Carbuncles
When furuncles spread and form multiple
tunnels
Collection of connecting furuncles
If become uncontrolled may lead to severe
infection, sepsis, and possible death
Prevention: hygiene, hand washing with
antibacterial soap, and do not “pop” them
Impetigo
Common, contagious, superficial skin
infection
Highly contagious in children
Streptococcus and staph aureus
Starts on face and around mouth. Lesions
have pus and form curst. Easily spread to
other parts of body by pus
May itch, not typically painful
Treatment: topical antibiotic ointment,
isolation
Associated with kidney failure/problems
A THLETE ’S FOOT
Tinea Pedis
Fungus can be found on floors, socks, and clothing
Thrives on moist, warm skin (feet)
When the skin is injured by the fungus, bacteria can
invade and cause cellulitis
Symptoms: itching, burning feet, skin may peel, crack
and bleed
Treatment: need to make the area less suitable for
growth and antifungal meds
Equally distributed in males and females
Ethnic link: Caucasian
Usually starts between ages of 15-35 years old.
Predisposing factors: stress, skin injury, strep
infections, and weather will all trigger psoriasis
E CZEMA P REVENTION
Moisturize frequently
Avoid sudden temperature and/or humidity changes
Decrease stress
Avoid scratchy materials
Avoid harsh soaps and detergents
Avoid environmental triggers
Prevention: does not need to bathe everyday or use
too hot water
If has eczema need to look to respiratory systems due
to link with asthma and allergies
Felons
“fingertip infection”
Infection in top portions of fingers, in the
pad of skin above the first joint
Usually the thumb or index finger (fingernail
bed)
Staph aureus
Causes: bacterial or viral infection that enters
skin by wound
Treatment: MD examine/ if abscessedincision and drainage/soak fingers 3-5 times a
day, antibiotics, 1-2 weeks to heal
T INEA C ORPORIS AND T INIA C APITIS (S CALP )
Fungus causes a characteristic lesion with clear center
and a rough, scaly, circular border
Causes: contagious/spread through infected pets or
through direct contact with infected individual
Treatment: antifungal meds (topical 1st), unsuccessful
then PO
Treat the source (infected pet)
Capitis is common in children, can cause scaling and
bald patches. No sharing hats, combs, brushes.
D ERMATITIS
Nonspecific irritation of the skin
Cause: bacteria, fungus, parasite, or foreign
substances such as detergents, perfumes, certain
materials
Contact dermatitis- allergic reaction to substance that
comes in contact with skin (soap)
Atopic Dermatitis- “eczema” chronic, itching
inflammation
Stasis Dermatitis- “eczema” of legs” caused by poor
circulation
Chronic dermatitis can cause thickening, change in
pigmentation, and scaling
Acute dermatitis presents as red, itching area of
blisters and oozing
Treatment: removal of offending substance and
corticosteroid ointments
P SORIASIS
Chronic and non-infectious
Patches of raised, reddish skin covered by silvery-white scale. Skin
usually looks very thick with different texture.
Elbow, knees, back and scalp, but can be anywhere on the body
May itch, scratch, and bleed
No cure- have flare up and remission
May develop “psoriatic arthritis”- causing inflammation of joints
Treatments: topical-mild, phototherapy- mild to mod, systemic
(orally or inject) mod-severe
Incidence: 4.5 million adults in the US
150,000 new cases each year
20% have moderate to severe cases
S YSTEMIC L UPUS E RYTHEMATOSUS (SLE)
E CZEMA
General term encompassing various inflamed skin
conditions, “atopic dermatitis”
Chronic, relapsing, itchy rash
Non contagious
No cure
10-20% of the world population is affected by eczema.
Usually appears during childhood- may clear or disappear
with age
Dry, red, extremely itchy patches on skin
Chronic scratching leads to leathery skin
What makes them itch? Triggers include rough or coarse
material, soaps, detergents, dander, stress…)
Chronic inflammation caused by autoimmune disease
(pg. 1065)`
Body produces abnormal antibodies in their blood
that target tissues within their own body rather than
foreign infectious agents.
