is more common in children than in adults. Impetigo is contagious, mostly from direct contact with someone who has it. Impetigo Assessment: Fever Swollen lymph nodes papule---pustule---vesicles---crust Characteristic honey colored crust- CBQ Diagnostic test Diagnosis is based mainly on the appearance of the skin lesion. Skin culture. Treatment: Topical antibiotics Oral antibiotics Wash the skin several times a day, preferably with an antibacterial soap, to remove crusts and drainage.

NURSING INTERVENTIONS Place the client on isolation precaution to limit spread of infection Monitor patient for any signs of increase infection Teach the patient & family members about good hand washing & skin care Always wear gloves and mask when handling, draining lesions Cover draining lesion CBQ. WHEN TO RETURN TO SCHOOL????? Cystic Acne (ACNE VULGARIS) Common, self limiting, multifactorial disorder Requires active treatment for control until it spontaneously resolves Types of lesions: comedones, pustules, papules, nodules Cause: unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium acnes No evidence that chocolate, nuts, fatty foods or cosmetics affect acne

Cystic Acne (ACNE VULGARIS) Etiology: Propiniobacterium acne Assessment: Papule Pustule nodule NURSING INTERVENTIONS Administration of topical or oral antibiotics Administer isotretinoin (accutane) Instruct the client to avoid sun exposure (Isotretinoin) No to pregnant ( Isotretinoin) Stop taking vitamin A during isotretinoin treatment

Nursing int. cont Instruct the client that improvement may not be apparent for 4-6 weeks Instruct not to scrub, squeeze, prick the facial lesion Do not over wash the face Use water based cosmetics, avoid contact with excessively oil-based products Scabies Scabies is an itchy skin condition caused by an infestation by the itch mite Sarcoptes scabiei. Assessment Hallmark sign??? intense itching, worse at night Erythematous papules and pustules Threadlike, brownish, linear burrows up to 1 cm long. Secondary lesions consist of vesicles, crusts, reddish brown nodules, and excoriations. Intense pruritus that worsens at night. Diagnostic test Biopsies / scraping of lesion NURSING INTERVENTIONS Administer anti-scabies creams( LINDANE KWELL), (PERMITHRIN). Lindane (kwell) not used in <2 years old, causes neurotoxicity and seizures Apply thinly from the neck down and leave for 12-14hrs then rins Apply to dry skin, moist skin increases absorption All family members and close contacts Beddings and clothings should be washed in very hot water and dried on hot dryer Cont. Administer antihistamine & topical steroids to relieve itching.

BURN PATIENT Types of Burns Thermal dry flames, moist and heat Mechanical friction or abrasion Chemical acid or alkali Electrical most fatal Radiation sunlight Classification of Burns Partial Thickness Burns 1st degree burns superficial o Epidermis o Common cause is thermal burn o (+) erythema o (-) blisters o Discomfort lasts about 48 hrs; healing occurs in about 3-7 days First-degree burns Superficial partial thickness burn red and painful affect the epidermis only (e.g. sunburn). Classification of Burns Partial Thickness Burns

2nd degree burns deep o Common cause is chemical o (+) Erythema o (+) blisters o (+) very painful o heals in 3 6 wks Second-degree burns Deep partial thickness burn characterized by blisters and pain, reach through the epidermis to parts of the dermis (e.g. minor burns from fires) Classification of Burn Full Thickness Burns 3rd-4th degree burns o Affect all layers of skin, muscle and bones o Common cause is electrical burns o Not painfull o Dry, thick, leathery texture, appears deep red, black, white, yellow or brown o healing takes weeks to months Third-degree Burns full thickness burn damage all layers of the skin, including appendages, blood vessels, and nerve endings. The destruction of nerve endings is the reason why severe burns are not painful.

