Angelite Nurses

• Burns
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• Impetigo
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• Ringworm
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• Pediculosis (Head Lice)
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• Diaper Rash
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• Poison Ivy
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• Eczema
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• Acne
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• Primary Lesions of the Skin
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• Contact Dermatitis
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• Psoriasis
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• Skin Cancer
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• Herpes Zoster (Shingles)
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• Herpes Simplex Virus, Type I

1. General information
1. Causes cold sores or fever blisters, canker sores and herpetic whitlow
2. Common disorder, frequently seen in women
3. Primary infection occurs in children, recurrences in adults
4. Self-limiting virus
2. Assessment findings: clusters of vesicles, may ulcerate or crust; burning, itching, tingling; usually appears on lip or cheek
3. Nursing interventions: keep lesions dry; apply topical antibiotics or anesthetic as ordered.

1. General information
1. Acute viral infection of the nervous system
2. The virus causes an inflammatory reaction in isolated spinal and cranial sensory ganglia and the posterior gray matter of the spinal cord
3. Contagious to anyone who has not had varicella or who is immunosuppressed
4. Caused by activation of latent varicella-zoster virus
2. Medical management
1. Analgesics
2. Corticosteroids
3. Acetic acid compresses
4. Acyclovir (Zovirax)
3. Assessment findings
1. Neuralgic pain, malaise, itching, burning
2. Cluster of skin vesicles along course of peripheral sensory nerves, usually unilateral and primarily on trunk, thorax, or face
4. Nursing interventions
1. Apply acetic acid compresses or white petrolatum to lesions.
2. Administer medications as ordered.
1. Analgesics for pain
2. Systemic corticosteroids: monitor for side effects of steroid therapy (see Interventions, Care of the Client on Corticosteriod Therapy).
3. Acyclovir (Zovivax): antivalagent reduces severity when given early in illness.

1. General information
1. Types of skin cancers
1. Basal cell epithelioma: most common type of skin cancer; locally invasive and rarely metastasizes; most frequently located between the hairline and upper lip
2. Squamous cell carcinoma (epidermoid): grows more rapidly than basal cell carcinoma and can metastasize; frequently seen on mucous membranes, lower lip, neck, and dorsum of the hands
3. Malignant melanoma: least frequent of skin cancers, but most serious; capable of invasion and metastasis to other organs
2. Precancerous lesions
1. Leukoplakia: white, shiny patches in the mouth and on the lip
2. Nevi (moles): junctional nevus may become malignant (signs include a color change to black, bleeding, and irritation); compound and dermal nevi unlikely to become cancerous
3. Senile keratoses: brown, scalelike spots on older individuals
3. Contributing factors include hereditary predisposition (fair, blue-eyed people; redheads and blondes); irritation (chemicals or ultraviolet rays)
4. Occurs more often in those with outdoor occupations who are exposed to more sunlight
2. Medical management: varies depending on type of cancer; surgical excision with or without radiation therapy most common; chemotherapy and immunotherapy for melanoma
3. Assessment findings: characteristics depend on specific type of lesion; biopsy reveals malignant cells
4. Nursing interventions: provide client teaching concerning
1. Limitation of contact with chemical irritants
2. Protection against ultraviolet radiation from sun
1. Wear thin layer of clothing.
2. Use sun block or lotion containing para-amino benzoic acid (PABA).
3. Need to report lesions that change characteristics and/or those that do not heal.

1. General information
1. Chronic type of dermatitis that involves accelerated turnover rate of the epidermal cells
2. Predisposing factors include stress, trauma, infection; changes in climate may produce exacerbations; familial predisposition to the disease
2. Medical management
1. Topical corticosteroids
2. Coal tar preparations
3. Ultraviolet light
4. Antimetabolites (methotrexate)
3. Assessment findings
1. Mild pruritus
2. Sharply circumscribed scaling placques that are mostly present on the scalp, elbows, and knees; yellow discoloration of nails
4. Nursing interventions
1. Apply occlusive wraps over prescribed topical steroids.
2. Protect areas treated with coal tar preparations from direct sunlight for 24 hours.
3. Administer methotrexate as ordered, assess for side effects.
4. Provide client teaching and discharge planning concerning
1. Feelings about changes in appearance of skin (encourage client to cover arms and legs with clothing if sensitive about appearance)
2. Importance of adhering to prescribed treatment and avoidance of commercially advertised products