Internal organs are involved
Can affect skin, heart, lungs, kidneys, joints, and
nervous system
More women than men (worse prior to menstrual
period) female hormone link
Usually 20-45 years old when diagnosed
Ethnic link: more African American and Asians
Causes: genetic link, viruses, drugs that stimulate
immune system, UV light exposure)
No known cause but associated with allergies
Have increased risk of allergic rhinitis and asthma
S YSTEMIC L UPUS E RYTHEMATOSUS (SLE)
Chronic inflammation caused by autoimmune disease (pg.
1065)`
Body produces abnormal antibodies in their blood that
target tissues within their own body rather than foreign
infectious agents.
Internal organs are involved
Can affect skin, heart, lungs, kidneys, joints, and nervous
system
More women than men (worse prior to menstrual period)
female hormone link
SLE
`
Systemic Lupus Erythematosus
Usually 20-45 years old when diagnosed
Ethnic link: more African American and Asians
Causes: genetic link, viruses, drugs that stimulate immune
system, UV light exposure)
Have low blood clotting factors so they have a high risk of
excessive bleeding
Butterfly rash on the face
Fingers become white due to lack of blood flow, then blue
as vessels dilate to keep blood in tisuues, finally red as
blood flow returns (Raynaud’s syndrome)
A CNE V ULGARIS
Treatment: no permanent cure the goal is to relieve
symptoms and protect organs by decreasing
inflammation and/or the level of autoimmune
activity in the body
Mild- Intermittent anti-inflammatory meds
Severe- corticosteroids
Increase rest during active disease
May use NSAIDS for pain (ibuprofen, Motrin) antiinflammatory
“common acne”
Inflammatory condition of sebaceous glands of skin.
Results from excessive stimulus of the skin by
androgens (hormones).
Red, elevated areas on the skin that may develop
into pustules and even further into cysts that can
cause scarring
Common in teenagers because of the hormonal
factor
A CNE T REATMENT
Dietary: no support for chocolate or iodine in diet in
clinical research
Topical: (mild cases) astringent lotions, oil-removing
pads, acne soaps, clean skin often to decrease the
bacterial count
Oral: (severe) oral antibiotics
Accutane: form of Vitamin A that decreases the
amount of sebum (oil) released by the sebaceous
glands. Avoid Accutane if pregnant or could become
pregnant for 1 month after taking because it can
cause severe birth defects. They need to avoid
sunlight.
H ERPES Z OSTER
“shingles”
Caused by varicella zoster (same herpes virus that causes
chicken pox)
Decreased immune system makes you more susceptible to
Herpes Zoster
After infected with chicken pox, the varicella virus remains
dormant in the sensory dorsal ganglia. Years after the
initial chicken pox infections, the virus become inactivated.
Childhood chicken pox- dormant to sensory dorsal ganglia
along sensory nerve fibers, reactivated and travels from
ganglia via sensory nerves to corresponding skin
dermatone area.
N EVUS
“moles”
Benign (not cancerous) overgrowth of skin pigment
forming cells called malanocytes on the skins surface
Present at birth (congenital) or appearing early in life
(acquired)
Check any changes in the skin. Use the ABCD rule.
SKIN INSPECTION INTERVENTION
H ERPES SIMPLEX
“Fever Blister” or “Cold Sore”
Caused by 2 types of Herpes viruses: HSV1 and HSV2
Transmission is by direct contact with lesions
Lives in nerve ganglia, triggered by sunlight,
menstruation, injury or stress
S/S: burning, tingling, erythema, vesicle formation,
pain
Vesicles-pustules-ulcers-crusting
Healing time is 10-14 days for the exterior portion
and then grows dormant
May cause systemic reactions such as fever and sore
throat
Herpes Zoster
Begins as papules and then develops into vesicles with
erythematous base unilaterally on face, trunk, and/or
thorax. Stay for 3-5 days and then erupt, crust, and dry.
