9.3 Severe Integumentary Disorders Flashcards
Steven-Johnson Syndrome and Toxic Epidermal Necrolysis
- Fatal acute skin disorders characterized by widespread erythema and macule formation with blistering resulting in epidermal detachment or sloughing/erosion formation.
- TEN is more severe
- MAINLY TRIGGERED BY REACTIONS TO ANTIBIOTICS (SULFONAMIDES), NSAIDS, ALLOPURINOL, and OXICAM
Risks
- Age 46-63
- Polypharmacy in older adults
- Genetics (involved in immune system)
- Genetic strongly associated with HLA-B gene (a type of human leukocyte antigen (HLA).
HLA - Helps immune system distinguish bodies own proteins from foreign invaders.
Clinical Manifestations
Initially
- Conjunctival burning/itching
- Cutaneous tenderness
- Extreme malaise
- Myalgias (muscle pain)
- Fever, cough, sore throat, headache
After
- Rapid widespread erythema
- Danger of damage to airway from ulcerations
- Large flaccid bullae and large sheets of epidermis are shed (exposing underlying dermis)
- Fingernails, toenails, and eyelashes may shed
- VERY TENDER SKIN (similar to a burn)
Nursing Process
Assessment
- Skin and oral cavities
- VS, respiratory status, tachycardia
- Fatigue/Pain
- Urine volume and specific gravity
- Infection at IV site
- Daily weight
- Evaluate anxiety
Diagnosis
- Impaired tissue integrity
- Deficient fluid volume (from loss through skin)
- Acute pain
Diagnostics
- Studies of frozen skin cells from fresh lesion
- History of medication use that may have caused it (especially 4 weeks prior to reaction)
- CBC for leukopenia or normochromic, normocytic anemia
DEFINITIVE DIAGNOSIS
- Skin biopsy showing necrotic keratinocytes with full thickness epithelial necrosis
Complications
- Keratoconjunctivitis (impairs vision)
- Sepsis
- MODS
Treatment
- Maintain skin integrity
- Fluid balance
- Prevent hypothermia
- Relieve pain
- Infection (reverse isolation)
- GOAL IS TO CONTROL FLUIDS, PREVENT SEPSIS, AND PREVENT EYE ISSUES
- SUPPORTIVE CARE
- Discontinue medications that may have caused it immediately
- Treated in burn center due to similarities with burns
- Tissue samples for culturing
- Crystalloid fluid
- Total Parental Nutrition (TPN)
- IVIG for skin healing (corticosteroids are not useful)
- CRUCIAL TO PROTET SKIN WITH TOPICAL AGENTS (anti-bacterials and anesthetics to prevent sepsis)
- Biological dressings (pig skin or amniotic membranes)
- Vigilon (plastic semipermeable membranes)
- Eye care
Skin Cancer
- Most common type of cancer
- Frequently related to sun exposure
Prevention
- Sunscreen
- Avoid sun exposure
- Avoid excessive tanning
- Skin inspections
Risks
- <30 and >50
- Family history
- Large number of moles (nevi)
- Immunosuppression
- Light skin, blonde/red hair, blue/green eyes
Basal Cell Carcinoma
- Most prevalent (rarely causes death)
- Appears on sun exposed hands, face, neck, scalp
Appearance
- Waxy nodules with rolled, translucent pearly borders
- Shiny, flat, grey, or yellow
- Rarely metastasizes
- Reoccurrence is common
- Neglected lesions can cause loss of nose, ear or lip
Squamous Cell Carcinoma
- Sun damaged skin (epidermis)
- Can cause death but less aggressive than melanoma
- Can metastasize by blood for lymph
- Rough, thick, scaly tumor
- Border is wide, infiltrated and inflammatory
- Secondary infection can occur
- FIRM NODULAR LESION TOPPED WITH CRUST
Common Sites
- Exposed areas (especially upper extremities such as face, lower lip, ears, nose and forehead)
Prognosis
- Depends on metastases
Treatment
- Radiation, photodynamic therapy (PDT) or topical chemotherapy creams
Photodynamic Therapy (PDT)
- Application of 5-aminolevulinic acid to the lesion and then photoactivation with blue light for 1 hour
- Destroys neoplastic cells
Topical Cream
- 5-fluorouracil cream
- Skin may become red and blistered
GOAL
- REMOVE TUMOR ENTIRELY
Surgery
Surgical Excision
- Reconstruction surgery
Mohs Micrographic Surgery
- Most accurate. Remove tumor layer by layer. Each layer is analyzed to see if tumor has been removed completely.
Electrosurgery
- Removal through electricity and heat
Cryosurgery
- Freezes tumor with liquid nitrogen to remove.
Malignant Melanoma
- Neoplastic melanocytes in the epidermis and dermis
- Most lethal
- Average age of diagnosis is 57
Risks
- BRAF genetic mutation (a protein that sends signals for cell growth) - When this is mutated it increases growth/spread of cancer.
