Understanding Medical Surgical Nursing, 4th Edition Diagnosis

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Understanding Medical Surgical Nursing, 4th Edition Diagnosis
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Chapter 54
Nursing Care of Patients with
Skin Disorders
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Pressure Ulcers
 Pathophysiology
 Pressure Against Skin
 Tissue Anoxia
 Etiology
 Pressure
 Friction
 Shear
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Risk Factors


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Immobility
Impaired Circulation
Impaired Sensory Perception
Elderly
Very Thin or Obese
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Prevention

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Assess Daily
Cleanse and Dry Daily and PRN
Lubricate Daily
Clean Incontinence Promptly
Use Moisture Barrier PRN
Do Not Massage Reddened Areas
Shift every Weight every 15 min
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Prevention (cont’d)
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Turn/Reposition at Least every 2 hr
Keep Heels Off Bed
Pad/Protect Bony Prominences
Use Pressure-Reducing Mattress
Use Lift Sheet to Move
Provide Nutrition and Hydration
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Braden Scale
 Sensory Perception
Moisture
 Activity
 Mobility
 Nutrition
 Friction and Shear
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
 Pain
 Open Ulcerated Area
 Color Tip
 Black: Necroses
 Yellow: Infection
 Red: Healing
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis


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Physical Examination
Culture and Sensitivity
Blood Supply Studies
Wound Biopsy
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions
 Remove All Pressure
 Debride
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Mechanical
Enzymatic
Autolytic
Surgical
 Cleanse
 4 – 15 PSI
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Dressings
 Types
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Hydrogel
Polyurethane Film
Hydrocolloid Wafer
Biological
Alginate
Gauze
 Moist Environment
 Caution with Tape
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Negative Pressure Wound Therapy
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Stages
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Deep Tissue Injury
I – Skin Intact, Red, Does Not Blanch
II – Partial Thickness Skin Loss
III – Full Thickness Skin Loss, May Have
Eschar
 IV – Damage to Muscle, Bone, or Support
Structures
 Unstageable
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Stages (cont’d)
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Nursing Diagnoses
 Impaired Skin Integrity
 Risk for Infection
 Pain
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Dermatitis
 Pathophysiology
 Inflammation of the Skin
 Etiology
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Allergens
Irritants
Heredity
Stress
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Types of Dermatitis
 Contact
 Irritant
 Allergic
 Atopic
 Seborrheic
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
 Rash, Itching
 Lesions
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Scales
Crusts
Fissures
Macules
Papules
Pustules
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Complications
 Infection
 Sepsis
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
 History and Physical
 Culture and Sensitivity
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions

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
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
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Antihistamines
Analgesics
Antipruritics
Steroids
Colloidal Oatmeal Baths
Wet Dressings
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Nursing Diagnoses
 Impaired Skin Integrity
 Disturbed Body Image
 Deficient Knowledge
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Psoriasis
 Pathophysiology
 Inflammatory Disorder
 Proliferation of Epidermal Cells
 Scaling
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Aggravating Factors
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Stress
Strep Pharyngitis
Hormone Changes
Cold Weather
Skin Trauma
Some Drugs
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
 Papules, Plaques
 Silvery Scales
 Itching
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Complications
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Infection, Fever, Chills
Arthritis
Nail Changes
Lymphadenopathy
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
 Physical Assessment
 Rule Out Infection
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions

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Tub Baths
Corticosteroids
Salicylic Acid
Keratolytics
Vitamin D Creams
Retinoids
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Coal Tar, Anthralin
UV Light
Chemotherapy
Occlusive Dressings
Fish Oil Supplements
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Herpes Simplex
 Pathophysiology
 Viral Infection
 HSV1 – Above Waist
 HSV2 – Below Waist
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Herpes Simplex (cont’d)
 Primary Infection
 Direct Contact
 Respiratory Droplet
 Fluid Exposure
 Lies Dormant
 Recurs with Stress
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
 Prodromal Phase
 Burning, Tingling
 Vesicles and Pustules
 Burning, Itching, Pain
 Contagious Until Scabs Form
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
 History and Physical
 Culture
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions
 Antiviral Agents (Acyclovir/Zovirax)
 Topical
 Oral
 Antibiotics for Secondary Infection
 Avoid Triggers of Recurrence
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Herpes Zoster (Shingles)
 Pathophysiology
 Acute
Inflammation/Infection
 Painful Vesicules
 Follows Nerve
Distribution
 Usually One-sided
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Etiology
 Reactivation of Varicella Zoster Virus
(Chickenpox Virus)
 Occurs with Reduced Immune Function
 Elderly
 AIDS
 Immunosuppressed
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Prevention
 Avoidance of Infected Persons
 Varicella Vaccine (Varivax)
 Zostavax
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
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Vesicles, Plaques
Irritation
Itching
Fever
Malaise
Pain
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Complications