Recovery takes 2-3 weeks
Pain is associated with lesion eruption and it may stay after
the lesion is gone because nerve ganglia had been exposed
Treatment: Acyclovir or Famvir (antiviral agents) topical,
oral, Parenteral. Pain=over-the-counter anti-inflammatory
or prescription pain meds.
Infectious until lesions dry and decreased risk if never had
varicella
ABCD R ULE
A. Asymmetry; one-half of the nevus does not match
the other half
B. Border Irregularity (edges are ragged, blurred, or
notched)
C. Color variation or dark black color
D. Diameter greater than 5 mm ( size of a pencil eraser)
W ART T REATMENT
Skin:
salicylic acid “Compound W”
Liquid nitrogen- freezes the wart off
Burning the wart off
Assess ABCD
Look for any parallel growth around surgical incision
Vertical growth- determine metastasis and treat
accordingly
Genital
Liquid nitrogen
Chemical treatment
Laser surgery
Interferon injections to the site
W ARTS
“verrucae”
Caused by the human papilloma virus (HPV)
Can affect the skin or the mucous membranes
Most warts in the non-genital area are benign, but most
genital warts are precancerous
Transmitted by skin contact
3 most common types
I.
Common wart: skin/mucous membranes and
grows above skin surface
II.
Plantar wart: on feet- extend deep into skinpainful
III.
Condylomata Acuminata: (venereal wart) moist
areas, cauliflower-like appearance- pink purple
color.
1)
2)
3)
Basal Cell Carcinomas:
most common form,
any area that has constant sun exposure,
does require treatment,
stay out of the sun,
slow-growing and rarely metastasize
Squamous cell carcinomas:
Develop in the middle layer of epidermis
Can spread
Life threatening if not treated
Malignant Melanoma:
Abnormal growth of melanocytes
Most aggressive cancer with faster growth rate
Much greater potential for metastasis if untreated
Fair skin at most risk
P EDICULI
S CABIES
3 T YPES OF L ICE
L ICE T REATMENT
“lice”
Parasite that live on blood of animal or human host
“louse” living parasite
“nit” is the un-hatched egg laid by female louse on
hair shaft. Pearl-gray or brown color.
Not sharing clothes, hats, coats, hair accessories,
especially with children
i.
Pediculosis Corporis: body lice
*live on clothing and bed linens
*bites cause macule and itching
Pediculosis Capitis: Head lice
*Common behind ears, nape of the neck
*transmitted by contact (hat, comb, coat)
Pediculosis Pubis: pubic Lice
*spread through sexual activity or contact with
infested clothing or linens
*skin irritation and itching
ii.
iii.
B URN C LASSIFICATION BY D EPTH
1.
First Degree: damage to outer layer of skin. Pain,
redness, swelling (superficial)
“itch mite”
Between fingers, inner surface of wrist, elbows, and
belt line
Small red-brown burrows- 2mm in length
Puritis- always present especially at night
Highly contagious- wear gloves with care to clients
RID: Over-the-counter
Pesticide in the form of a shampoo/gel/home
spray
Safe
Lindane: prescription
Pesticide
Potentially neurotoxic
Not recommended for 1st line treatment
2.
Second Degree: “partial thickness: 1st layer (epidermis) burned all
the way through and some level of burning to dermis. Bright red
skin, blistered, swollen, and moist- very painful!
Superficial partial thickness burn- involves the entire
epidermis
Deep partial thickness burn- involves the entire dermis
plus hair follicles, dermis is damaged
o
*pink skin with blisters*
Extremely painful. May leave permanent scars
Treatment:
Do not break the blisters.
