Integumentary Function



Integumentary Function


Sabrina Friedman, MSN, PhD, EdD, FNP, CNS



Learning Objectives


On completion of this chapter, the reader will be able to:


1. Discuss the primary functions of the integumentary system.


2. Identify normal age-related skin changes.


3. Discuss four common skin problems and conditions experienced by older adults and their associated nursing implications.


4. Describe three types of skin cancer that affect older adults.


5. Differentiate between the three types of lower leg ulcers.


6. Describe the risk factors for pressure ulcer development.


7. Identify five pressure ulcer preventive strategies endorsed by the Agency for Healthcare Research and Quality (AHRQ) clinical guidelines.


8. State three principles necessary for successful wound healing.


9. Conduct an assessment for a client with impaired skin integrity.


10. Determine when to appropriately use antiseptics.


11. Discuss six types of dressings, including indications, contraindications, advantages, and drawbacks.



The skin is the protective outer covering of the body. The skin, hair, nails, and glands make up what is called the integumentary system. The integumentary system is the largest organ of the body. The primary function of the skin is to serve as a barrier against harmful bacteria and other threatening agents, which makes the skin the first line of defense for the immune system. Other major functions of the integumentary system include (1) preventing fluid loss or dehydration, (2) protecting the body from ultraviolet (UV) rays and other external environmental hazards, and (3) protecting underlying organs from injury. In addition, the skin provides thermal regulation of body temperature. Radiation, conduction, convection, and evaporation are facilitated by sensory perceptions that occur in the skin’s nerve endings. Blood vessels in the skin assist in regulating blood pressure because of the amount of blood that can be stored within the system. The integumentary system also reveals emotions such as anger, fear, or embarrassment through vasodilatation, which reddens the skin tissue. In the presence of the sun’s UV rays, the skin synthesizes vitamin D, which is then used by other parts of the body. Subcutaneous fat, the deepest layer of the integumentary system, provides insulation and acts as a caloric reservoir. Hair serves as body insulation and provides unique physical characteristics by virtue of its varying textures, shades, patterns, and colors.


A careful and thorough assessment of the integumentary system is essential when a physical assessment is performed on a patient. Skin assessment can help determine hydration status, potential for or actual infection, and other information about the individual (e.g., sun exposure, attention to personal appearance, and scars). Palpation of the skin can identify tender areas, nodules, and masses (see Assessments in Chapter 4).


The value of the integumentary system is demonstrated by the high morbidity and mortality rates associated with extensive burns when all functions of the skin are greatly compromised. The overall state of health is affected by physical or emotional insults to this system, such as loss of thermal regulation or fluid, impaired barrier protection, and other catastrophic changes in physical appearance and functioning. The integumentary system provides valuable information for comprehending its complexities.



Age-Related Changes in Skin Structure and Function


The integumentary system reflects the normal aging process, which includes graying hair, increased number and depth of wrinkles, loss of elasticity, and discoloration and thickening of the nails. Box 30–1 describes basic age-related skin changes.



BOX 30-1   AGE-RELATED SKIN CHANGES





Epidermis


The epidermis is the outermost layer of the skin. The replacement rate of the stratum corneum, the first layer of epidermis, declines by 50% as a person ages. This decline results in slower healing, reduced barrier protection, and delayed absorption of medications and chemicals placed on the skin. The area of contact between the epidermis and dermis decreases with age, which results in easy separation of these layers. Therefore skin tears occur from harmless activities such as removing a bandage or pulling an older client up in the bed. Bruising occurs more easily as a result of these age-related skin changes. A thinner epidermis allows more moisture to escape and may compound previously existing skin problems. The number of melanocytes, which provide pigment and hair color, decreases with age, giving older adults less protection from UV rays, paler skin, and graying hair. Melanocytes also produce uneven pigmentation, causing the development of lentigines, also known as “age spots” or “liver spots.”





Appendages


With aging, fewer eccrine glands (sweat glands of the palms, feet, and forehead) and apocrine sweat glands (sweat glands of the axilla, scalp, face, and genital areas) exist, resulting in decreased body odor and reduced evaporative heat loss because of decreased sweating. There is less need for antiperspirants and deodorants. However, older adults are at greater risk of heat stroke as a result of a compromised cooling mechanism. Older adults should avoid heat exposure over long periods and in areas of high humidity. Hats with wide brims and cool, light, breezy clothing should be worn when outdoors. It is important that older adults drink extra fluid (minimum of 2000 mL/day, unless contraindicated by a medical condition, such as renal failure or congestive heart failure) to maintain adequate hydration (Ebersole, Touhy, Hess, et al, 2008).


Sebum oils the skin and provides an antimicrobial property. The sebaceous glands and pores become larger with aging. Nevertheless, many older adults experience dry skin, which places them at a greater risk of infection as a result of an impaired immune response.


