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CLIENT TEACHING GUIDE
BACK STRETCHES
You have been approved to do back-stretching exercises to help with your low back pain. Follow the instructions, starting slowly
to build your strength.
EQUIPMENT Use a mat or a towel on the oor for extra padding and
comfort.
A. In the lying position:
1. Lie on your back with knees bent. Cross your arms over your chest.
2. Raise your head and shoulders and curl your trunk upward, no
more than 6 in.
3. Keep the small of your back pressed against the mat.
4. Exhale during the curl up.
5. Hold ____________ seconds; do ______________ repetitions
______________ times a day (Figure 1).
B. In the standing position:
1. Stand with your back against the wall.
2. Place your feet shoulder width apart and 18 in. from the wall.
3. Slowly slide down the wall until you are in the “chair” position.
4. Hold for 10 seconds and relax, then slide back up the wall to a
standing position.
5. Do ____________ repetitions ___________ times a day (Figure 2).
C. In the lying position:
1. Bring your right knee slowly to your chest, holding it in place with
your hands on your knee.
2. Relax the buttock and your back muscles.
3. Hold _____________ seconds, then relax with your right knee down.
4. Repeat with your left knee.
5. Now that you have stretched both legs, pull both of your knees up,
holding them in place with your hands on your knees.
6. You will be curled in the fetal position.
7. Hold ____________ seconds, then relax with your knees down.
8. Do _____________ repetitions, ________________ times per day (Figure 3).
D. In the lying position:
1. Lie on your back with your knees bent.
2. Tighten your abdominal muscles and squeeze. As you squeeze the
buttock muscles, atten your back toward the mat/towel. Relax.
3. Tighten your buttock muscles and lift your abdomen or “tummy”
toward your knees while arching your back. Relax.
4. Hold ___________ seconds; do _____________ repetitions
___________ times a day (Figure 4).
FIGURE 1 Lie on a mat or towel. Raise yourhead
and shoulders as demonstrated.
FIGURE 2 Place your feet shoulder width apart.
Slide down against the wall to the “chair”
position.
FIGURE 3 Pull your left knee toward your chest to
stretch; repeat with your right knee as demonstrated.
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
FIGURE 4 Lie with knees bent, flatten your back,
and then lift your tummy toward knees with back
arched.
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CLIENT TEACHING GUIDE
CHRONIC PAIN
RESOURCES Many client resources on pain are available at your local library, bookstores, and on the internet. Look for a local sup-
port group in your area to join and learn how other people are coping with the same condition as yours.
An excellent resource for clients, families, and physicians is How to Cope With Chronic Pain, by Nelson Hendler, MD (Cool Hand
Communications, 1993).
There are many pain organizations available to assist clients. Clients may wish to visit the following websites for further information:
A. American Academy of Pain Medicine: painmed.org.
B. American Chronic Pain Association: www.theacpa.org.
C. Arthritis Foundation: www.arthritis.org.
D. National Fibromyalgia Association: www.fmaware.org.
E. U.S. Pain Foundation: uspainfoundation.org.
F. International Association for the Study of Pain—Patient Resources: www.iasp-pain.org/PatientResources?navItem
Number=678.
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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DERMATOLOGY
Jill
C. Cash and Amy C. Bruggemann
ACNE
ROSACEA
GUIDELINES
DEFINITION
A.
Acne rosacea is a multifactorial vascular skin disorder
characterized by chronic inammatory processes in which
ushing and dilation of the blood vessels occur primarily on
the face (Figure 4.1). It is manifested in four stages of pathologic events.
FIGURE
4.1 Acne rosacea.
Source:
Reproduced from Lyons, F., & Ousley, L. (2015).
Dermatology for the advanced practice nurse. Springer
Publishing Company, Figure III.47.
INCIDENCE
A.
Acne rosacea affects approximately 13 million people in
the United States. It occurs in all ethnic backgrounds but is
frequently observed in people with fair pigmented skin.
Prevalence ranges from 1% to 10% among fair-skinned people. Females over the age of 30 also tend to have a higher incidence of rosacea. Rosacea can occur in adolescence; however,
it is rarely seen in children.
PATHOGENESIS
A.
Rosacea is a functional vascular anomaly with a ten-
dency toward recurrent dilation and ushing of the face.
Inammatory mediator release to cutaneous microorganisms,
extravasation of inammatory cells of the immune system,
exposure to ultraviolet light, and heightened activity of the
vascular system are the factors believed to cause the symptoms of rosacea. Ocular involvement may also include the
eyelid and conjunctiva.
PREDISPOSING
A.