1. General information
1. An irritation of the skin from a specific substance or from a hypersensitivity immune reaction from contact with a specific antigen
2. Caused by irritants (mechanical, chemical, biologic); allergens
2. Assessment findings
1. Pruritus
2. Erythema; localized edema; vesicles (oozing, crusting, and scaling [later])
3. Diagnostic test: skin testing reveals hypersensitivity to specific antigen
3. Nursing interventions
1. Apply wet dressings of Burrow's solution for 20 minutes 4 times a day to help clear oozing lesions.
2. Provide relief from pruritus (see Cirrhosis of the Liver).
3. Administer topical steroids and antibiotics as ordered.
4. Provide client teaching and discharge planning concerning
1. Avoidance of causative agent
2. Preventing skin dryness
1. use mild soaps (Ivory).
2. soak in plain water for 20-30 minutes.
3. apply prescribed steroid cream immediately after bath.
4. avoid extremes of heat and cold.
3. Allowing crusts and scales to drop off skin naturally as healing occurs
4. Avoidance of wool, nylon, or fur fibers on sensitive skin
5. Need to use gloves if handling irritant or allergenic substances

1. Macule: a flat, circumscribed area of color change in the skin without surface elevation, up to 2 cm in diameter
2. Papule: a circumscribed solid and elevated lesion, up to 1 cm in size
3. Nodule: a solid, elevated lesion extending deeper into the dermis, 1-2 cm in diameter
4. Wheal: a slightly irregular, transient superficial elevation of the skin with a palpable margin (e.g., hive)
5. Vesicle: circumscribed elevated lesion filled with serous fluid, less than 1 cm in diameter
6. Bulla: a vesicle larger than 1 cm in diameter
7. Pustule: a vesicle or bulla containing purulent exudate

1. General information
1. Skin condition associated with increased production of sebum from sebaceous glands at puberty.
2. Lesions include pustules, papules, and comedones.
3. Majority of adolescents experience some degree of acne, mild to severe.
4. Lesions occur most frequently on face, neck, shoulders and back.
5. Caused by a variety of interrelated factors including increased activity of sebaceous glands, emotional stress, certain medications, menstrual cycle.
6. Secondary infection can complicate healing of lesions.
7. There is no evidence to support the value of eliminating any foods from the diet; if cause and effect can be established, however, a particular food should be eliminated.
2. Assessment findings
1. Appearance of lesions is variable and fluctuating
2. Systemic symptoms absent
3. Psychologic problems such as social withdrawal, low self-esteem, feelings of being "ugly"
3. Nursing interventions
1. Discuss OTC products and their effects.
2. Instruct child in proper hygiene (handwashing, care of face, not to pick or squeeze any lesions).
3. Demonstrate proper administration of topical ointments and antibiotics if indicated

1. General information
1. Atopic dermatitis, often the first sign of an allergic predisposition in a child; many later develop respiratory allergies
2. Usually manifests during infancy
2. Medical management
1. Drug therapy
1. Topical steroids
2. Antihistamines
3. Coal tar preparations
4. Cautious administration of immunizations
5. Medicated or colloid baths
2. Diet therapy: elimination diet to detect offending foods
3. Assessment findings
1. Erythema, weeping vesicles that rupture and crust over
2. Usually evident on cheeks, scalp, behind ears, and on flexor surfaces of extremities (rarely on diaper area)
3. Severe pruritus; scratching causes thickening and darkening of skin
4. Dry skin, sometimes urticaria
4. Nursing interventions
1. Avoid heat and prevent sweating; keep skin dry (moisture aggravates condition).
2. Monitor elimination diet to detect food cause.
1. Remove all solid foods from diet (formula only).
2. If symptoms disappear after 3 days, start 1 new food group every 3 days to see if symptoms reappear.
3. The food that is suspected of causing the rash is withdrawn again to make sure symptoms go away in 3 days and is then introduced a second time (challenge test).
3. Check materials in contact with child's skin (sheets, lotions, soaps).
4. Avoid frequent baths.
1. Add Alpha Keri to bath.
2. Provide lubricant immediately after bath.
3. Pat dry gently with soft towel (do not rub) and pat in lubricant.
4. Avoid the use of soap (dries skin).
5. Administer topical steroids as ordered (penetrate better if applied within 3 minutes after bath).
6. Use cotton instead of wool clothing.
7. Keep child's nails short to prevent scratching and secondary infection; use gloves or elbow restraints if needed.
8. Apply wet saline or Burrow's solution compresses.

