Theme 1 week 1

NURSING CARE OF DISORDERS OF THE SKIN/INTEGUMENTARY/EYE, EAR, NOSE AND THROAT SYSTEM Presenter Mrs. S Ayub 1/8/11

Objectives At the end of the session the student should be able to :

Define key terms Demonstrate the knowledge and skills in the assessment of medical / surgical conditions affecting the Skin, EENT .

Objectives Cont
Demonstrate nursing knowledge and skills to care for the patient with Skin and EENT problems using the Nursing process model as a framework.

Prepare and assist patients undergoing diagnostic, therapeutic, corrective surgery and rehabilitative procedures.

Assessment of the skin

Equipment needed: good lighting Small centimeter ruler Penlight Gloves

Skin
Examination is correlated with information obtained in the history Inspection : observe for color Skin color, pigmentation, lesions, jaundice, cyanosis, scars, moisture, edema, color of the mucous membrane, hair distribution, nails.

Palpation
Examine the skin for: Temperature, texture, elasticity, turgor. Skin findings: Normally warm, slightly moist Smooth and returns quickly to original shape when picked up by two fingers when released. Characteristic hair distribution over body, Nails present, smooth and care for.

Physical examination
Focus on skin, hair and nails, Ask patient skin are of concern Examine the skin surface under good light Compare right and left side of the body Note the distribution and configuration of skin lesions Note shape, boarder, texture and surface of lesion.

 Palpate lesions for texture, warmth and tenderness Use metric ruler to determine size of lesionserve as a baseline for comparison with sequent measurements Examine scalp, nails and oral mucous for dark skinned individuals Look for black, purple or grey lesions palpate carefully- determine if rashes are present.

Skin disorders
Skin disorders are the major cause of disability, disfiguration and discomfort. Skin is integral to self image. As the largest and most visible organ of the body, skin is involved in relating to others. Facial expressions and temporary changes in skin color reflect emotion and contribute to nonverbal communication. One's image is altered by changes in and styling of hair and nails.

Tinea

Tinea (dhani)

Psoriasis

 Skin also provides a sensitive form of communication touch. Appearance is often important Undesirable skin changes may not only create visual abnormalities but also may make a person feel less perfect. Skin comprises of 15 % of body weight. Three layers: epidermal, dermal, and subcutaneous.

Diagnostic procedures.
Explain any procedure to the patient and significant others. Allow them to ask questions and express concerns Teach them appropriate wound care and indications of possible side effects and complications that should be reported.

Skin biopsy
Removes a skin tissue specimen for histological assessment. Three types: shave, dermal punch and surgical excision.

Shave biopsy
Obtain tissue for analysis from possibly malignant epidermal growths. Dermal punch biopsy: a circular instrument with a sharp cutting edge to remove a specimen of skin that includes the epidermal, dermal and the subcutaneous layer. Surgical Excision Biopsy: used when necessary to totally incise a lesion

Inflammatory skin conditions

Atopic dermatitis(atopic and flexural Eczema) eczematous dermatoses (eczema, nummular, dyshydrotic, and hand eczema, neurodermitisis)

Atopic dermatitis/atopic eczema :

Medical intervention Control of pruritis, symptom relieve, and prevention of secondary infection are most important. Protect the skin from scratching Avoid excessive washing or bathing because soap and water may aggravate the problem. Clean the skin with bath oils.

Atopic dermatitis/atopic eczema : Nursing diagnosis:

Impaired skin integrity due to inflammation: Nursing intervention: use prescribed treatment baths to rehydrate skin and relieve pruritis. Apply emollients frequently Reapply when the skin feels dry. Hold medication and notify the physician if burning, discomfort, or increased pruritis occurs.

Comfort, alteration in, due to inflammation

Nursing intervention: during the acute phase try to remove the patient from the environment or home to prevent from more itching or environmental and other triggering factors that induce itching. Provide a well ventilated, cool room and light, loose clothing, avoid irritating fibres such as wools or polyester.

 Protect skin from self injury. ( cut nails short, use cotton gloves and socks) Assess possible triggering factors such as allergens, or irritants, bacterial and viral, or fungal infection, environmental changes, such as temperature and humidity changes, or emotional or physical stress. Protect from exposure to herpes simplex virus.

Potential alteration in self concept due to body image change

Some skin conditions evoke feelings of anxiety, embarrassment, disgust, or repulsion in an affected patient and others Nursing intervention: recognize the psychosocial impact of the skin disorder on the person and significant others and evaluate your feelings about the person, the persons skin condition ways you communicate your feelings and the persons perception of them.