Tendency to ush frequently.
B.
Exposure to heat, cold, or sunlight.
FACTORS
C.
Consumption of hot or spicy foods and alcoholic beverages.
D.
Some topical medications, astringents, or toners.
E.
Psychological stress.
F.
Menopause hot ashes.
COMMON
A.
COMPLAINTS
Papules, pustules, and nodules. Hallmarks for diagnosis
are the small papules and papulopustular. Many presenting
erythematous papules have a tiny pustule at the crest. No
comedones are present.
B.
Periodic reddening or ushing of face, primarily the nose
and medial cheeks.
C.
Increase in skin temperature of face.
D.
Face ushing in response to heat stimuli (hot liquids) in
the mouth.
OTHER
SIGNS AND SYMPTOMS
A.
Periorbital erythema.
B.
Telangiectasia, paranasally and on cheeks.
C.
Rhinophyma.
D.
Blepharoconjunctivitis with erythematous eyelid margins.
E.
Conjunctivitis: diffuse hyperemic type or nodular.
F.
Keratitis: lower portion of cornea, associated with pain,
photophobia, and foreign-body sensation.
SUBJECTIVE
A.
Ask the client to describe the location and the onset. Was
DATA
the onset sudden or gradual? How have the symptoms continued to develop?
B.
Assess if the skin is itchy or painful.
C.
Assess for any associated discharge (blood or pus).
D.
Complete a drug history. Has the client recently taken any
antibiotics or other medications?
E.
Determine whether the client has used any topical medica-
tions, astringents, toners, or new skin-care products.
F.
Rule out any possible exposure to industrial or domestic
toxins, insect bites, and possible contact with venereal disease
or HIV.
G.
Ask the client about close contact with others with skin
disorders.
H.
Identify whether exposure to heat, cold, or sunlight pro-
vokes the symptoms.
I.
Ask whether eating or drinking hot or spicy foods or con-
sumption of alcoholic beverages provokes the symptoms.
PHYSICAL
A.
Check temperature, pulse, and blood pressure.
B.
Inspect:
EXAMINATION
1.
Skin, focusing on face and scalp.
2.
Nose and paranasal structures.
The
contributions of Cheryl A. Glass to this chapter in prior editions are acknowledged here.
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3.
4: DERMATOLOGY GUIDELINES
Eyes, eyelids, conjunctiva, and cornea. An ocular manifes-
tation, rosacea keratitis, may cause corneal ulcers to develop.
DIAGNOSTIC
A.
Consider skin biopsy to rule out lupus, sarcoidosis, or
TESTS
other possible causes if history and physical examinations
warrant further testing.
DIFFERENTIAL
A.
Acne rosacea.
B.
Acne vulgaris.
C.
Steroid-induced acne.
D.
Perioral dermatitis.
E.
Seborrheic dermatitis.
F.
Lupus erythematosus.
G.
Cutaneous sarcoidosis.
DIAGNOSES
PLAN
A.
General interventions:
1.
Identify any causative or provocative factors: heat, cold,
hot or spicy foods, alcoholic beverages, sunlight, and so forth.
2.
Advise washing face with a mild cleanser, such as
Cetaphil or CeraVe, in the morning and at night.
3.
Avoid direct sunlight exposure by wearing protective
clothing/hats when outdoors. Suggest using a sunscreen
with sun protection factor (SPF) 30 when exposed to sunlight.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Acne Rosacea.”
C.
Pharmaceutical therapy:
1.
Topical treatment:
a.
Metronidazole 0.75%: Apply BID after cleansing
skin. Cheapest and best used for facial sensitivity.
b.
Sodium sulfacetamide may be used as an alternative.
c.
Azelaic acid: This is a dicarboxylic acid that reduces
swelling and redness, kills bacteria, and reduces the
production of keratin. Apply gel to skin BID.
d.
Ivermectin: This is an antiparasitic agent that targets
parasites and inammation on the skin.
2.
Oral treatment:
a.
Drug of choice: tetracycline 500 to 1,000 mg twice to
four times daily for 2 to 4 weeks.
b.
Others: doxycycline 100mg daily until clear.
c.
Minocycline (Minocin) 50 to 200 mg daily divided
into two doses.
3.
Steroids: Do not use topical steroids. Topical steroids
may worsen irritation.
4.
Isotretinoin: Oral isotretinoin is used to treat severe
acne and refractory cases. Must be closely monitored and
suggested to the dermatologist for treatment.
FOLLOW-UP
A.
Follow up in 2 weeks to evaluate therapy.
B.
See the client monthly for evaluation until maintenance is
reached.