Don’t try to remove stuck clothing
Use cool running water for 5-10 minutes (no
ice)
Elevate above the heart level
Keep clean to prevent infection (may cover
with a clean sheet)
Depth and tissue damage- may need burn
center care or wound management
3.
Third Degree: “full thickness”- extends into hypodermis, causing
destruction of the full thickness of skin with its nerve supply
(numbness). Leaves scars and may cause loss of function and/or
sensation.
Will need hospital management
Will need to monitor for I&O, infection, pain, and
respiratory problems
May not be painful- nerve endings are destroyed
Skin will be white, brown, black , or red with no
blanching
Look at color of urine, may be dark red or ruby colored,
this is caused by muscle breakdown. The myoglobin is
excreted through the urine.
Life threatening depending on % of body surface
injured
`Will have to look at possible skin grafting. The skin
will not regenerate when damaged down to the
hypodermis area.
Graft site- burned area covered with skin graft
Will need dressing for 2-5 days
Donor site- unburned area that was removed
to cover burned site, “skinned knee”
Dressing for 1-2 weeks
INFECTION C ONTROL AND B URNS
Infection control begins at admission and continues
until grafting is complete
Use reverse isolation
Septicemia can occur at any time during
hospitalization
Z
T YPES OF SKIN G RAFTS
Autograft: transplant of the client’s own tissue. This
is the most successful. These are considered
“permanent grafts:. Immobilize area after grafted.
Xenograft- skin transplants from animal species to a
human. Not very successful. Pig skin commonly
used for temporary coverage for a massive burn.
Homograft: fresh skin from a human cadaver- may
be a precursor to an autograft.
C LASSIFICATION BY SEVERITY
Age: less than 4 or greater than 60 years, higher
chance of complications and death from severe
burns.
Infants: poor antibody response and fluid
requirements can be very tricky
Older patients: may have underlying complicationscause exacerbations and complicate situation
T HE R ULE OF N INES
% of body surface burned
Each leg=18%
Each arm=9%
Front torso=18%
Back torsos=18%
Head=9%
Genital area=1%
*Not used in infants (larger head to body ratio)
*Not good with short, obese, or very thin individuals
*Don’t need to remember actual percentages
C OMPLICATIONS AND B URNS
All burns result in complications
Common complications
Septicemia
Renal failure
Pneumonia
P ARTS OF THE B ODY AND B URNS
Head, neck and chest: risk of respiratory problems
Neck: prone to contractures
Perineum: very susceptible to infection
P ATHOPHYSIOLOGY AND B URNS
Immediate effect is destruction of protective skin
area. This leads to disruption of homeostasis,
diffusion of vascular components into extra-vascular
tissue, electrolyte imbalance, and diminished blood
volume. Can lead to multisystem trauma.
1st 24 hours: protect airway- airway edema leads
stridor, hoarseness, wheezing (usually on inspiration),
and mental status change. Position for airway
intubation and correct fluid loss.
Heart failure/disease
FLUID S HIFTS
With exposure to heat, capillaries are damaged and
become permeable to fluid. They let fluid leak out
of the capillaries and into the interstitial spaces
resulting in edema and blister formation.
The resulting fluid shifts are directly proportional to
the depth and extent of the burn.
Treatment- fluid therapy is going to be directly
related to the severity of the burn.
Really watch intake and output Really watch intake
and output
B URN SEVERITY
Severity is based on:
Size of the burn (expressed in % of total
body area using Rule of Nine’s)
Depth of the burn
Past medical history
Part of the body that is burned
They will lose a lot of plasma through burn surface.
Urine output is going to decrease drastically.
FLUID R EPLACEMENT AND B URNS
Parkland Formula- 4mL X wt/kg X % burned
Use rule of nines for percent burned with no
decimals
Physician will determine and nurse will check behind
If possible, give half the calculated amount over the
first eight hours from the time of injury and the
remaining half over the next 16 hours.