Hair thins, and its growth declines. A progressive loss of melanin occurs, resulting in graying of the hair. Heredity influences when this graying process begins. Older women may have increased lip and chin hair while experiencing a thinning of hair on the head, axilla, and perineal area. Men lose scalp and beard hair yet experience increased growth over eyebrows and in ears and nostrils. The increased hair in ears predisposes men to cerumen impaction, which leads to impaired hearing (see Chapter 31). Changes in patterns of hair growth and distribution as a person ages are thought to be hormone related. Nails grow more slowly with age and become thicker, brittle, and dull and also develop longitudinal striation with ridges (Ebersole et al, 2008). These changes can affect a person’s body image and self-concept (see Cultural Awareness Box).



Common Problems and Conditions


Benign Skin Growths


Cherry Angiomas


Cherry angiomas are common, bright red, 1-to 5-mm superficial vascular lesions that begin around age 30 and increase in number with age. The cause of these lesions is unknown. They are red or deep purple dome shaped papules. Although they are most commonly found on the trunk, they can be located anywhere on the body and vary in number. Because cherry angiomas are new growths, clients are often concerned that they are malignant or indicate a serious health problem. Clients need to be reassured that cherry angiomas are benign growths resulting from increased vascularity in the dermis and occur in most people.



image CULTURAL AWARENESS


Biocultural Variations in Integumentary System During Health and Illness


Normal skin color ranges vary, and health care practitioners have attempted to describe the variations seen by labeling observations with some of the following adjectives: copper, olive, tan, and various shades of brown (light, medium, dark). The term ashen is sometimes used to describe pallor.




Cyanosis


Cyanosis is the most difficult clinical sign to observe in darkly pigmented people. Because peripheral vasoconstriction can prevent cyanosis, environmental conditions such as air conditioning, mist tents, and other factors that may lower the room temperature should be noted. For an older adult to manifest clinical evidence of cyanosis, the blood must contain 5 g of reduced hemoglobin in 1.5 g of methemoglobin per 1 dL of blood.


Given that most conditions causing cyanosis also cause decreased oxygenation of the brain, other clinical symptoms, such as changes in level of consciousness, are evident. Cyanosis usually is accompanied by an increased respiratory rate, the use of accessory muscles of respiration, nasal flaring, and other manifestations of respiratory distress. When assessing people of Mediterranean descent, the nurse should be aware that the circumoral region is normally dark blue.



Jaundice


In both light- and dark-skinned clients, jaundice is best observed in the sclera. Many darkly pigmented people (e.g., blacks and Filipino Americans) have heavy deposits of subconjunctival fat that contain high levels of carotene in sufficient quantities to mimic jaundice. The fatty deposits become denser as the distance from the cornea increases. The portion of the sclera that is revealed naturally by the palpebral fissure is the best place to assess color accurately. If the palate does not have heavy melanin pigmentation, jaundice can be detected there in the early stages (i.e., when serum bilirubin is 2 to 4 mg/dL). The absence of a yellowish tint of the palate when the sclera are yellow indicates carotene pigmentation of the sclera rather than jaundice. Light or clay-colored stools and dark golden urine often accompany jaundice in both light-and dark-skinned clients.



Pallor


When assessing for pallor in darkly pigmented older adults, the nurse may experience difficulty because the underlying red tones that give brown or black skin its luster are absent. The brown-skinned individual manifests pallor with a more yellowish brown color and the black-skinned person appears ashen or gray. Generalized pallor can be observed in the mucous membranes, lips, and nail beds. The palpebral conjunctiva and nail beds are preferred sites for assessing the pallor of anemia. When inspecting the conjunctiva, the nurse should lower the lid sufficiently to visualize the conjunctiva near both the outer canthus and the inner canthus. The coloration is often lighter near the inner canthus.


In addition to changes in skin color, the pallor of impending shock is accompanied by other clinical manifestations such as increasing pulse rate, oliguria, apprehension, and restlessness. Anemias, particularly chronic iron deficiency anemia, may be apparent by the characteristic “spoon” nails, which have a concave shape. A lemon-yellow tint of the face and slightly yellow sclera accompany pernicious anemia, which is also manifested by neurologic deficits and a red, painful tongue. The nurse will also note the following symptoms in the presence of most severe anemias: fatigue, exertional dyspnea, rapid pulse, dizziness, and impaired mental function.



Erythema


Erythema (redness) is commonly associated with localized inflammation and is characterized by increased skin temperature. When assessing inflammation in dark-skinned clients, it is often necessary to palpate the skin for increased warmth, tautness, or tightly pulled surfaces that may indicate edema and hardening of deep tissues or blood vessels.