1. General information
1. Contact dermatitis; mediated by T-cell response so rash is not seen for 24-48 hours after contact.
2. Poison ivy is not spread by the fluid in the vesicles; can be spread by clothes and animals that retain the plant resin.
2. Assessment findings: very pruritic impetigo-like lesions
3. Nursing interventions
1. Administer antihistamines and cortisone as ordered.
2. Provide client teaching and discharge planning concerning
1. Plant identification
2. Need to wash with soap and water after contact with plant
3. Importance of washing clothes to get the resin out

1. General information
1. Contact dermatitis
2. Plastic/rubber pants and linings of disposable diapers exacerbate the condition by prolonging contact with moist, warm environment; skin is further irritated by acidic urine
3. May also be caused by sensitivity to laundry soaps used
2. Medical management: exposure of skin to air/heat lamp
3. Assessment findings
1. Erythema/excoriation in the perineal area
2. Irritability
4. Nursing interventions
1. Keep area clean and dry; clean with mild soap and water after each stool and as soon as child urinates.
2. Take off diaper and expose area to air during the day.
3. Use heat lamp as ordered.
4. Provide client teaching and discharge planning concerning
1. Proper hygiene/infant care
2. Diaper laundering methods
3. Need to avoid use of plastic pants or disposable diapers with a plastic lining
4. Need to avoid use of cornstarch (a good medium for bacteria once it becomes wet)
5. Need to avoid use of commercially prepared diaper wipes since they contain chemicals and alcohol, which may be irritating

1. General information
1. Parasitic infestation
2. Adult lice are spread by close physical contact (sharing combs, hats, etc.)
3. Occurs in school-age children, particularly those with long hair
2. Medical management: special shampoos followed by use of fine-tooth comb to remove nits
3. Assessment findings
1. White eggs (nits) firmly attached to base of hair shafts
2. Pruritus of scalp
4. Nursing interventions
1. Institute skin isolation precautions (especially head coverings and gloves to prevent spread to self, other staff, and clients).
2. Use special shampoo and comb the hair.
3. Provide client teaching and discharge planning concerning
1. How to check self and other family members and how to treat them
2. Washing of clothes, bed linens, etc.; discouraging sharing of brushes, combs, and hats

1. General information
1. Dermatomycosis due to various species of fungus
2. Infected sites include
1. Scalp (tinea capitis)
2. Body (tinea corporis)
3. Feet (tinea pedis or athlete's foot)
3. May be transmitted from person to person or acquired from animals or soil
2. Assessment findings
1. Scalp
1. Scaly circumscribed patches on the scalp
2. Base of hair shafts are invaded by spores of the fungus; causes hair to break off resulting in alopecia
3. Spreads in a circular pattern
4. Detected by Wood's lamp (fluoresces green at base of the affected hair shafts)
2. Skin: red-ringed patches of vesicles; pain, scaling, itching
3. Nursing interventions
1. Prevention: isolate from known infected persons.
2. Apply antifungal ointment as ordered.
3. Administer oral griseofulvin as ordered.

