Skin Conditions and Infections, Exams of Nursing

Download Skin Conditions and Infections and more Exams Nursing in PDF only on Docsity! MARYVILLE NURS 623 EXAM 1-with 100% verified solutions-2023-2024 Basics with skin conditions •Alopecia •Rash •Pruritus •Uticaria •Pigmentation change Skin lesion—New vs. Change HPI questions for skin problems Duration of symptoms Precipitating factors •Medications •Food •Occupation •Outdoors •Hobbies/Sport participation •Exposure to insects •Jewelry/metals/chemicals •Family history Is it: Local or systemic Pruritus- all day or worse at night Uticaria - duration Pigmented changes Pigmentation/Changes of the skin Diff diagnosis Nevi- brown, beige or pink(< 5mm) Melanoma Related to pregnancy- melasma (mask of pregnancy) Addison disease Side effect of medication- steroid therapy skin lesions Macule - flat, nonpalpable (freckle, petechia) Papule - PALPABLE, solid elevation of skin (elevated nevus) Nodule - elevated solid mass, deeper and firmer than papule (wart) Tumor - solid mass deep in subcutaneous tissue (epithelioma Wheal - irregularly shaped, elevated area (hive, mosquito bit Vesicle - elevation of skin with serous (clear) fluid Pustule - similar to vesicle but filled with pus (acne) Ulcer - deep loss of skin (venous statis ulcer) Atophy - thinning of skin Bullae-Clear fluid-filled blisters > 10 mm in diameter. These may be caused by burns, bites, irritant or allergic contact dermatitis, and drug reactions. primary versus secondary skin lesions Primary skin lesions are those which develop as a direct result of the disease process Secondary lesions are those which evolve from primary lesions or develop as a consequence of the patient's activities. Parasitic Skin Infections scabies and lice · non purulent assume staph aureus Purulent cellulitis · I&D first line ·NO 1st gen cephalosporine ·Consider MRSA- Bactrim, Cleocin, Doxycycline Impetigo Honey crusted plaques, usually on face Bullous: begin as small vesicles that rupture easily with serous fluid turning into crust Nonbullous, vesticulopustular: thick, adherent lesions, dirty yellow-colored crust with erythematous margins Treatment: Clean lesions. Bactroban TID x 7 days. Antibiotic (Keflex, Augmentin, Cloxacillin). With no treatment, it is self-limiting 2-3 wks follilculitis Staphylococcus. Multiple small papules on erythematous base, can be large yellow white tender pustules in adults. Common in places hair is present, widespread is characteristic, bumpy rash, no itching. Treatment: Only if becomes infected. Large lesions cleansed with weak soap solution, followed by soaking with saline or aluminum subacetate BID. TAO can be used BID for 5 days. Oral ABT 1st gen cephalo. if resistant Localized cellulitis The typical lesion of cellulitis is wide, diffuse area of erythematous skin that is warm and tender to palpation. Infection is occasionally accompanied by severe edema. Systemic symptoms such as fever, chills, and malaise may also be present. CAUSES- Diabetic patient or other immunocompromised patients. Any break in the skin. Skin breaks from surgical incisions, skin tears, wounds, trauma, insect bites or stings, and animal or human bites. PREEXISTING conditions- stasis ulcers, dermatitides, viral skin infections, superficial bacterial infections, and bolus disease all have the risk for secondary infections. Subjective- tender, warm, erythematous areas of skin usually on face, neck, and extremities. Usually report an insect bite or some form of skin break. If recurrent cellulitis may deny any trauma or injury. Objective- Lower leg most common site of infection .If lower extremity cellulites should look for SS of tinea pedis (Athletes foot) infection can be point of entry for bacteria. In children and occasionally adults the checks and periorbital area are more common sites of involvement. Red and warm appearance to the skin will be noted. Red boarders are flat and diffused. Localized cellulitis treatment Diagnostic testing- most cases are diagnosed by history and PE . Usually no discharge or obvious wound therefore unable to obtain a culture. If open wound or purulent discharge present a culture and gram stain should be obtained. For patients with fever a CBC should be done . If periorbital cellulitis EOM should be done and test of cranial nerves. Management- Take into consideration