 Be aware of your non- verbal communication e.g. negative body language and expressions of rejection. Assess the persons and significant others for negative reactions to the skin disorder. Develop rapport Acknowledge concerns and facilitate the expression of feelings. Beware of individuals feelings

 Assess the persons perception of self, the skin disorder, and its impact. Use helpful verbal and non- verbal therapeutic communication skills. Use physical touch appropriately. Observe the persons interactions with others and assess interpersonal relationship.

 Anticipate social isolation, depression and withdrawal during the acute phase or exacerbation of chronic skin conditions. Foster self esteem by giving sincere complements on the persons activities and appearances. Discuss ways of covering the skin disorder if the patient wishes e.g. cosmetics to conceal scars.

 Recognize that as an individuals condition improves, the persons perception of self and others will improve.

Eczema
In acute phase topical corticosteroids may be prescribed. Apply emollients frequently. During the acute phase use only lotion bases. For chronic phases rehydrate the skin with emollient socks and treatment baths. reapply when skin is dry, If eczema worsens suspect intolerance to new topical medication and report this to the physician

Eczema in arms

Alteration in comfort due to pruritis and pain.

Observe indications of secondary infections (bacterial, viral, or fungal) Depending of location of dermatitis assess for and avoid environmental irritants

Xerotic eczema/ dry skin

Skin is dehydrated, erythemotous, scaling and finely cracked. Occurs in patches and may involve any skin surface. Common in elderly people If severe, skin is tight, it itches and is painful. In low humidity, excessive water is lost from the stratum corneum. Water loss causes Xerotic chapping, especially in artificially heated rooms

Medical intervention
Preventing dryness and relieving symptoms Rehydrate the skin by tepid soaks Emollients impede the fate of water evaporation from the skin by their residual oil film. Avoiding bathing with soap and using a coldair humidifier is recommended.

Xerotic eczema/ dry skin : impaired skin integrity due to dehydration of stratum corneum
Correct skin cleaning, use superfatted soap or bath oil, limit use of soap except in intertriginous areas, avoid soap during shower or bath, avoid hot water baths. Practice proper dry skin care daily, pat rather than rub, dry.

Stasis dermatitis
Provide dry skin care Assess for self- induced injury and a history of trauma. Assess for evidence of skin thinning and the presence of ulceration Teach person and significant others way of reducing and relieving pruritis and explain prescribed medication

 Teach ways to reduce edema (elevating the legs 30 degrees, wearing professionally fitted support hose, avoiding standing, crossing the legs and ankles and wearing shoes and clothing that are constricting).

Contact dermatitis
Take a thorough health history, including information about recent exposure to soap/ detergents, lotions, powders, toilet items, medications, ( oral, topical, OTC), solvents, chemicals, plants, new clothing, cosmetics, and fragrances.

 Until patch testing is completed, reduce exposure to suspected environmental allergens/ irritants. Patch testing may worsen the condition if performed during the acute stage of the dermatitis.

Knowledge deficit
Review identified allergens/irritants ,possible sources of allergen/ irritant contact, recognition of irritants/ allergens, ways to avoid and limit contact, and ways to relieve pruritis.

Sunburn
Reduce skin temperature and inflammation by applying cool tap water soaks or by cool tap water baths. Warn the person that it is too dangerous to become too cool ( hypothermia) is skin intact, apply an oil- in water moisturizing lotion.

 Assess skin for blistering. Apply cold sterile, normal saline soaks continuously to blisters. Apply nonadhering sterile dressing. Observe for bacterial infections. Soak and cool baths promote comfort. Provide teaching/ learning opportunities to view photo protection methods Advise person to avoid sun exposure until desquamation is resolved.

Furuncles and carbuncles

Hasten lesion maturation and relieve discomfort by applying warm compressions t.i.d. Prepare for incision when infection becomes localized and fluctuates when palpated. Obtain bacterial culture and sensitivity test. Provide teaching/learning opportunities.

Knowledge deficit regarding communicability of bacterial infection.

Teach the patient to change the dressings on an open draining furuncle/ carbuncle frequently, to dispose off dressing carefully and to wash hands Bath in antibacterial skin cleanser to use disposable razor and discard after each use. The persons linen should be washed thoroughly and separately from other linen.

Nail disorders
Onycholysis: nursing diagnosis: impaired skin integrity due to inflammation Intervention: take an appropriate culture of the nail to detect bacterial, viral or myocotic infection. Instruct the person about the prescribed treatment. Assess the persons history for trauma and / or chemical irritants.

Knowledge deficit regarding condition and its management.