Treatment
- Very few single therapies work due to complexity of the cancer
- High-dose interferon alpha-2 via IV for 4 weeks then Sub-Q with immunotherapeutic agents help decrease rate of relapse
- Monoclonal antibodies can help in stage 3 (ipilimumab) which helps patients T-cells become more adept to killing tumor cells.
- MONOCLONAL ANTIBODIES FOR LATE STAGE MELANOMA
ABCDE Rule Melanoma
A - Asymmetry
B - Borders (uneven)
C - Color (multiple colors)
D - Diameter (usually bigger than 6 mm)
E - Evolving (changes in size/shape or begins to bleed is a bad sign)
Melanoma Manifestations
- Change in nervus (new growth on skin) from cutaneous epidermal melanocytes.
- Dark, red/blue and irregular in shape
- May be itchy, ulcerate or bleed
Growth Phases
1st - Radial Phase (spreads radially - best treated during this stage)
2nd - Vertical Phase (growth into dermal layer and eventually metastasis)
Nursing Process Melanoma
- Inspect skin carefully
- Ask questions about pruritis, tenderness, pain, or changes
Diagnostics
- Biopsy (tells type, level of invasion, and thickness of lesion)
- 1-2cm margin of normal tissue and portion of underlying sub-q fatty tissue
- Familial cancer (genetics)
AFTER DIAGNOSIS IS CONFIRMED
- Chest x-ray, CBC, Creatinine, liver function tests, lactate dehydrogenase
- LDH may be elevated
Complications with Melanoma
- Metastasis
- Infection at surgical site
Nursing Interventions
- Pain relief
Surgical Excision - for small superficial lesions
Local Excision - For deep lesions
Lymph node biopsy and possible removal
Necrotizing Fasciitis (NF)
- Decaying infection of fascia (soft tissue of connective tissue system)
- Rapid and progressive inflammatory infection of fascia
- Caused by bacteria that attacks subcutaneous tissue (enters through open wound and spreads rapidly through tissue surrounding muscle and causes necrosis)
- Can cause significant tissue loss
Bacteria
- Strep Pyogenes
- Strep and Staph
- E-Coli, Pseudomonas, Klebsiella
Type 1
- Polymicrobial (most common)
- Risks include post-op, obesity, diabetes, and older adults
Type 2
- Typically affects upper/lower extremities
- Caused by hemolytic-strep with/without staph aureus
Pathophysiology of NF
- Bacteria penetrates the skin barrier and spreads along fascial planes invading lymphatic system and blood vessels
- Bacteria releases chemicals that prevent immune system from fighting off the infection by decreasing normal protective tissue factors.
- Immune system then has an exaggerated response.
- Blood vessels then dilate (to distribute more WBCs in the blood) which increases permeability and reduces actual flow of blood/oxygen. This causes cell death.
- Ischemia progresses to thrombosis which can cause vascular occlusion and further necrosis
- Septicemia can develop as infection progresses
Predisposing Factors
- Surgical/Trauma Wounds (burns, frostbite, skin lesions, varicella)
- Diabetes, obesity, renal failure, vascular insufficiency, immunocompromised patients have higher risk.
Early Symptoms
- First 24 hours of bacterial invasion
Manifestations
- Fever, pain, malaise thirst
- Often mistaken for flu
HALLMARK SIGN
- Quickly spreading erythema with margin of redness that extends to normal skin with no raises or sharply demarcated.
Advanced Symptoms
- Next 48-72 hours
Manifestations
- High fever
- Hypothermia and dehydration
- Significant pain with erythema, edema, warmth
- Discolored skin
- Dusky blue vesicles and bullae (which can rupture and leak foul smelling dirty gray fluid “dishwater pus”)
Critical symptoms
- 4-5 days
Manifestations
- Numbness
- Hypotension
- Toxic Shock
- Unconsciousness
Nursing Care for NF
- RAPID AGGRESSIVE TREATMENT
- Broad spectrum antibiotics at first
- Once bacteria is identified (penicillin, aminoglycosides, clindamycin AROUND THE CLOCK)
- Monitor KIDNEY FUNCTION
- Surgical debridement of all necrotic tissue
- Excision of all non-viable skin
Hyperbaric Therapy
- Adjunct with antibiotics and debridement
- Elevates oxygen saturation by 1000 to infected wound which is bactericidal
- Also enhances wound healing, bodies ability to fight infection, stimulates growth of new capillaries to injured area.
Fasciotomies
- Division of fascia to relieve pressure (in areas of compromised viability)
- Left open to heal via secondary intention rather than primary closure
- May require amputation
Complications
- Infection
- Loss of protective mechanisms of Sub-Q tissue (from shearing, and blunt forces)