The erythema associated with rashes is not always accompanied by noticeable increases in skin temperature. Macular, papular, and vesicular skin lesions are identified by a combination of palpation and inspection, combined with the client’s description of symptoms. For example, people with macular rashes usually complain of itching, and evidence of scratching will be apparent. When the skin is only moderately pigmented, a macular rash may become recognizable if the skin is gently stretched. Stretching the skin decreases the normal red tone, thus providing more contrast and making the macules appear brighter. In some skin disorders with generalized rash, the hard and soft palates are the locations where the rash is most readily visible.


The increased redness that accompanies carbon monoxide poisoning and the blood disorders collectively known as the polycythemias can be observed in the lips of dark-skinned clients. Because lipstick masks the actual color of the lips, older adult women should be asked to remove it with a tissue.



Petechiae


In dark-skinned clients petechiae are best visualized in the areas of lighter melanization such as the abdomen, buttocks, and volar surface of the forearm. When the skin is black or very dark brown, petechiae cannot be seen. Most of the diseases that cause bleeding and microembolus formation, such as thrombocytopenia, subacute bacterial endocarditis, and other septicemias, are characterized by the presence of petechiae in the mucous membranes and skin. Petechiae are most easily visualized in the mouth, particularly the buccal mucosa, and in the conjunctiva of the eye.


Ecchymotic lesions caused by systemic disorders are found in the same locations as petechiae, although their larger size makes them more apparent on dark-skinned individuals. When differentiating petechiae and ecchymosis from erythema in the mucous membrane, the nurse should note that pressure on the tissue momentarily blanches erythema but not petechiae or ecchymosis.



Seborrheic Keratoses


Seborrheic keratoses are benign lesions more commonly seen in the older adult. These are scaly growths that have a “stuck-on,” crumbly appearance that varies in color from tan to brown to black. The lesions may be elevated and range in diameter from 2 to 3 mm. Characterized by slow growth, these lesions begin to appear later in life. The borders may be round and smooth or irregular and notched. To the untrained eye, these lesions can resemble a malignant melanoma, particularly when dark brown or black. They have a greasy feeling and often occur in sun-exposed areas (face, neck, or trunk) but can appear anywhere on the body. In an Australian study of the relationship between sun exposure and the prevalence of seborrheic keratoses, the median number of lesions in those who had them increased with age from 6 per person among 15- to 25-year-olds to 69 per person in those older than 75 years of age. The growths are usually removed for cosmetic reasons (often related to self-esteem) or if irritated. If the lesion is “picked off,” it will recur. Therefore it is best to have a physician remove the growth if it is bothersome to a client. Cryotherapy is effective, and the lesion usually sloughs off in a few weeks. Clients should be reassured that the growths are benign and are a commonly occurring skin manifestation.




Inflammatory Dermatoses


Seborrheic Dermatitis


Seborrheic dermatitis is a common, chronic inflammation of the skin. The scalp, ear canals, eyebrows, eyelashes, nasolabial folds, axilla, breasts, chest, and groin are common sites. It is more common in clients who have Parkinson’s disease or who have suffered a stroke.


In differentiating between dandruff and seborrheic dermatitis, note that dandruff is scaling without inflammation, and seborrheic dermatitis is an inflammatory response sometimes associated with scaling. With inadequate management, dandruff can evolve into seborrheic dermatitis. Seborrheic dermatitis appears as a white or yellow scale with a plaquelike appearance. An erythematous red base, indicating an inflammatory process, is always present. Mild itching is not uncommon. The usual pattern of distribution begins with the scalp and moves down toward the eyebrows, progressing to the chest with a bilateral, symmetric presentation.




Psoriasis


Psoriasis is an autoimmune condition that affects 2% to 5% of the world’s population and approximately 2.6% of the United States population (Aldredge, 2009). The condition may affect persons of any age, although it often begins during early adulthood. Psoriasis is sometimes associated with other diseases such as arthritis, myopathy, enteropathy, spondylitic heart disease, and acquired immunodeficiency syndrome (AIDS). Approximately one third of patients with psoriasis have a first-degree relative affected by the disease; those developing the disease before age 40 have a stronger genetic component (Aldredge, 2009). Once psoriasis begins, there are periods of remission and relapse with varying degrees of intensity. There is no known cure.


Clinically, psoriatic lesions are typically seen as well-circumscribed, pink plaques covered with silver-white, loosely adherent scales. These scaly plaques result from the accelerated replication of the dermis and epidermis over certain parts of the body. Psoriasis frequently affects the skin of the elbows, knees, scalp, lumbosacral areas, intergluteal cleft, and glans penis. Changes in the nails occur in approximately 30% of clients and consist of yellow-brown discoloration with pitting, dimpling, separation of the nail plate from the underlying bed (oncolysis), thickening, and crumbling. Psoriasis is a reactive disorder. Triggers such as infection, smoking, climate, and hormonal factors may exacerbate an attack; other factors such as sunlight may decrease the severity of an attack.


