Bacterial Skin Infections and Viral Skin Conditions, Exams of Nursing

Download Bacterial Skin Infections and Viral Skin Conditions and more Exams Nursing in PDF only on Docsity! NURS P 423 - Exam 3 Study Guide-Guaranteed Success. Bacterial infections on skin (usually because areas are already open) caused by MRSA, staph aureus, Group A strep (pyogenic), Methicillin sensitive staph aureus, less common= pseudomonas, H flu., corynebactor Primary INF: • Impetigo-primary infection by staph aureus or strep bacterial infection • Ecthyma-thighs or buttocks-pustular • Folliculitis-staph – klebsiella-hair follicle gets infected-staph, MRSA- or pseudomonas from water (pool or hot tub). Folliculitis=TX with clindamycin and Erythromycin (topical). • Follicular eczema-allergic response • Cellulitis-group a strep, staph aureus, H. influenza • Furuncle-boil =use warm compress • More than one-carbuncle-caused by staph/MRSA Secondary from open skin (ulcer/abrasion/surg wound/eczema) • MRSA • staph aureus • streptococci • enterococci • Anerobes KNOW DIFFERENCE /B/ primary and secondary inf. • Methicillin sensitive staph aureus, Strep pyogenes, methicillin resistant staph aureus are the most common causes of skin infection in the setting. a) Hospital b) NSG home c) Primary care TX: NON PHARM- • Chlorhexidine baths, keep clean, warm compresses for pustules, bleach baths, Incise and drainFIRST-culture to guide antibiotic choice Impetigo: Bacitracin-not as effective-USE BACTROBAN- ORAL abo for skin infection-Keflex-cephalosporin, dycloxicilin, Cipro Pseudomonas? Cipro or beta lactam and macrolide First class cellulitis-keflex-cephalexin-first gen cephalosporin • Which of the following is the first line treatment for cellulitis? a) Vanco b) Keflex (it’s a cef) c) Omnicef c) Rocephin Meds: 1. Keratolitic-first line, antibacterial, reduce hyperkeritinization 2. Retinoid-Retin-second class A-effective for acne and reverses abnormal keratinization- 3. ATB’s 1. Keratolytic : • benzyl peroxide-OTC, comes in all kind of forms-acne wash • Salicylic acid-acne wash • Axelaic acid • Sulfur (rarely used d/t odor). 2. Retinoids: causes local irritation that gets better with time-most therapies make the acne worse before it gets better. Pea sized amount around entire face. Start slow. Once a week. Then twice a week. Etc. • Tretinoin (Retin-A): causes local irritationthat gets better with time. MUST BE WORN WITH SUN SCREEN. • Differin (Adapalene)- less irritation but more expensive. • Tazarotene (Tazorac): used when pts have trouble with other options. 3. Topical ATBs: (gel, solution, or lotion) MUST BE USED WITH BENZOYL PEROXIDE TO AVIOD DRUG RESISTANCE & KERATINIZATION. • Erythromycin & Clindamycin (Erythromycin, clindamycin. MUST BE used together.) • Sulfacetamide 4. Oral ATB’s: for severe acne. Give this and send to Derm! • Tetra, doxy, and mino-cycline 5. ACCUTANE: Severe cystic acne only!!! • Prego cat X!!! • Monitor prego test (HCG levels), lipids, depression/mood changes, and OP. • cause irritation, scaly Step wise treatment- • always start with non- pharmacological care > Topical Keratolytic> nightly topical (RETIN-A) not together with a keratolytic> Topical ATB with item 2 in the AM and item 3 in HS> systemic ATB>Isotretoin (Accutane) Infestations: Scabies-put on Elimite cream at night and then wash clothes and bedding in AM with hot H2O Pediculosis-Head lice-prometherine-otc-SE: skin irritation and neurotoxicity-if patient does not want neurotoxin risk, give a lotion-Fear of neurotoxicity- Atopic dermatitis-the itch that rashes (MUST ITCH to be AD)-skin that doesn’t hold in moisture- lichenification-hx-any other allergies, irritant exposure, smoke, laundry detergent-decrease frequency of bathing, loose clothing, and emollient- make sure there is no metal allergy 1. Mosturizer (Emollients) o Emollient is 1stline-atopic dermatitis-steroid sparing-bid and after patient bathes-ideal moisturizer is thick, no fragrance, and no alcohol o Emollients are: a) Last resort b) Steroid spring c) Acne treatments 2. Second line=Topical corticosteroids - o action-anti-inflammatory-for atopic dermatitis-First line- vasoconstriction-anti- inflammatory corticosteroid from class 1-class 7. 