Stages of burns 1st 48 hours ( fluid accumulation phase) s/sx: Generalized dehydration Hypovolemia Oliguria Inc. hematocrit Metabolic acidosis Hyperkalemia 2nd 48 hours ( fluid remobilization phase) s/sx: Hypervolemia Diuresis Dec. hematocrit hypokalemia Cont. Third stage: recovery stage Healing phase BURN MANAGEMENT Emergency Room ABCDE assessment ( how??) Airway and fluid resuscitation (priority) Check for arrythmia ( check ECG) Check for kidney function Give Tetanus vaccine Prophylactic antibiotic Sterile dressing for wound ABCDE

A-irway - check nose, face and neck (priority) singed and sooty hair of the nose B-reathing rise and fall of chest C-irculation - if there is no breathing and circulation start CPR D-isability check and manage accordingly E-xpose to determine extent of injury ETT Insertion Cont. To check other injuries Determine TBSA Rule of Nines Berker Formula Parkland Formula (4ml x TBSA x BWkg) 1st 8H give , 2nd 8H give and for the 3rd 8H give the last part Repeat ABCDE assessment RULE OF NINE Management of Burns First-degree burns Keeping the skin clean and dry Second-degree burns Removal of blisters. Antibiotic ointment application ( silver sulfadiazine) or ( mafenide) then dressing. debridement Third-degree burns Excision of the eschar and split-thickness skin grafting REMEMBER: Practice asepsis!!! Protect the patient from infection Pediculosis Capitis Pediculosis capitis is a common infestation of the scalp. "head lice". It can occur at any age, but it is more frequently seen in children. Pediculosis capitis is very contagious. You get lice by close contact with objects that are easily infested like combs, hats, clothing and linen Signs & symptoms Typically it appears as red itchy bumps on the back of the neck and scalp. Careful examination of the hairs will reveal the lice (they often look like moving dandruff) and their egg cases called nits Pruritus and severe itchng (intensifies 3-4 wks after initial infestation) Secondary infection Diagnostic test? Diagnosis and symptoms To diagnose infestation, the entire scalp should be combed thoroughly with a louse comb and the teeth of the comb should be examined for the presence of living lice after each time the comb passes through the hair. The use of a louse comb is the most effective way to detect living lice.

TREATMENT Pediculicides: These include permethrin, lindane, malathion, or mercuric oxide ointment. All family members and close contacts must be treated Avoid sharing of personal belongings

Tinea Etiology: Dermatophytes, yeasts Tinea Tinea Tinea Tinea Tinea capitis- fungal infection of scalp corporis- fungal infection of the body cruris- fungal infection of the inguinal area pedis- foot inguinum- nails

TINEA CAPITIS Tinea Cruris- (jock itch)- small,red, scaly patches in the groin area Tinea pedis- (athletes foot)- scaling, maceration,erythema,blistering,and pruritus,usually found between the toes Tinea Diagnosis Woods light exam KOH smear ( sputum) Treatment: Topical/oral antifungals ( giseofulvin) (amphotericin B) VI. Antifungal Drugs (Topical) Drugs alter the cell wall of the fungus and disrupt enzyme activity, resulting in cell death. Drugs are manufactured in cream, ointment, lotion, and shampoo forms. Butenafine (Mentax) Ciclopirox (Loprox, Penlac nail lacquer) Clioquinol Clotrimazole (Cruex, Desenex, Lotrimin, Lotrimin 1%) VI. Antifungal Drugs (Topical) Econazole (Spectazole) Haloprogin (Halotex) Ketoconazole (Nizoral, Nizoral A-D) Miconazole (Lotrimin AF 2%, Micatin, Monistat-Derm, Prescription Strength Desenex, Ting) Naftifine (Naftin) Oxiconazole (Oxistat) Sulconazole (Exelderm) Terbinafine (Lamisil AT, Lamisil DermGel) Tolnaftate (Absorbine Athlete's Foot Cream, Absorbine Footcare, Aftate for Athlete's Foot, Aftate for Jock Itch, Tinactin, Tinactin for Jock Itch) NURSING INTERVENTIONS: Keep area clean and dry Do not scratch Proper hygiene avoid using the same comb scarves and hats should be washed thoroughly and not be shared use loose fitting cotton underwear's change socks daily Cut off nails or trim nails (onychomycosis)