severity of infection, site of infection, underlying disease, and virulence of the pathogen. For those who have cellulitis not related to human or animal bites takes DICLOXACILLIN or CEPHALEXIN for 10-14 days. Patients with penicillin allergy get Erythromycin. Infected human and animal bites are treated with Augmentin for at least 2 weeks. LE's cellulitis requires bedrest and elevation of the leg. Need to consider comorbid conditions and consider referral of treatment. Hemophilus influenza can e treated with Ceftin If gram neg microorganism treat with fluoroquinolones such as levofloxacin can be used. Diabetic are typically treated with Augmentin purulent cellulitis treatment · I&D first line ·NO 1st gen cephalosporine ·Consider MRSA- Bactrim, Cleocin, Doxycycline Viral Skin Infections chicken pox, shingles, measles, warts, herpes Herpes Zoster (shingles) Unexplained pain along dermatome. Unilateral vesicular rash along dermatome lasting 3-5 days, up to 30. Treatment Famcyclovir, Acyclovir, Valacyclovir. Prednisone taper. Vaccine. herpes simplex Oral or genital, can be asymptomatic. Tenderness, pain, mild paresthesia's, or burning before onset. Prodrome can include headache, fever, muscle ache, lymphadenopathy, local pain. Grouped vesicles on erythematous base. No cure. o Caused by Increased production of sebum o Scaly, greasy rash- affected skin is pink, edematous, and cover with yellow to brown scales and crusts. o Usually seen on scalp, forehead, eyebrows, and area surrounding the nose/ears. o Common in infancy and called "cradle cap" Subjective- pink scaling rash located on face and scalp, typically male . May itch Objective- scaly patches that may be slightly papular. Each patch is surrounded by erythema. Greasy and appear yellow. Seborrheic Dermatitis treatment OTC dandruff shampoo, leave on 5-7 mins to be effective. Resistant seborrhea dermatitis may require a prescription shampoo 2.5 selenium sulfide shampoo, a ketoconazole shampoo (Nizoral shampoo) and a detoconazole shampoo are available. Keratolytic or oil based lotions are used to soften heavy crust. If significant erythema is present may need topical corticosteroid Hydrocortisone cream. For a superinfection of gram positive skin infection Cephalexin 7-10 days is required. Asteatotic Dermatitis Common in elderly •Secondary to aging, dehydrated skin, and malnutrition Pruritus, cracked, erythematous patches •usually shins or extensor surface of arms •Seasonal potentially •Men > women Prevention •Humidifier •Moisturizers Treatment •Avoid hot water showers/baths •Hydrophilic petrolatum or urea 10% cream immediately after shower/bath •Avoid rubbing skin with towel •Class 4 topical steroid ointment bid for 2-3 weeks to break itch cycle (i.e. 0.1% triamcinolone acetonide) Bullous Phephigoid Average onset 65y -Primary lesions, tense vesicles or bulla filled with serous or serosanguineous fluid -Pruritus -Autoimmune •Can be caused by drugs -Diuretics -Antibiotics -Ace Inhibitors Dx: Two Biopsies Tx: Topical corticosteroid <5% body •Oral corticosteroids (0.5-1mg/kg tapered slowly over 6-12 months) Psoriasis o An inflammatory disease that manifests most commonly as well-circumscribed, erythematous papules and plaques covered with *silvery scales. o Bilaterally symmetrical o Commonly occurs in ear canal o Areas of the body most commonly affected are the back of the forearms, shins, navel area, extensor surfaces of the elbows and knees, umbilicus, gluteal cleft, and scalp o Varies in severity from small, localized patches to complete body coverage Five main types of psoriasis: o Plaque psoriasis: presents as red patches with white - silvers scales on top, bilateral, seen on knees, elbows, neck, scalp, between buttock, and back, positive auspitzs sign and kobners phenomenon o Guttate psoriasis: drop-shaped lesions, small red papules less than 1 cm, usually on genital/lips o Pustular psoriasis: small non-infectious pus-filled blisters, persistent or recurrent dry red/scaly rash, first appears infancy, history of dry skin since birth o Inverse psoriasis: red patches in skin folds, armpit,groin, etc, oErythrodermic psoriasis: widespread rash Treatment for Psoriasis Topical treatments o Corticosteroids o Vitamin D3 analogs (e.g., calcipotriol [calcipotriene], calcitriol o Calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) o