C HILDREN AND R EHYDRATION P OST B URN
Dehydrate more rapidly than adults (increase ratio of
body surface area to weight, increased metabolism,
and thinner skin)
Need more fluids than adults
Use formal and add 1,500 mL of LR per square meter
of surface area, and adjust this based on urine output
monitored hourly
Keep child’s minimum hourly output at 1 mL/kg/hr
FLUID O VERLOAD
Edema, dyspnea, neck vein distension, ascites, weight
gain
Must continually assess for these signs and symptoms
They may be weighed twice a day
1 ST 48 HOURS
Monitor for shock (<BP, >HR, pale, clammy skin, blue
lips,…), monitor electrolyte and protein loss (caused by
volume shifts from intravascular to extra vascular
compartment secondary to > in capillary permeability)
Any partial thickness burn over 9% can cause shock.
Immediate < in BP treat for shock.
Prevent shock with LR and Albumin
48-72 hours: eschar (scabbing over the burned area) formsinitially is sterile, in absence of topical antimicrobial,
bacteria will colonize. Primary source of bacterial
infections secondary to burns is the intestinal tract, whether
from vomitus, diarrhea, etc.
Should not have anything PO for first 48 hours due to
N/V. After 48 hours and free from respiratory problems
and shock, then can give small amounts of fluids (1-2
ounces an hour). If unable to tolerate, will switch back to
NPO.
T OPICAL A NTIMICROBIALS AND B URNS
Goal is to reduce bacterial count, not to sterilize
Sulfamylon Acetate- broad bacteriostatic action against
many gram negative and gram positive organisms
(pseudomonas). Easy to apply, but tends to be painful
with application b/c it burns. Must pre-medicate with use.
May cause acid-base imbalances and should not
be used on large areas of the body- use on ears
and nose
Silver Nitrate- Liquid, used to kill antibiotic resistant strains
of bacteria. Not used much anymore. Cover with moist
dressing. If allowed to dry out, further burns site! Turns
everything brown.
Silvadene- (topical crème) antibacterial/antifungal- wear
sterile gloves and use sterile technique- easy to use and
painless. Do not use if allergic to septra.
Betadine: broad spectrum antiseptic- used for > 30 years.
To prevent and treat wound infections. Active agent
providone iodine (prevents infection and does not harm
wound).
Neosporin and Bacitracin- used commonly on 1st degree
facial wounds. Antimicrobial effects.
C LIENT M ANAGEMENT
AND
B URNS
Pain Management: NSAIDS- minor burns. Morphine for
more advanced burns. IV preferred (SQ, IM not well
absorbed) Pre-medicate before dressing changes. May be
on a morphine drip or PCA. (Make sure that respirations
are at least 12 before administering morphine)
Nutrition: high calorie (metabolic rate triples), high protein
(wound-healing) not including high fat. Vitamin C assists in
collagen formation.
Environment: temperature should be greater than 84
degrees, air currents will cause tremendous pain.
Positioning: prevent contractures- change position
frequently, don’t bend at joints for extended time,
encourage ROM, Supine- flat
Don’t use Fowler’s position which promotes contractures.
Do not use knee gatch or pillows
Follow order with splints and exercise programs initiated
by physical therapy.
W OUND C ARE
Exposure- “open method” – mainly used with 1st
degree burns. Not used much for advanced burnsdries out surface, and impeded delivery of nutrients
to skin cells.
Use an occlusive dressing: works by excluding
atmospheric oxygen while promoting growth of new
blood vessels.
Advantages: Decreased dressing changes and
decreased cost
Disadvantages: adhere to skin- pain, and
can’t control wound discharge and odor
Wet Dressing: prevents scab formation, and debrides
wound. Needs to be sterile
Hydrotherapy- dilates blood vessels, removes wastes
from body tissues. May do mechanical debridement
during hydrotherapy. Do not use for more than 30
minutes to prevent metabolic stress and to keep the
client from getting cold.