C.
Relapses are common following discontinuance of antibi-
otics; repeat treatment.
CONSULTATION/REFERRAL
A.
Consult or refer the client to a dermatologist if there is no
improvement or if the client is unable to reach maintenance.
B.
Provide an immediate referral to an ophthalmologist for
treatment and follow-up for ocular involvement.
INDIVIDUAL
A.
Adults:
1.
CONSIDERATIONS
Tinted sulfacetamide (Sulfacet-R) lotion may be used
to cover erythema in fair-skinned clients.
BIBLIOGRAPHY
Acmaz, G., Cınar, L., Acmaz, B., Aksoy, H., Kafadar, Y. T., Madendag, Y.,
zdemir, F., Sahin, E., & Muderris, I. (2019). The effects of oral isotretinoin in women with acne and polycystic ovary syndrome. BioMed
Research International, 1–5. https://doi.org/10.1155/2019/2513067
2019
Brackenbury, J. (2016). Recommended topical treatments for man-
aging adult acne in women. Nurse Prescribing, 14(3), 126–129.
https://doi.org/10.12968/npre.2016.14.3.126
dall’Oglio, F., Lacarrubba, F., Luca, M., Boscaglia, S., & Micali, G. (2018).
Clinical and erythema-directed instrumental evaluation of papulopustular rosacea treated with topical ivermectin. Journal of the American
Academy of Dermatology, 79(3), AB75. https://doi.org/10.1016/j.jaad.
2018.05.335
Gold, L. S., Lain, E. L., & Harvey, A. (2018). The anti-inammatory proper-
ties of ivermectin and brimonidine in the treatment of papulopustular
rosacea. Journal of the American Academy of Dermatology, 79(3), AB281.
https://doi.org/10.1016/j.jaad.2018.05.1115
Oge, L. K., Muncie, L. H., & Phillips, A. R. (2015). Rosacea: Diagnosis and
treatment. American Family Physician, 92(3), 187–196.
Palmer, W. J. (2019). New therapies in development to manage acne, rosa-
cea. Dermatology Times, 40(4), 1–20.
Radley, K. (2015). The management and treatment of acnes. Primary
Health Care, 25(4), 34–41. https://doi.org/10.7748/phc.25.4.34.
e996
ACNE
VULGARIS
DEFINITION
A.
Acne vulgaris is a disorder of the sebaceous glands charac-
terized by numerous hair follicles on the face, back, and chest
(Figure 4.2). The sebaceous glands become inamed and form
papules, pustules, cysts, open or closed comedones, and/or
nodules on an erythema base. In severe cases, scarring can
result.
FIGURE
4.2 Acne vulgaris.
Source:
StatPearls Publishing. (2019). https://www.ncbi.nlm.nih.
gov/books/NBK459173/.
INCIDENCE
A.
Acne vulgaris is the most common skin disorder in the
United States, affecting 40 to 50 million persons of all ages and
races. Nearly 80% to 90% of all adults experience acne during
their lifetime. Acne vulgaris, commonly seen in adolescence,
may even extend into the third or fourth decade of life.
PATHOGENESIS
A.
Sebum is overproduced and collected in the sebaceous
gland. Sebum and keratinized cells are collected in the hair
follicle. With the presence of Propionibacterium acnes, the duct
becomes clogged, and lesions (noninammatory and/or
inammatory) evolve.
PREDISPOSING
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A.
Age (adolescence).
B.
External irritants to skin (makeup, oils, equipment contact
FACTORS
on skin).
C.
Hormones (oral contraceptives with high progestin
content).
D.
Medications (lithium, halides, hydantoin derivatives,
rifampin).
E.
Hot, humid weather.
COMMON
A.
COMPLAINTS
Outbreak of pimples on face, chest, shoulders, and back
that does not resolve with over-the-counter (OTC) treatment.
B.
Acne rosacea: presence of telangiectasia, ushing, and
rhinophyma.
OTHER
SIGNS AND SYMPTOMS
A.
Mild: open comedones (blackhead) and closed comedones
(whitehead).
B.
Moderate: comedones with papules and pustules.
C.
Severe: nodules, cysts, and scars.
SUBJECTIVE
A.
Elicit the age of onset of outbreak, duration, and course of
DATA
symptoms.
B.
Determine what makes the lesions worse or better.
C.
Ask whether there are certain times of the month or year
when lesions are better or worse.
D.
Identify the client’s current method of cleanser or moistur-
izer treatment.
E.
Ask if the client has ever been treated by a provider for this
problem. If so, determine the treatment and the results of the
treatment.
F.