Tazarotene o Emollients o Salicylic acid o Coal tar Squamous cell carcinoma *· Red firm bump or · Scaly patch or · Sore that heals then reopens o A malignant tumor originating from keratinocytes, which can invade the dermis and occasional metastasize to distant sites. o More common on head and neck (55%) o More common in fair skinned o 2nd most common type of skin cancer o Tends to form in high sun exposure areas: o Rims of ears o Face o Neck o Arms o Chest o Back Testing: · Test a suspicious area by gently rubbing with a tongue depressor. If it bleeds, be suspicious of squamous cell Treatment: Early diagnosis/treatment can prevent this and stop SCC from spreading. Basal cell carcinoma *· Flesh colored, pearly domed nodule with overlaying telangiectatic vessels. · Pinkish patch of skin, Later stage, central ulceration and crusting. o Malignant tumor of the skin that originates from the basal cells of the epidermis; o Slow-growing and locally invasive tumor that rarely metastasizes; o Common in 50-60 year-olds; o Common in fair skinned but can occur in darker skin; o Usually on head and neck but can occur anywhere; o Early diagnosis/treatment is important as it can invade surrounding tissue; Testing: Biopsy Treatment: Simple excision: Electrodesiccation and curettage Cryosurgery Laser surgery Mohs microsurgery - highest cure rate Melanoma (malignant) o Deadliest form of skin cancer (75% of all skin cancer deaths) o Arises from malignancy of epidermal melanocytes o >90% arise from skin o few arise from eye (uveal melanoma) o <4% do not have primary site o If >4 mm in depth, poor prognosis (75% mortality) o Frequently develops in a mole with notable changes or o Suddenly appears as a new dark spot on skin, assymetrical lesion with irregular border, notching, and a diameter >6mm. o Variegation in color, with admixtures of blue, red, tan, brown, black, and white. Pneumonic: A = asymmetry B = border is irregular C = colors are different in same region D = diameter > 6 mm E = enlargement (evolution) Malignant melanoma types Types: o Superficial spreading (70-85%), extensive lateral or radial growth before vertical growth o Nodular (15-30%), vertical growth only) o Lentigo maligna (5%), in situ form that may persist for years before vertical extension o Acral lentiginous (2-8%), aggressive form most common in darker skinned persons, especially when appearing on hands/feet Malignant melanoma testing and management Testing: o Full body inspection o Lesion biopsy o Excisional biopsy is preferred o Classification System: o Clark/Breslow methods o TNM (tumor, node, metastasis) pg 244 Management: o Treatment depends on the stage of the lesion: o Biological therapy o Chemotherapy 1. How many grams of topical cream or ointment are needed for a single application to the hands? A. 1 B. 2 C. 3 D. 4 B 1. How many grams of topical cream or ointment are needed for single application to an arm? A. 1 B. 2 C. 3 D. 4 C 1. How many grams of topical cream or ointment are needed for a single application for the whole body? A. 10-30 B. 30-60 C. 60-90 D. 90- 120 B 1. You write a prescription for a topical agent and anticipate the greatest rate of absorption when it is applied to the A. Palms of hands B. Soles of feet C. Face D. Abdome n C 1. You prescribe a topical medication and want it to have maximum absorption so you choose the following vehicle: A. Gel B. Lotion C. Cream D. Ointmen t D 1. One of the mechanisms of actions of a topical corticosteroid preparation is as: A. An antimitotic B. An exfoliant C. A vasoconstrictor D. A humectant C 1. To enhance the potency of a topical corticosteroid, the prescribed recommends that the patient apply the preparation: A. To dry skin by gentle rubbing B. And cover with an occlusive dressing C. Before bathing D. With an emollient B 1. Which of the following is least potent topical corticosteroid? A. Betamethasone dipropionate 0.1% (Diprosone) B. Clobetasol propionate 0.5% (Cormax) C. Hydrocortisone 2.5% D. Fluocinonide 0.05% (Lidex) C 1. Antihistamines exhibit therapeutic effect by: A. Inactivating circulating histamine B. Preventing the production of histamine C. Blocking the activity of histamine receptor sites D. Acting as a procholinergic agent C 1. A possible adverse side effect with the use of first generation antihistamines such as diphenhydramine