Psoriasis can be a cause of a total body erythema and scaling termed erythroderma. Another variant of psoriasis is the pustular type, which manifests as multiple small pustules forming the erythematous plaques. Pustular psoriasis may be benign and localized or life-threatening and generalized. In the more generalized form, the client will also have fever, leukocytosis, arthralgias, diffuse cutaneous and mucosal pustules, secondary infection, and electrolyte disturbances.



Nursing Management


image Assessment


Nursing assessment consists of recognizing the inflammatory dermatitis and noting its location, degree of erythema, itching, and scaling. The dermatitis should be examined for an erythematous base with yellow, white, or silvery scales or plaques. The nurse should inquire about itching, usual hygienic habits, and steps the client has taken to control the scaly, erythematous dermatitis. Bedbound individuals are more prone to develop seborrheic dermatitis; therefore targeting these clients for assessment, in addition to thorough cleansing of scalp, hair, and skin, is a preventive strategy.





image Intervention


One crucial aspect of nursing management is to ensure proper use of an antiseborrheic shampoo containing zinc pyrithione, selenium sulfide, or ketoconazole. One successful strategy is to wet the hair, chest, axilla, and affected areas, apply selenium shampoo, and then proceed with the rest of the bath or shower. After cleansing the affected areas, the client should apply hydrocortisone 1% cream or another prescribed steroid cream, which decreases the inflammation and irritated red appearance of the skin. Low-dose steroid creams or the newer nonsteroidal cream, such as pimecrolimus cream (Elidel), must be used on the face to prevent scarring, atrophy, or acne. After inflammation and scaling have resolved, the client should continue using selenium shampoo on the scalp twice weekly as preventive maintenance therapy.


Nursing interventions for a client with psoriasis consist of reinforcing the directions of the physician or advanced practice nurse (APN) to optimize treatment and identify client-specific triggers that may be avoided to decrease the severity of flare episodes. Because psoriasis varies in type and severity, treatment plans may use both prescription and over-the-counter topical ointments. As with seborrheic dermatitis, a common therapy used to treat psoriasis is a topical steroid. Topical steroids may be over-the-counter or prescription strength and are not recommended for use on the face. Coal tar has been used topically for many years to relieve the itching and scaling in minor cases of psoriasis. These compounds are messy and can make the skin more sensitive to UV rays and sunlight. A topical vitamin D3 ointment, calcipotriene skin ointment (Dovonex), is used for moderate cases of psoriasis. It is available by prescription only and has few known side effects. Calcipotriene ointment should not be used on the face, and photosensitivity is likely. Tazarotene (Tazorac) is a retinoid, a group of drugs related to vitamin A. It should be applied only to the affected areas, and contact should be avoided with the eyes, eyelids, and mouth. Because the medication may result in photosensitivity, exposure to sunlight should be avoided.


Light therapy using ultraviolet B (UVB) rays has been shown to be beneficial when used in prescription light boxes. It is currently thought that ultraviolet A (UVA) light therapy used in combination with psoralen (an oral or topical medication) is the preferred method (called PUVA). The UV dosage is carefully monitored for the amount of exposure because there is a limit on the total exposure time. With UVA light therapy, it is important to be aware of the potential risk of developing skin cancer. A number of reports suggest that foods may trigger psoriasis attacks; therefore approaches to diet modification and other homeopathic remedies abound in client resource literature. Clients should be encouraged to discuss with their health care team any and all remedies used. The nurse should teach the older adult client, family members, and staff the causes of inflammatory dermatitis to alleviate anxiety and misconceptions. An explanation of treatment measures and the importance of follow-through will increase compliance and involvement in care. Symptom management is an area where nurses can have a positive effect on an older adult’s quality of life.




Pruritus


Pruritus is another term for itching that is so intense it causes the client to scratch. The most common cause of itching is dry skin, or xerosis. The mechanism of itching is not fully understood, but histamine is a known mediator of pruritus. Itching can be precipitated by heat, sudden temperature changes, sweating, clothing, cleaning products such as soap, fatigue, and emotional stress, and it can be more severe in the winter (Ebersole et al, 2008). Pruritus can be related either to a skin disorder or systemic disease; therefore the complaint should not be dismissed and warrants a complete assessment (Box 30–2). Pruritus can occur with other dermatologic conditions, and systemic disorders such as liver, renal, hematologic, and thyroid conditions.



BOX 30–2   POSSIBLE SOURCES OF PRURITUS


Skin Disorders







Modified from Bernhard JD. In Moschella SL, Hurley HJ, editors: Dermatology, ed 3, Philadelphia, 1992, WB Saunders; Ebersole P, Touhy T, Hess P, et al: Toward healthy aging: human needs and nursing response, ed 8, St Louis, 2008, Mosby.