1. General information
1. Superficial bacterial infection of the outer layers of skin (usually staphylococcus or streptococcus)
2. Common in toddlers and preschoolers
3. Related to poor sanitation
4. Very contagious
2. Medical management: topical and systemic antibiotics
3. Assessment findings
1. Well-demarcated lesions
2. Macules, papules, vesicles that rupture, causing a superficial moist erosion
3. Moist area dries, leaving a honey-colored crust
4. Spreads peripherally
5. Most commonly found on face, axillae, and extremities
6. Pruritus
4. Nursing interventions
1. Implement skin isolation techniques.
2. Soften the skin and crusts with Burrow's solution compresses.
3. Remove crusts gently.
4. Cover draining lesions to prevent spread of infection.
5. Administer antibiotics as ordered, both orally and as bacteriocidal ointments.
6. Prevent secondary infection.
7. Provide client teaching and discharge planning concerning
1. Medication administration
2. Proper hygiene techniques

1. Types
1. Thermal: most common type; caused by flame, flash, scalding, and contact (hot metals, grease)
2. Smoke inhalation: occurs when smoke (particular products of a fire, gases, and superheated air) causes respiratory tissue damage
3. Chemical: caused by tissue contact, ingestion or inhalation of acids, alkalies, or vesicants
4. Electrical: injury occurs from direct damage to nerves and vessels when an electric current passes through the body.
2. Classification
1. Partial thickness
1. Superficial partial-thickness (first degree)
1. depth: epidermis only
2. causes: sunburn, splashes of hot liquid
3. sensation: painful
4. characteristics: erythema, blanching on pressure, no vesicles
2. Deep partial thickness (second degree)
1. depth: epidermis and dermis
2. causes: flash, scalding, or flame burn
3. sensation: very painful
4. characteristics: fluid-filled vesicles; red, shiny, wet after vesicles rupture
2. Full thickness (third and fourth degree)
1. Depth: all skin layers and nerve endings; may involve muscles, tendons, and bones
2. Causes: flame, chemicals, scalding, electric current
3. Sensation: little or no pain
4. Characteristics: wound is dry, white, leathery, or hard
3. Medical management
1. Supportive therapy: fluid management (IVs), catheterization
2. Wound care: hydrotherapy, debridement (enzymatic or surgical)
3. Drug therapy
1. Topical antibiotics: mafenide (Sulfamylon), silver sulfadiazine (Silvadene), silver nitrate, povidone-iodine (Betadine) solution
2. Systemic antibiotics: gentamicin
3. Tetanus toxoid or hyperimmune human tetanus globulin (burn wound good medium for anaerobic growth)
4. Analgesics
4. Surgery: excision and grafting
4. Assessment
1. Extent of burn injury by rule of nines: head and neck (9%); each arm (9%), each leg (18%), trunk (36%), genitalia (1%) (See Figure 4.23)
2. Lund and Browder method determines the extent of the burn injury by using client's age in proportion to relative body-part size.
3. Severity of burn
1. Major: partial thickness greater than 25%; full thickness greater than or equal to 10%
2. Moderate: partial thickness 15%-25%, full thickness less than 10%
3. Minor: partial thickness less than 15%; full thickness less than 2%
5. Stages
1. Emergent phase
1. Remove person from source of burn.
1. thermal: smother burn beginning with the head.
2. smoke inhalation: ensure patent airway.
3. chemical: remove clothing that contains chemical; lavage area with copious amounts of water.
4. electrical: note victim position, identify entry/exit routes, maintain airway.
2. Wrap in dry, clean sheet or blanket to prevent further contamination of wound and provide warmth.
3. Assess how and when burn occurred.
4. Provide IV route if possible.
5. Transport immediately.
2. Shock phase (first 24-48 hours)
1. Plasma to interstitial fluid shift causing hypovolemia; fluid also moves to areas that normally have little or no fluid (third-spacing).
2. Assessment findings
1. dehydration, decreased blood pressure, elevated pulse, decreased urine output, thirst
2. diagnostic tests: hyperkalemia, hyponatremia, elevated hct, metabolic acidosis