in an 80 yr old man is: A. Urinary retention B. Hypertension C. Tachycardia D. Urticaria A 1. Which of the following medications is likely to cause the most sedation? A. Chlorpheniramine B. Cetirizine C. Fexofenadine D. Loratadine A C. 72 D. 96 A 1. The use of which of the following medications contributes to the development of acne vulgaris? A. Lithium B. Propranolol C. Sertraline D. Clonidine A 1. First line therapy for acne vulgaris with closed comedones includes: A. Oral antibiotics B. Isotretinoin C. Benzoyl peroxide D. Hydrocortisone cream C 1. When prescribing tretinoin (Retin A) the nurse practitioner advises the patient: A. Use it with benzoyl peroxide to minimize irritating effects B. Use sunscreen because the drug is photosensitizing C. Add a sulfa based cream to enhance anti acne effects D. Expect a significant improvement in acne lesions after 1 week of use B 1. In the treatment of acne vulgaris, which lesions respond best to topical antibiotic therapy? A. Open comedones B. Cysts C. Inflammatory lesions D. Superficial lesions C 1. You have initiated therapy for an 18 yr old man with acne vulgaris and have prescribed doxycycline. He returns in 3 wks complaining that his skin is not any better. Your next action is to: A. Counsel him that 6-8 wks of treatment is often needed before significant improvement is achieved B. Discontinue the doxycycline and initial minocycline therapy C. Advise him that antibiotics are likely not an effective treatment for him and should not be continued D. Add a second antimicrobial agent such as trimethoprim- sulfamethoxazole A 1. Who is the best candidate for isotretinoin (Accutane) therapy? A. 17 yr old with pustular lesions and poor response to benzoyl peroxide B. 20 yr old with cystic lesions who has tried various therapies with minimal effect C. 14 yr old with open and closed comedones and a family history of ice pick scars D. 18 yr old with inflammatory lesions and improvement with tretinoin (Retin A) B 1. In a 22 yr old women using isotretinoin (Accutane) therapy, the NP ensures follow up to monitor for all of the following tests except: A. Hepatic enzymes B. Triglyceride measurements C. Pregnancy D. Platelet count D How do you know what type of anemia? Look at WBC and platelets Then look at the size of RBC MCV Reticulocyte count Once you know the size of the RBC: Whats their diet like Do they have blood loss- females mensus, blood in stools? Decreased red blood cell distruction? Increased RBC destruction? Distinguish from pancytopenia -Related to problem in bone marrow: -Decrease in Hgb, WBC count (absolute neutrophil count) Platelet count MCHC (mean corpuscular hemoglobin concentration) 31-36% Hb/cell* (commonly used: 32 - 36 g/dL) Concentration of hemoglobin per RBC Micocytic anemia Small size MCV is *<80 fl Causes: Iron deficiency- ? GI problem, blood loss Anemia of chronic disease (ACD)- inflammation, infection, malignancy, NSAIDS,ASA Thalassemia -inherited (typically RBC normal, Fe normal, Ferritin normal) Sideroblastic anemia - alcoholism Diagnostic: Serum Ferritin , <30,g/L pathological for Fe deficiency ( TIBC, Serum Iron, Total Iron binding capacity) Signs & Symptoms Microcytic Anemia Tachycardia/palpitations Fatigue Shortness of breath/dyspnea on exertion Dizziness Pale mucous membranes Sallow- colored skin Management of microcytic anemia Treat and eradicate the cause Possibly transfuse if HCT <27% Iron deficiency—increase dietary iron and/or supplemental iron (what are your concerns with prescribing Iron supplements) ACD—transfuse or growth factors to stimulate erythropoesis Thalassemia—transfuse/folate supplementation/oral iron chelation Sideroblastic—transfusions/vitamin B6 Normocytic Anemia Chronic disease state (ACD)0 lupus, RA, long term steroids Acute blood loss Hemolysis Volume overload -Pregnancy -parenteral overhydration Normocytic Anemia: Management Initially, symptomatic treatment Correct anemia and stabilize underlying cause -Erythropoietin-alpha- ACD -Prednisone for AIHA -Early delivery for pregnant mothers with HELLP -DIC—heparin (if thrombus), platelets, and FFP Macrocytic anemia MCV > 100 Megaloblastic -Vitamin B12 deficiency -Pernicious anemia -Folate deficiency -Antimetabolite drugs (e.g., methotrexate) Miscellaneous macrocytic etiologies (not megaloblastic) -Chronic alcoholism -Liver disease