Nursing Management


image Assessment


A full skin assessment is warranted when a client complains of pruritus. The client is interviewed to determine the location, intensity, and onset of itching. The nurse should inquire about any patterns of behavior that precipitate itching (e.g., anxiety, environmental exposures, friction [rubbing the skin with a towel]) and obtain information about bathing practices and kinds of soaps, detergents, and skin products used. The nurse should also look for rashes, vesicles, scaling, and erythema; any of these suggests a skin disorder.





image Intervention


Nursing interventions are influenced by the cause of the pruritus. If dry, scaly skin (xerosis) is present with no lesions or erythema, the nurse should suggest that the client apply emollients (e.g., Lubriderm, Moisturel, or Eucerin lotion or cream), which have more lanolin or oily substances than many commercial lotions. Emollients should be applied at least twice daily and immediately after bathing to trap moisture. The client should gently pat the skin dry and avoid brisk drying with a towel. If the client is unable to apply lotion, the nurse should instruct the caregiver in its use. The client should decrease the frequency of baths to a maximum of every other day (see Client/Family Teaching Box). Antihistamines may be needed to relieve itching and to prevent tissue breakdown from scratching but are to be used with caution because of adverse effects in the elderly.



image CLIENT/FAMILY TEACHING


Prevention and Treatment of Dry Skin (Xerosis)




Bathing or showering with warm water should not exceed a frequency of every other day. Pat skin dry to avoid irritation. In the winter, when the air is drier, one bath or shower a week is sufficient, with a daily sponge bath to underarms, perineal area, and skin folds.


Bath oil can be used in a basin when sponge bathing but not in the tub or shower. To avoid risk of slipping in the tub or shower, apply oil after bathing.


Avoid the use of harsh soaps (e.g., Zest, Ivory, Dial); instead use a superfatted soap (e.g., Dove, Basis, Tone, Cetaphil) in limited quantities with only one lathering.


Use heavy emollient lotions or creams containing urea or lactic acid (e.g., Lubriderm, Nivea, Eucerin, Aveeno) after bathing when skin is moist. Mineral oil, petroleum jelly, and shortening are less expensive alternatives.


Never use alcohol or other drying rubs on skin because these deplete natural skin oils.


Drink at least 1500 to 2500 mL of water a day to ensure adequate hydration, if not contraindicated by other medical conditions (e.g., CHF).


Avoid tight-fitting clothes that rub against the skin.


Modified from Davis C. In Carnevali DL, Patrick M, editors: Nursing management for the elderly, ed 3, Philadelphia, 1993, JB Lippincott; Ebersole P, Touhy T, Hess P, et al: Toward healthy aging: human needs and nursing response, ed 7, St Louis, 2008, Mosby.


A diagnostic workup may be conducted to identify any systemic cause for persistent pruritus (e.g., cancer or diabetes). Anxiety or stress may be the source of itching. If so, the nurse should assess the client’s self-esteem and coping strategies and identify any family or role strain or other factors that may lead to anxiety. He or she should also discuss stress management strategies and assist the client in determining effective ones. A referral to a community agency or professional such as an APN, psychologist, or psychiatrist may be needed for continued support and guidance.


The older adult client, family members, and staff need to be taught the management of pruritus and the need to prevent skin trauma from scratching. Treatment measures should also be explained to increase compliance and involvement in care. The causes of pruritus may be difficult to determine, and the expected effects of topical agents may be diminished as a result of the delayed absorption of medications placed on aging skin.




Candidiasis


Candidiasis is an inflammatory process of the epidermis caused by the yeastlike fungus Candida albicans. C. albicans is a normally occurring flora in the mouth, vagina, and gut (moist habitats). Pregnancy, oral contraception, antibiotics, diabetes, topical and inhalant steroids, skin maceration, and immunocompromised conditions create an environment that fosters the development of yeast infections such as candidiasis. Candidiasis is most commonly seen in diaper-clad infants, incontinent clients, and bedbound individuals and in moisture-prone areas of the body (e.g., skin folds and axillae).


Candidiasis is characterized by erythematous, denuded, or raw skin usually surrounded by satellite papules or pustules. Satellite lesions are a helpful diagnostic clue. Red, erythematous areas on the buttocks, perineum, or intertriginous areas of incontinent clients also have diagnostic significance. Scaling may also be present, usually at the borders.



Nursing Management


image Assessment


Nursing assessment includes inspection of the skin, particularly under any fat folds, where moisture will accumulate. A hallmark of candidiasis is a bright red erythema with satellite papules or pustules. Any breaks in the skin, which place the client at greater risk for infection or further breakdown, should be noted. The client may be the one to alert the nurse to the infection. The nurse should conduct a medication assessment to identify any medications that may have precipitated this fungal infection, such as antibiotics or steroids. If the client has diabetes, hyperglycemia may be present; therefore the nurse should conduct a diet assessment to evaluate compliance and should check the blood sugar level. For some individuals with type 2 diabetes, a candidiasis infection may be the first clinical manifestation of hyperglycemia. Therefore a thorough health history is warranted when a candidiasis infection is present.





image Intervention


The main nursing intervention is keeping the skin dry, especially the intertriginous areas. A client’s discomfort, costs, and nursing time can be minimized through preventive strategies such as drying the skin well (particularly the skin folds) after bathing or sweating episodes and changing the sheets as soon as possible after an incontinent episode. After changing linens, the nurse should cleanse and dry the skin well and apply a zinc-based cream (such as Desitin) to the buttocks and perineal area. Cornstarch or powder, whether medicated or scented, is not recommended because of clumping and hence limited long-term skin protection. Creams are much more effective and efficient.