Intervention.: provide teaching/ learning opportunities including(a) method of reducing trauma, e.g. clipping nails to reduce further separation (b) avoiding manicuring or self induced trauma. (c) limiting chemical irritants such as soap, cleansers, nail products. (d) keeping the nail dry, and if rubber gloves are used reduce maceration by lining them with thin cotton gloves.

Paronychia
Impaired skin integrity due to inflammation and bacterial and fungal infection. Intervention: apply warm soaks three times a day to reduce pressure and pain. Assist in incision and drainage of inflamed sites. Obtain appropriate cultures of purulent material. Teach the person about prescribe topical /or systemic antibiotic therapy, emphasizing need for compliance during treatment.

Unguis Incarnatus ( ingrown toe nails)

Impaired skin integrity due to local trauma and inflammation Intervention: warm soaks 20 several times a day. Assess for secondary bacterial infection.

 Explain postsurgical wound care. if nail potion is removed or clipped, keep a white petroleum impregnated cotton wick under the remaining nail edge. Teach the person to change wick daily.

Premalignant and malignant skin conditions

Basal cell epithelioma: impaired skin integrity due to cutaneous malignancy. Intervention: encourage prompt treatment to minimize local tissue destruction. Teach postoperative wound care.

Potential alteration in copying due to fear and malignancy

Intervention: explain that metastases seldom occur with this condition. Knowledge deficit regarding condition and its management Intervention: assess the history of sun exposure and evaluate the signs of skin damage. Review photo protection methods with the person and significant others.

Actinic Keratosis ( Solar Keratosis)

Potential skin integrity impairment due to chronic repetitious actinic damage. Intervention: assess all sun- exposed skin sites for actinic damage. A shave biopsy may be used to rule out malignancy in a suspicious lesion . Explain the treatment plan to the person and significant others.

Knowledge deficit regarding condition and its management.

Intervention; discuss the necessity for reassessment to detect early signs of skin damage. (b) need to avoid sun exposure, and (c ) methods of photo protection

Squamous cell carcinoma, Prickle cell carcinoma

Potential alteration in coping due to fear of malignancy and disfigurement. Intervention: discuss the impact of chronicity or malignancy, exacerbations, social isolation, depression, and coping mechanisms with the person and significant others. Feelings of anger and frustrations may be experienced and expressed to health professionals

 Help the individual and significant others to identify and expect realist treatment outcomes and to set realistic goals. Provide appropriate realistic goals. Recognize the complexity of the condition. Acknowledge expressed fears of reoccurrence or progressive worsening of the condition.

Malignant melanoma
Knowledge deficit regarding condition and its management : intervention: review the planned surgical procedure, discuss postoperative wound care, recognize that the extent of surgical intervention depends on the stage of the lesion. Additional treatment may include chemotherapy or immunotherapy

 Discuss the need for medical supervision and demographic assessment every three to six months. Prevention guidelines include (a) monthly self assessments scalp, trunk and intertriginous and genital areas to identify pigmented lesions, (b) seek medical follow up for any nevi changes, ( c) encourage blood related relatives to obtain demographic assessment (d) limit sun exposure and (e) perform photo protection measures.

The eye structure

Equipment
Ophthalmoscope, Snellens chart. Inspection: Sclera and iris: check for color Pupils: check for size, shape, symmetry, reactions to light and accommodation Eye movement; extra ocular movements. Eye naturally moves in conjugate fashion.

Cross visual fields

Confrontation: normally is full medially and laterally, superiorly and inferiorly in both eyes. Visual acuity: check with Snellens chart normal vision: 6/6 Myopia -- near sightedness and Hyperopia far sightedness.

Common disorders of eye and related structures.

Normal eyelid function is to(1) protect the eyes from foreign bodies, external injury, undue exposure, and excessive light, and (2) lubricate the eyeballs by distributing secretions over them, washing away dust and keeping the corneas moist and transparent.

Blepharitis (granulated eyelids)

Inflammation of the eyelid margin. Assessment reveals eyelid irritation, burning and itching. The eyelid margins appear redrimmed and have scales or granulations on them. Sometimes the eyelids margins are ulcerated and the eyelashes fall out.

Intervention
Removing scales from the eyelids daily with a damp cotton applicator followed by applying warm compression Cleaning the scalp, eyebrows and lid margins, Applying antibiotic or sulfonamide eye ointment daily to the lid margins to prevent buildup of the scales (preferably at night since ointment blurs vision).