1 most potent 7 least potent o Know some of them to describe to patient o Low potency topical steroid for maintenance and more potent for acute exacerbation o Can use on Infanta-0.5% to 1% hydrocortisone otc o Steroid induced acne, atrophy of the skin, intraocular pressure, and contact dermatitis- SE of the topical steroids 3. Oral Steroids o Low potency for long term o High potency for short term “burst” (flares) 4. Calcineurin Inhibitors : inhibs phosphatase activity of calcineurin: results in inhibition of T-cell activation o Immunomodulator o For pt 2 yr and up (espelidel) o increased risk of skin ca and lymphoma o Adverse calcineurin inhibitors-CA, lymphoma, allergic rxn, asthma, fever, HA, flu like symptoms, viral infections, varicella, warts, and allergic reactions 5. Also oral antihistamines, phototherapy, antimicrobials Seborrheic dermatitis – (Think seborr=sebaceous gland issue) flaky, scaly, dandruff, popular rash, area looks swollen with increase to greasy crusty lesions. Coal tar, selenium, teach about compliance and how to take. • Topical immunomodulators-older than 2 years old-imiquimod-seborrheic dermatitis-amixarone AN ISSUE. ▪ Imidazoles- mainly topical usage (for tinea pedis/cruris/manuum) o Types=Butoconazole, clotrimazole, ketoconazole, Econazole, oxiconazole, sulconazole, terconazole, and ticonazole o Ketoconazole-tinea versicolor and seborrhea-decreases fungal shedding o Topical imidazoles are used to treat: a) Acne b) Dermatitis c) Tinea Pedis o ▪ Triazole o Types include= Flucon-, Itracon-, Posocon-, &Voricon-azole o Fluconazole-commonly given-azoles-less active against human cyp450-can be given as a topical ointment or (po =MONITOR LIVER) Allylamine Antifungals_ Butenafine, Naftifine, & Terbinafine -“fine” Action inhibs synthesis of ergosterol by inhibiting squalene epoxide ▪ Terbinafine (Lamisil)—reduce ergosterol & prevents synthesis of fungal cell membrane. o SYSTEMICALLY=HEPATOTOXIC=Liver labs Q Month!!! And Ask about alcoholism o No other hepatotoxic drugs or alcohol while using-and chart really well. Control the prescriptions for a month at a time.B/C don’t want them taking this for 5-6 months ect. o Local/ topical side effects -redness, burning, irritation, common o Topical antifungal-tinea-two to three weeks to work o Lamisil-treats onychomycosis (a nail infection) o Which population should not be treated with Lamisil? a) Daily alcohol intake (d/t damage to liver) b) Active acne c) HTN Misc antifungals= Ciclopirox, flucytosine, Griseofulvin, tinactin ▪ Griseofulvin - o Inhibs fungal cell mitosis o Is FIRST LINE TX FOR tinneacapitus. o Can be used for tinneacorporus, teaching- o give with a high fatty meals-enhances absorption (teach @ dinner with gravy, butter, whole milk, ice cream, fried foods). o -monitor for hepatotoxicity (LFTs @ baseline and 1 month after stared tx). o You can also use selenium or nizoral shampoo to decrease shedding in tinneacaputus but they need to understand it is NOT a treatment. o SE’s=N/V, decreased appitite, changes in stools, jaundice, icteric eyes or mucous membranes. o Which of the following should be taken with fatty foods? a) Griseofluvin b) Amoxicillin c) Flagyl o Micro-liquid and ultramicro-pill-exactly 2 times difference in dosage Tinactin-otc for athletes foot-long term prevention • Hydration is important when taking: a) Matrix b) Acyclovir c) ASA Valcyclovir-sort of the same as acyclovir-more powerful with less dosing-causes vomiting, rash, nausea, more thrombocytopenia purpura risk Famcyclovir-herpes, varicella, hip, and Epstein Barr Ganciclovir- ONLY prescribed for immuno comp patients: • hiv, post-transplant, CMV immunosuppressed- • Can cause BONE marrow suppression • SE’s: rash headache, insomnia, peripheral neuropathy Viral skin infection The body doesn’t know something is wrong and so these drugs “wake” the body up by Irritation/injury tx for Warts inf =- salicylic acid-Warts (but not for genital warts), imiquimod, blister beetle, cryotherapy, cimetidine, podophyllin, retinoic acid(-flat warts) • Warts-Freeze warts-every three weeks-Duct tape over wart is better than anything. Occlude it. Immune system is activated. Scotch tape and salicylic acid are appropriate treatment for: • Mild warts • Ache • Cellulitis Verruca vulgaris - skin viral warts-duct tape or scotch tape and seratitic acid • 50 year old Frank comes in with multiple verucca vulgaris lesions on his hands. He has tried OTC salicylic acid without effect. o Can use cryotherapy in office, occlusion with tape at home, or a combination of those (or one with salicylic acid). Imiqimod is another option. o Cimetidine systemically evidence is strongest primarily in children. Cantharidin, TCA, acid, Intralesional therapy are all traditionally done by Dermatology. o Oral therapy cimetidine in children Podophyllin-like mandrake root-cytotoxic-interrupts metaphase-do not be pregnant (cytotoxic in embryo) for genital warts, can cause conjunctivitis-Given in clinic • Toxicity-sensorium disturbance, coma, death, muscle weakness Podofilox-done by self-bid for 3 days-then 4 day break • Cause irritation so that the body notices something is wrong. Salicylic acid -keratolytic-affects cell surface proteins-caution with diabetes and peripheral vascular disease Imiquimod-immunomodualtor-warts/genital warts • how does med work-patients can apply themselves. Causes inflammation to the site where the wart is growing-interrupts interleukins • Can use for genital warts, keritinic, applied 2-5 times a week topically • SE if imiquimod-local-inflammation, erythema, Systemic-flu like symptoms, itching, erosion Influenza-tx= Tamiflu, Oseltamivir, Zanamivir (MOA-Neuramidase inhibitors & M2 Protieninhib) • Tamiflu and Oseltamivir=1st choice for all age groups • Oseltamivir preferred for under 7 and infants • Zanamivir-7 and up • Check the cdc every year (September) • Antiflu use-old, young, immunocompromised, chronic diseases-best within 48 hours after symptoms Varicella-Herpes simiplex-antiviral-acyclovir-5 times a day-vancyclovir-fewer times a day but is more expensive HERPES of mouth- gingivostamastitis-comfort, pain meds, non spicy foods. OR topical coating agent- lidocaine? Not in children. Route of using systemic antiviral. Support hydration. Cold sores -a topical acyclovir-abreva, carmax-use sunscreen, chapstick SKIN infections with HSV-can treat with ointment-or not treatment Neonatal herpes -fatal disease if untreated-IV acyclovir Genital herpes- acyclovir, valcyclovir, famcyclovir-recurrent, chronic, first time- cost-Valtrex (valcyclovir) once a day dosing. • primary outbreak of Herpes simplex (assume type 2 but could be type 1). First line treatment is Acyclovir, famicyclovir or valacyclovir. • Valacyclovir is normally given to ease compliance – 1 gram BID x 7-10 days, but Acyclovir of • Deep pain- aching throbbing-RA, OA, joint pain • Visceral pain- organs underlying mucosa of the abdomen-thorax-visceral nociceptors-surgical incision, IBS, pancreatitis-response to nsaids • How it is perceived, etc A type of deep somatic pain is: a) Abrasion b) Arthritis c) Pancreatitis Acute-sudden onset VS Chronic- more than 3 months-RA, OA, bone disorders Meds affecting activities of daily living Find out what is causing the pain-underlying cause For a patient with abdominal pain, the first priority is to: a) Reassess b) Find the cause c) Give morphine RICE-Rest, Ice, compression, elevation WHO ladder slide: • Analgesic Ladder- consistent across the ages. • Step 1: For mild to moderate pain, treat with nonopioid. • Step 2: For moderate or severe pain, or fail Step 1, use oral opioid + nonopioid. • Step 3: For severe pain or fail Step 2, treat with opioid with or without nonopioid, and practice around-the-clock dosing. And Adjuvant medications For acute pain, the WHO recommendsthen low dose opiates if the pain is not relieved. a) Morphine b) IBU c) Phenergan CDC Recommendations for Prescribing Opiods for Chronic Pain • Non-pharm is preferred • Establish goals • Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy. • When opioids are started, clinicians should prescribe the lowest effective dosage. • When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long- acting (ER/LA) opioids. History of patient- Start with non-pharmacological measures • non-pharmacological treatments: Ice/heat therapy, massage, acupuncture, physical therapy/OT, TENS (electrical stimulation patches), distraction, relax, music, meditation, energy