The nurse should teach the older adult client, family members, and support staff to pat the skin dry; the nurse should also educate the staff and provide the scientific rationale for changing linen, cleansing the affected area, and using a moisture barrier such as zinc oxide or Desitin. The importance of prompt delivery of care after an incontinent event must be stressed. It is important to keep topical antifungal agents on the infected area until healing is complete, which may take 2 to 3 weeks. If the yeast infection does not improve, the physician or advanced practice nurse (APN) should be informed so that an alternative agent can be considered.


Management protocols can be developed and approved by the employee’s institution and medical and nursing staff with the intent of empowering the professional nurse to act immediately when candidiasis is present. This promotes high-quality care, client comfort, a sense of professional pride, and a team approach. Nursing management is key in resolving a candidiasis infection.




Herpes Zoster (Shingles)


Herpes zoster, also known as shingles, is caused by the reactivation of latent varicella zoster (chickenpox) virus. The virus remains in the dorsal nerve endings after an episode of chickenpox, which is usually experienced in childhood. The main reason for recurrence is an immune system deficiency. Conditions that may impair the immune system are advanced age, stress or emotional upset, fatigue, or radiotherapy. An immunocompromised state caused by disease (e.g., human immunodeficiency virus, lymphoma, leukemia, and other malignancies) or drugs (e.g., chemotherapy and steroids) can also activate the latent virus. Chickenpox is highly contagious because it is an airborne virus. Herpes zoster is not as infectious because it is related to reactivation of latent varicella zoster. Therefore it is not necessary to isolate a client with herpes zoster. Cases of contracting shingles after personal exposure have been reported, but these have been in individuals who have not had chickenpox. Consequently, clients with herpes zoster should be cared for only by health care personnel who have had chickenpox or have positive serum varicella titers (Habif, 2004). As always, universal precautions should be exercised.


Approximately 50% of herpes zoster cases involve the thoracic region, 15% involve the cranial dermatomes, and 10% affect the cervical and lumbar regions. Ophthalmic herpes zoster is referred to an ophthalmologist for evaluation and treatment because blindness could result from corneal scarring.


Herpes zoster often has prodromal symptoms of tingling, hyperesthesia, tenderness, and burning or itching pain along the affected dermatome. The prodromal symptoms are followed by vesicles with an erythematous base occurring within 3 to 5 days. A unilateral, bandlike, erythematous, maculopapular rash first occurs along the involved dermatome and rarely crosses the midline of the body. The rash develops into clustered vesicles (usually on an erythematous base) that become purulent, rupture, and crust. These vesicles are vulnerable to secondary bacterial infections. Some lesions become necrotic or hemorrhagic. This occurs more often in older adults. It may take up to 1 month for the crusting lesions to heal; mild cases resolve in 7 to 10 days. The average duration for herpes zoster is 3 weeks. Scarring and permanent or temporary pigment discoloration may occur, especially in severe cases. Lymphadenopathy and an occasional temperature elevation are not uncommon. Postinfection paresthesias and meningoencephalitis may occur for 2 to 4 weeks when motor neurons and the central nervous system (CNS) are involved (Habif, 2004).


The incidence of herpes zoster increases with age, most likely as a consequence of diminishing immune function. The older adult is also at a greater risk of developing postherpetic segmental pain. Dissemination is often seen in older adults or immunosuppressed clients. Disseminated herpes zoster, which is rare and occurs in only 2% to 5% of clients, is more serious because of its systemic nature. In disseminated herpes zoster, satellite lesions appear outside the affected dermatome within 4 to 6 days after the initial eruption. Dissemination may be associated with fever, lymphadenopathy, headache, neck rigidity, and an increased risk of serious complications such as encephalitis, hepatitis, and pneumonitis. Disseminated herpes zoster may occur in as many as 15% to 50% of clients with active Hodgkin’s disease, and 10% to 25% of these clients die (Habif, 2004).


One of the major complications from this acute viral infection is postherpetic neuralgia, which is pain that persists along the affected dermatome after resolution of vesicular lesions. Postherpetic neuralgia can last less than 1 year, but it may last a lifetime with little pain relief. It affects approximately 33% of clients age 40 or older, and by age 70 the risk increases to 74%. Postherpetic neuralgia is more common in persons with trigeminal nerve involvement (Habif, 2004).