Hordeolum (Stye)
Is the postular infection of the eyelash follicle or sebaceous gland on an eyelid margin (typically staphylococcal in origin). Assessment reveals a very painful red swelling on the eyelid margin. The intensity of pain relates to the amount of swelling. Common in all age groups. Begins with local irritation, redness and swelling and progresses to an acute tender abscess.

Intervention
Teaching the person not to squeeze at the lesion since this spreads the infection. Apply warm, moist compresses to hasten suppuration Compresses usually cause a stye to open and drain without surgery.

Virus infection
Herpes Zoster involving the eye typically has an unilateral trigeminal distribution. Skin lesion are deeper than those of herpes simplex. They are painful, can become secondarily infected, and often leave permanent scars.

Intervention
Ocular treatment is vigorous with mydriatic, antibiotic, and corticosteroid ointment. Keep skin lesions clean of infections and crusts by cleaning and applying antibiotic ointment and hot soaks.

Disorders of the Conjunctiva, Sclera, and Cornea

Conjunctivitis is the inflammation of the conjunctiva. Generally exogenous and results from bacterial or viral infection May result from endogenous inflammation, allergy, chemical irritations, and fungal or parasitic infections

Assessment
Redness, swelling and lacrimation Pain occurs if cornea is involved. If conjunctivitis is associated with allergy, itching occurs Eye discharge varies in amount and nature depending on the causative organism. Ask if eyelids stick together when waking.

Intervention
With corneal involvement, photophobia may occur and dark glasses are required. Specific antibacterial medications (local and systemic) Eye irrigations Hot moist compressions Eye drops or ointments

 Corticosteroids are contraindicated in infectious conjunctivitis since they reduce the ocular resistance to bacteria. Eye patches are also contraindicated since covering an eye that has surface bacterial infection promotes bacterial growth. Allergic conjunctivitis can be treated with topical decongestants, steroids or nonsteroidal agent such as 4 % cromolyn sodium

Trachoma
a chronic infectious disease of the conjunctiva and cornea caused by Chlamydia trachomatis. Is caused by direct contact and is very communicable If untreated leads to blindness Trachoma responds well to local and systemic sulfonamides or local antibiotics (tetracycline or erythromycin). Personal cleaniness is essential

Increased intraocular pressure: Glaucoma

Assessment reveals red eye, steamy cornea, shallow interior chamber, turbid aqueous, greatly elevated IOP and moderately dilated nonreactive pupil. The person typically experiences blurred vision, halos around lights, or a rapid loss of vision.

Intervention
To control nausea and relieve the intense pain. The pain tends to subside once the IOP is reduced. A peripheral iridectomy is the surgical procedure of choice when the acute episode is relieved.

Postoperative intervention
Dilation of pupils with cycloplegic drugs to prevent posterior synechiae and steroid drugs to decrease inflammation. Immediate ambulation is usual. Eye patch is not required , though a shield is used to protect the eye.

Lens Opacity (cataract)

Cataract surgery is the only available treatment. The cloudy lens is removed

Disorders of the nose

Epistaxis: assessment: bleeding usually apparent however person often swallows blood making assessment of degree of blood difficult Nausea secondary to swallowing blood. Hypotension or frank shock if bleeding prolonged or severe. Site of bleeding may be anterior or posterior localization of bleeding site may be difficult.

Intervention
Position patient sitting up unless hypotensive pinch nostrils together to apply pressure Obtain postural vital signs Order hemotocrit or hemoglobin if bleeding is significant Locally applied vasoconstrictors e.g. cocaine or epinephrine are often used to control bleeding , silver nitrate is used occasionally, xylocaine nasal spray

Cont
Nasal packing with non adherent gauze Provide mouth care Provide reassurance Learning / teaching: techniques for homeostasis Follow up care Humidification and application of water soluble lubricant Indication of airway obstruction

 Group A: External ear disorders: deformities, foreign bodies, impacted cerumen (ear wax) , external otitis, furunculosis, malignant tumors, ear drum perforation, Group b: Internal ear disorders: otitis media, otosclerosis, Aural surgical procedures: Rehabilitation for hearing impaired people

Disorders of the ear

 Group c : rhinitis, (common cold), allergic rhinitis, nasal polyps, epistaxis Group D: sinusitis, assessment and intervention Group e: swallowing disorders (Dysphagia), esophageal disorders Group F : achalasia, esophagitis, Group G: hiatus hernia and esophageal cancer Group H: tonsillitis, thyroid and parathyroid disorders Prepare assessment, nursing diagnosis and intervention for you group work

Nasal and sinus disorders

Ear, nose and throat disorders

Prepare assessment, nursing diagnosis and intervention for you group work