work. What concerns do you have in the elderly with pain medication? ▪ Constipation (already increased in elderly)- ▪ increased side effect s due to hepatic metabolism-may be on multiple drugs. ▪ Falls ▪ Confusion. ▪ BP elevated due to poor pain control. ▪ If antiplatelet is Coumadin- can’t use IBU If it is not Coumadin- can use NSAIDS> Toradol while in hospital Equianalgesic doses • Equianalgesic find the equivalent and prescribe one half. • Nice example: https://palliative.stanford.edu/opioid-conversion/equianalgesic-doses/ • Convert from one to another-incomplete cross tolerance-decrease by 1/3 or ½ The equianalgesic chart recommends tells you the morphine equivalent is 40 mg of oxycodone. You prescribe: a) Half this amount b) This amount c) 75% of this Methadone-chronic pain, neuropathic pain, long and variable half-life- accumulation of drug and sedation. Methadone in high doses-more than 300mg a day, QT prolongation-torsade’s –DO an ECG and follow up about QT-consider amiodarone and methadone, risk is higher Neuropathic pain tx - Think about a Neuromodulator, such as gabapentin or lyrica to decrease neuropathic component; OR tricyclic antidepressant, such as nortriptyline… anticonvulsants= Neurontin (Neurontin 1st line), tri cyclic antidepressants-(amitriptyline), corticosteroids, or Lidoderm patch. KNOW THESE DEF’s • Tolerance - given more to reach the same comfort level-more frequent dosing or higher dose • Dependence -withdrawal if you stop and not taper it-diaphoresis, tachycardia, GI symptoms, fever. • Addiction -improper use –psychological effects and not for pain. • MOA for Opioids= produce their pharmacological actions, including analgesia, by acting on receptors located on neuronal cell membranes. The presynaptic action of opioids to inhibit neurotransmitter release is considered to be their major effect in the nervous system. ADHD Diagnosis criteria- ADHD Diagnostic Criteria • Must be consistent through time • Must be present in more than one setting o Structure can cause out-of-control behavior, o Interfering with school, peers, learning, family • Must have existed before 12 years of age • Must show clear impairment in functioning • No longer disqualified by comorbid diagnosis (e.g., autism spectrum disorder) • Treatment-Ritalin/stimulant-LA, then non-stims>clonidine (catapras ) helps with (bp) and tic disorders as well,> bupropion, • If Not tx/adequately treated=Get hurt a lot, fail in relations in all aspects of life, conflicts with family and behave with high risk behavior Untreated- risk taking behavior-get into motor vehicle accidents, more cigarette smoking, and self-medicating with drugs, criminal acts. • St;imulants=FIRST LINE- Next= non-stims>FDAapproved other-clonidine and guanfacine. > Then /;on FDA other-bupropion. ;”:’/’/]” • Minimize symptoms= start meds at small dose and then titrate up until symptom control. • Choose between short and long acting stimulation=long acting is preferred. • ADHD and then psychosis or depression= assess for suicide • Monitoring with adhd meds= Follow closely-every month. 30 day prescription. Follow up history. Symptoms controlled and not controlled. Eating? HA? Tics? Muscle movements? Maintain weight, Mainias or other psychosis coming out? • Adjust med as needed. • If fails 3 stims= ok to move on to non-stim. • Sleep issue?Metadate given the shorter duration, so she can sleep at night. Sometimes stimulants are given with trazodone or something similar at night if insomnia is worsening daytime performance. • Stimulants: • Stims are #1 for tx and Mixed amphetamine= Adderall & Methylphenidate-Ritalin = favored meds d/t safety profile effect. (First two stimulant families-methylphenidate and mixed amphetamine salts) Anorexia is a side effect of: a) Adderall b) Fluoxetine c) Ambien Screen for substance abuse, er stimulants, Comorbids: HTN, Sleep disorders. Stimulant contraindications -Hx of psychosis, schizo, drug abuse in family history Stimulant SE’s: • common -weight loss, tachycardia, tremors, insomnia, appetite, delay in onset on sleep, may increase the tics, increase bp • With tics? Stop stimulant and try something else or retry in a couple of weeks or from short acting to long acting stimulant