Nursing Management


image Assessment


Nursing assessment begins with interviewing the client to identify prodromal symptoms, such as burning, itching, or tingling along a dermatome before rash development. The nurse should obtain a pertinent health history that addresses chickenpox history, medications, diabetes, malignancy with recent chemotherapy or radiotherapy, and AIDS and other immunocompromised states. The nurse should also identify persons with whom the client has had close physical contact who have not had chickenpox or the chickenpox vaccine because they may be at risk of infection. He or she should inspect the area of discomfort for the characteristic unilateral, bandlike, erythematous, maculopapular rash that may have clustered vesicles. Initially, the area may be a raised, erythematous rash before the vesicles appear. Intense pain is often associated with the rash, particularly in older adults. On the basis of the lesions and prescribed treatments, the nurse must determine the effect on the client’s mobility and capacity for activities of daily living. Recommended treatment measures may require the assistance of another person.




image Planning and Expected Outcomes


The goals of nursing management are pain relief and the prevention of secondary infection and scarring. Local skin care treatments may need to be taught to the client or caregiver. The nurse must be alert to the possibility of long-term pain (postherpetic neuralgia) and the resulting depression that can occur. Expected outcomes include



1. Skin lesions will remain free from necrotic tissue and infection.


2. The client will experience adequate periods of restful sleep, as evidenced by



3. The client will obtain adequate pain relief, as evidenced by



4. The client will demonstrate increased knowledge of his or her condition, as evidenced by




image Intervention


Nursing interventions consist of notifying the physician or APN as soon as the characteristic rash and vesicles are identified, especially if they follow a dermatomal pattern. After a diagnosis is made, follow-through with medical and nursing management is paramount to client comfort. Lesions should be monitored closely for the development of secondary bacterial infections, as evidenced by erythema, tenderness, or a purulent discharge. If satellite lesions develop outside the dermatome, especially if the client is also experiencing headaches, neck rigidity, or pulmonary congestion, the physician or APN must be notified immediately because this is indicative of disseminated herpes zoster.


The nurse should teach the older adult client, family members, and staff the cause of shingles so that anxiety and misconceptions can be alleviated, and he or she should explain the treatment measures to increase compliance and involvement in care. Herpes zoster can be very painful, so prompt administration of pain medications is crucial for client comfort. For optimum pain control, clients should be instructed to inform the nurse when they experience the initial onset of pain, before the pain becomes well entrenched. Effective pain management is one area in which nurses can have a positive effect on a client’s quality of life (see Chapter 15). If postherpetic neuralgia occurs, antidepressants are used as adjuncts to analgesics for control of pain.



image Evaluation


Evaluation of interventions focuses on pain control, with documented results of analgesics and adjunct therapies, and on prevention of secondary infection by frequent monitoring of the site. Many barriers to effective pain management in older adults exist, leading to frequent underrecognition and undertreatment of pain (see Chapter 15). If pain is not relieved, the physician or APN should be consulted to obtain an alternative analgesic agent or adjunct drug therapy. The inflammatory response in an older adult may be diminished, even in the presence of severe infection, so the nurse should be alert to even slight symptoms of a secondary bacterial infection. If evidence of cellulitis is noted, the physician or APN should be informed to implement topical or oral antibiotic therapy. Documentation of assessment, the response to treatment measures, client comprehension of teaching, and other nursing interventions demonstrates nursing accountability (see the Nursing Care Plan: Herpes Zoster).



Premalignant Skin Growths: Actinic Keratosis


Actinic keratosis is a premalignant lesion of the epidermis that is caused by long-term exposure to UV rays. This precancerous lesion is more common in individuals with light complexions and occurs most commonly on the dorsum of the hands, scalp, outer ears, face, and lower arms. Actinic keratosis may evolve into squamous cell carcinoma (SCC) if not treated, so it should receive prompt attention (Habif, 2004).


Actinic keratosis begins in vascular areas as a reddish macule or papule that has a rough, yellowish brown scale that may itch or cause discomfort. During assessment the nurse should be attuned to the rough surface of the lesion and its location and be particularly alert if a suspicious lesion is on a sun-exposed area. Accumulation of keratin can also lead to the formation of a cutaneous horn that tends to develop on the outer ear. Because of an abundant vascular supply, removal of the crust may cause bleeding. Induration, inflammation, or oozing may be indicative of malignancy and merit prompt referral (Habif, 2004).



image NURSING CARE PLAN


Herpes Zoster



Clinical Situation


Mrs. K. is a 69-year-old woman who lives in her own home. She has severe rheumatoid arthritis and hypertension. She takes methotrexate, prednisone, lisinopril, and hydrochlorothiazide. She has had both hips replaced in the past 5 years.


