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Older Adults Part 3 > 9.3 Severe Integumentary Disorders > Flashcards

9.3 Severe Integumentary Disorders Flashcards

1
Q

Steven-Johnson Syndrome and Toxic Epidermal Necrolysis

A
  • 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.

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2
Q

Clinical Manifestations

A

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)

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3
Q

Nursing Process

A

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

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4
Q

Complications

A
  • Keratoconjunctivitis (impairs vision)
  • Sepsis
  • MODS
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5
Q

Treatment

A
  • 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
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6
Q

Skin Cancer

A
  • 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

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7
Q

Basal Cell Carcinoma

A
  • 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

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8
Q

Squamous Cell Carcinoma

A
  • 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

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9
Q

Treatment

A
  • Radiation, photodynamic therapy (PDT) or topical chemotherapy creams
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10
Q

Photodynamic Therapy (PDT)

A
  • Application of 5-aminolevulinic acid to the lesion and then photoactivation with blue light for 1 hour
  • Destroys neoplastic cells
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11
Q

Topical Cream

A
  • 5-fluorouracil cream
  • Skin may become red and blistered

GOAL
- REMOVE TUMOR ENTIRELY

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12
Q

Surgery

A

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.

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13
Q

Malignant Melanoma

A
  • 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
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14
Q

ABCDE Rule Melanoma

A

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)

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15
Q

Melanoma Manifestations

A
  • 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)

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16
Q

Nursing Process Melanoma

A
  • 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

17
Q

Nursing Interventions

A
  • Pain relief

Surgical Excision - for small superficial lesions

Local Excision - For deep lesions

Lymph node biopsy and possible removal

18
Q

Necrotizing Fasciitis (NF)

A
  • 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

19
Q

Pathophysiology of NF

A
  • 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
20
Q

Predisposing Factors

A
  • Surgical/Trauma Wounds (burns, frostbite, skin lesions, varicella)
  • Diabetes, obesity, renal failure, vascular insufficiency, immunocompromised patients have higher risk.
21
Q

Early Symptoms

A
  • 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.

22
Q

Advanced Symptoms

A
  • 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”)

23
Q

Critical symptoms

A
  • 4-5 days

Manifestations
- Numbness
- Hypotension
- Toxic Shock
- Unconsciousness

24
Q

Nursing Care for NF

A
  • 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
25
Q

Hyperbaric Therapy

A
  • 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.
26
Q

Fasciotomies

A
  • 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
27
Q

Complications

A
  • Infection
  • Loss of protective mechanisms of Sub-Q tissue (from shearing, and blunt forces)

Older Adults Part 3 (54 decks)

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