3. Fluid remobilization or diuretic phase (2-5 days postburn)
1. Interstitial fluid returns to the vascular compartment.
2. Assessment findings
1. elevated blood pressure, increased urine output
2. diagnostic tests: hypokalemia, hyponatremia, metabolic acidosis
4. Convalescent (Rehabilitation) phase
1. Starts when diuresis is completed and wound healing and coverage begin.
2. Assessment findings
1. dry, waxy-white appearance of full thickness burn changing to dark brown; wet, shiny, and serous exudate in partial thickness
2. diagnostic test: hyponatremia
6. Nursing interventions
1. Provide relief/control of pain.
1. Administer morphine sulfate IV and monitor vital signs closely.
2. Administer analgesics/narcotics 30 minutes before wound care.
3. Position burned areas in proper alignment.
2. Monitor alterations in fluid and electrolyte balance.
1. Assess for fluid shifts and electrolyte alterations (see Table 4.5).
2. Administer IV fluids as ordered (see Table 4.25)
3. Monitor Foley catheter output hourly (30 ml/hour desired).
4. Weigh daily.
5. Monitor circulation status regularly.
6. Administer/monitor crystalloids/colloids/H₂O solutions.
3. Promote maximal nutritional status.
1. Monitor tube feedings/TPN if ordered.
2. When oral intake permitted, provide high-calorie, high-protein, high-carbohydrate diet with vitamin and mineral supplements.
3. Serve small portions.
4. Schedule wound care and other treatments at least 1 hour before meals.
4. Prevent wound infection.
1. Place client in controlled sterile environment.
2. Use hydrotherapy for no more than 30 minutes to prevent electrolyte loss.
3. Observe wound for separation of eschar and cellulitis.
4. Apply mafenide (Sulfamylon) as ordered.
1. administer analgesics 30 minutes before application.
2. monitor acid-base status and renal function studies.
3. provide daily tubbing for removal of previously applied cream.
5. Apply silver sulfadiazine (Silvadene) as ordered.
1. administer analgesics 30 minutes before application.
2. observe for and report hypersensitivity reactions (rash, itching, burning sensation in unburned areas).
3. store drug away from heat.
6. Apply silver nitrate as ordered.
1. handle carefully; solution leaves a gray or black stain on skin, clothing, and utensils.
2. administer analgesic before application.
3. keep dressings wet with solution; dryness increases the concentration and causes precipitation of silver salts in the wound.
7. Apply povidone-iodine (Betadine) solution as ordered.
1. administer analgesics before application.
2. assess for metabolic acidosis/renal function studies.
8. Administer gentamicin as ordered: assess vestibular/auditory and renal functions at regular intervals.
5. Prevent GI complications.
1. Assess for signs and symptoms of paralytic ileus.
2. Assist with insertion of NG tube to prevent/control Curling's/stress ulcer; monitor patency/drainage.
3. Administer prophylactic antacids through NG tube and/or IV cimetidine (Tagamet) or ranitidine (Zantac) (to prevent gastric pH of less than 5).
4. Monitor bowel sounds.
5. Test stools for occult blood.
6. Provide client teaching and discharge planning concerning
1. Care of healed burn wound
1. assess daily for changes.
2. wash hands frequently during dressing change.
3. wash area with prescribed solution or mild soap and rinse well with H₂O; dry with clean towel.
4. apply sterile dressing.
2. Prevention of injury to burn wound
1. avoid trauma to area.
2. avoid use of fabric softeners or harsh detergents (might cause irritation).
3. avoid constrictive clothing over burn wound.
3. Adherence to prescribed diet
4. Importance of reporting formation of blisters, opening of healed area, increased or foul-smelling drainage from wound, other signs of infection
5. Methods of coping and resocialization

TABLE 4.25 Guidelines and Formulas for Fluid Replacement for Burns

1. For children, the rule of nines is modified; the head of a small child is 18%-19%, the trunk 32%, each leg 15%, each arm 9 1/2%.
2. Burns in infants and toddlers are frequently due to spills (pulling hot fluids on them or falling into hot baths); for older children, flame burns are more frequent.