Mrs. K. began to experience a burning with pain 2 days ago and this morning awoke with clustered vesicles on the left side of her torso extending from the midback around to the midline of the anterior aspect of her chest. She went in to see her primary care physician. The physician ordered acyclovir, analgesics as needed for pain, and a topical antibiotic to prevent secondary infection.





image INTERVENTIONS




Instruct the client not to scratch or rub the affected area so as not to break vesicles, which would increase the risk of secondary infection.


Assess vital signs, mental status, and skin lesions every shift to identify signs of infection (e.g., fever, tachycardia, erythema, tenderness, purulent discharge, and confusion).


If the client is febrile, ensure adequate hydration because a fever increases hydration needs.


Tachycardia could precipitate congestive heart failure (CHF) from decreased cardiac output; monitor for shortness of breath, rales, edema, and other signs of cardiovascular compromise.


If vesicle lesions rupture, implement topical treatment, noting the response.


Ensure adequate nutrition to foster healing.


Monitor food intake, and ensure food preferences are being met.


Teach the client the need to eat at least 2000 calories and drink a minimum of 1500 mL of liquid per day.


Be alert for vesicles outside of the involved dermatome, which could indicate disseminated herpes zoster; if vesicles appear, contact the physician or nurse practitioner immediately.


Teach the client, staff, and visitors the value of hand washing and proper disposal of dressing and treatment material as an infection control standard.


Identify staff and visitors who have no known history of chickenpox or vaccine and inform them that they are not able to provide care for the client because they may not have immunity to the varicella virus; isolation is not required; the infection control strategy is to take universal precautions.



Nursing Management


image Assessment


Nursing assessment begins with the client interview to determine risk factors, such as the frequency of activities with sun exposure and the use of preventive practices (e.g., wearing a hat and long sleeves while outside). The skin should be inspected and any rough lesions palpated and noted for location and texture. If hand lotion is used frequently, roughness will not be present; therefore the nurse should look for an erythematous macule or papule. The nurse should refer clients to their primary care provider whenever a suspicious lesion is found. The nurse should also explain the value of treating skin cancer early, which can minimize scarring and disfigurement.





image Intervention


Nursing intervention consists of reinforcing the treatment regimen with the client and family, monitoring the treated site to prevent secondary infection, providing support, and teaching preventive strategies. To lower a client’s anxiety and assist with body image changes, the nurse should explain the treatment, stressing that erythema and crusting are temporary. The resulting body image trauma from treatment of many facial lesions can isolate an individual. The nurse can identify the client’s fears and discuss them in an open, reassuring manner.


Wounds should be assessed for development of a bacterial infection, as evidenced by increased tenderness, increasing erythema around the treated site, purulent discharge, and possibly a fever. Topical management with an antibiotic ointment may be implemented prophylactically.


The nurse should teach older adult clients and family members strategies necessary to prevent recurrence and stress the need to wear hats with wide brims and long-sleeved shirts to protect the skin from sun exposure. If an individual is going to be in the sun, a sunscreen with a sun protection factor of at least 15 should be applied (Habif, 2004).




Malignant Skin Growths


Basal Cell Carcinoma


Basal cell carcinoma (BCC) is the most common skin cancer and is more prevalent in fair-skinned, blond, or red-headed individuals with extensive previous sun exposure. BCC rarely occurs in black persons because the darker skin pigmentation plays a protective role against UVB radiation, the spectrum thought to be causative in the development of skin cancer (Johnson, Moy, & White, 1998). It occurs more often in men than women; however, this gender difference has decreased in recent years. BCC is most commonly found on the face and scalp, less often on the trunk, and rarely on the hands. It may also arise from scars or burns, particularly in older adults who have experienced chronic sun damage. BCC usually does not metastasize, but if left untreated, it may metastasize to the bone, lungs, and brain (Habif, 2004).


Typically, BCC appears as a pearly papule with a depression in the center, giving the lesion a doughnut-shaped appearance with telangiectasia on or around the lesion. BCC can also appear as a blue-black pearly nodule (pigmented basal cell) or a red, scaly, or eczematous-appearing macule that is usually on the thoracic area (superficial spreading BCC).



Nursing Management


image Assessment


Nursing assessment begins with an interview focusing on the length of time the lesion has been present, the presence of risk factors such as chronic sun exposure, and a history of previous skin lesions. The nurse should conduct a skin assessment and be alert for pearly, doughnut-shaped lesions with telangiectasia. A magnifying glass may be useful for closely examining any lesion. The nurse should inspect and palpate the lesion, surrounding tissue, and lymph nodes (to identify possible metastasis). When a suspicious lesion is identified, the client is referred to the primary care provider for prompt treatment. The nurse should explain to the client that early treatment lessens the extent of scarring and lowers the risk of metastasis.


Tags:
Nov 26, 2016 | Posted by in NURSING | Comments Off on Integumentary Function

Full access? Get Clinical Tree
Get Clinical Tree app for offline access