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
Postherpetic Neuralgia
Persistent Dermatomal Pain
Hyperesthesia
Opthalmic Herpes Zoster
Sepsis
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
 History and Physical
 Culture
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions
 Acyclovir
 IV, Oral, Topical

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
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Analgesics
Anticonvulsants/Antidepressants
Antihistamines
Corticosteroids
Antibiotics for Secondary Bacterial Infection
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Fungal Infections
 Pathophysiology/Etiology
 Direct Contact with Fungus
 Overgrowth with Antibiotic Therapy
 Grows in Warm Moist Environment
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Types
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Tinea Pedis
Tinea Capitas
Tinea Corporis
Tinia Cruris
Candidiasis
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions


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
Keep Skin Clean and Dry
Topical Antifungals
Oral Antifungals
Corticosteroids
Teach to Avoid Spread
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Cellulitis
 Pathophysiology
 Inflammation of Skin/Connective Tissue
 Infection
 Staphylococcus/MRSA
 Streptococcus
 Etiology
 Open Wound/Trauma
 May be Unknown
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms






Warmth
Redness
Edema
Pain, Tenderness
Fever
Lymphadenopathy
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
 Culture and Sensitivity
 Blood Cultures
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions
 Antibiotics
 Topical
 Systemic
 Debridement
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Acne Vulgaris
 Increased Sebum
Production
 Obstruction of
Pilosebaceous Ducts
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Acne Vulgaris (cont’d)
 Signs and Symptoms
 Comedones
 Open
 Closed
 Therapeutic
Interventions
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
Benzoyl Peroxide
Vitamin A Acid
Antibiotics
Estrogen Therapy
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Nursing Diagnoses:
Skin Infections
 Risk for Spread of Infection
 Acute Pain
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Pediculosis
 Pathophysiology/Etiology
 Infestation by Lice
 Transmission by Direct Contact
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Types
 Pediculosis Capitis
 Pediculosis Corporis
 Pediculosis Pubis
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
 Itching
 Papular Rash
 Presence of Lice, Nits, and Excreta
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
 History and Physical
 Test for STD if Pediculosis Pubis
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions
 Pediculosides
 Permethrin, Pyrethrin, Lindane
 Mechanical Removal
 Antipruritics
 Topical Corticosteroids
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Patient Education




Self Medication
Removal of Nits
Cleaning of Clothing and Objects
Inspection of Family and Friends
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Scabies
 Pathophysiology
 Sarcoptes Scabiei Mites
 Burrow into Skin
 Etiology
 Contact with Infected Clothing or Animals
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
 Itching
 Rash
 Burrows
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
 Shaving of Lesion
 Microscopic Evaluation
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions
 Topical Scabicides
 Permethrin
 Crotamiton
 Antipruritics
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Patient Education




Self Medication
Treat Family Members
Wash Clothing and Linens
Itching May Continue 2 Weeks Following
Treatment
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Pemphigus
 Pathophysiology/Etiology
 Autoimmune Disorder
 Bullae on Skin and Mucous Membranes
 Triggers
 Sun
 Some Drugs or Foods
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
 Bullae
 Mucous Membranes
 Spread to Skin
 Rupture
 Raw Wounds
 Pain
 Burning
 Itching
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
 Positive Nikolsky’s Sign
 Biopsy
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions







Corticosteroids
Cytotoxic Agents
Antibiotics
Analgesics
Antipruritics
Fluid Replacement
High Protein, High Calorie Diet
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Nursing Care






Monitor Fluid Balance
Monitor Diet
Administer Wet Dressings or Baths
Control Pain
Maintain Oral Hygiene
Provide Psychosocial Support
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Malignant Skin Lesions
 Cancer Arising From
 Basal Cell Layer
 Basal Cell Carcinoma
 Epidermis
 Squamous Cell Carcinoma
 Menalocytes
 Malignant Melanoma
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Basal Cell Carcinoma
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Squamous Cell Carcinoma
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Malignant Melanoma
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Lentigo Maligna Melanoma
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Risk Factors






Ultraviolet Rays
Fair Skin
Genetic Tendency
X-Ray Therapy
Chemicals
Immunosuppressive Therapy
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Prevention
 Limit Exposure to UV Rays
 Use Sunscreen
 Wear Protective Clothing
 Report Changes in Moles
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
 Examination
 Biopsy
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions
 Surgical Excision
 Chemotherapy
 Radiation Therapy
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Dermatological Surgery




Rhinoplasty
Blepharoplasty
Rhytidoplasty
Otoplasty
Copyright © 2011. F.A. Davis Company

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