Assess whether other family members have the same
problem.
G.
Ask the client for a description of their environment and
occupation.
H.
Explore with the client any current stress factors in their
life.
PHYSICAL
A.
Inspect:
EXAMINATION
1.
Observe skin for location and severity of lesions.
2.
Rate severity of lesions as mild, moderate, or severe.
a.
Mild: few papules/pustules, no nodules.
b.
Moderate: several papules/pustules, rare nodules.
c.
Severe: many papules/pustules with many nodules.
3.
Take a picture of areas of affected skin for chart and
document date. Use this for future appointments as a reference to compare results for follow-up visits.
DIAGNOSTIC
A.
No tests are generally required.
B.
Culture lesions to rule out Gram-negative folliculitis in
TESTS
clients on antibiotics.
C.
Consider hormone testing if other primary causes of acne
are taken into account (follicle-stimulating hormone, luteinizing hormone, testosterone levels).
DIFFERENTIAL
A.
Acne vulgaris.
B.
Acne rosacea.
C.
Steroid rosacea.
DIAGNOSES
ACNE VULGARIS
D.
Folliculitis.
E.
Perioral acne.
F.
Drug-induced acne.
PLAN
A.
General interventions:
1.
Document location and severity of lesions. Assess
quality of improvement at each ofce visit.
2.
The primary goal of treatment is prevention of scar-
ring. Good control of lesions during puberty and early
adulthood is required for best results. Anticipate ups and
downs during the normal course of treatment.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Acne Vulgaris.”
1.
Instruct the client on proper cleansing routine. The cli-
ent should wash affected areas with a mild soap (Purpose,
Cetaphil) twice a day and apply medications as directed.
2.
Warn the client that washing the face more than two
to three times a day can decrease oil production and cause
drying.
3.
Discuss current stressors in the client’s life and discuss
treatment options.
4.
Recommend an exercise routine 3 to 5 days a week.
5.
Recommend oil-free sunscreens.
C.
Pharmaceutical therapy: It may take 1 to 3 months before
results are visible when using medications.
1.
Mild: Treatment of choice is topical. Use one of the
following:
a.
Benzoyl peroxide, 2.5%, 5%, or 10%: Start with 2.5%
at bedtime, may graduate to 5% or 10% BID if needed
and as tolerated.
b.
T-Stat: Apply to dried areas BID. Avoid the eyes,
nose, and mouth creases.
c.
Topical tretinoin 0.1% (Retin-A Micro): Use at
bedtime.
i.
With Retin-A use, the client may see rapid turn-
over of keratin plugs.
ii.
Instruct the client to avoid abrasive soaps.
iii.
Warn the client regarding photosensitivity.
iv.
Warn the client regarding increased dryness.
Moisturizers such as CeraVe or Cetaphil may be
applied, if needed.
d.
Desquam-E: Use at bedtime. Wash face with soap
and then apply Desquam-E.
2.
Moderate: Use one of the aforementioned topical med-
ications in addition to one of the following oral medications for 3 to 4 months.
a.
Use tetracycline 500 mg BID for 3 to 6 weeks, for
adolescents older than 14 years. As condition improves,
begin tapering medication to 250mg BID for 6 weeks,
then to daily or to every other day.
i.
Instruct the client to take tetracycline on an
empty stomach and to avoid dairy products, antacids, and iron.
ii.
Warn the client about photosensitivity. This
medication may be used as a maintenance dose at
250mg daily or every other day in clients who break
out after discontinuing antibiotic therapy. No drug
resistance is seen with tetracycline.
b.
Use erythromycin 250mg QID after meals or topical
erythromycin 2%, solution or gel, BID, or clindamycin
(Cleocin T) solution, pads, or gel, BID. Erythromycin
resistance has been seen.
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4: DERMATOLOGY GUIDELINES
c.
Use minocycline 100mg BID. When this is effective,
taper to 50mg BID.
d.
Have the client drink plenty of uids.
e.
Central nervous system side effects (headaches)
have been seen.
f.
Use Bactrim single strength BID if the aforementioned
regimens do not work well. Bactrim works well if others
fail because it is effective against gram-negative folliculitis.
g.
Doxycycline 100 mg BID. Reevaluate every 4 to 6
months.
h.
Oral contraceptives with higher doses of estrogen have
also been effective in girls. There are three oral contraceptives approved by the Food and Drug Administration
(FDA) to be used for acne:
i.
Estradiol 20/30/35 mcg/norethindrone 1 mg
(Estrostep).
ii.
Ethinyl estradiol 35 mcg/norgestimate
180/215/2,501 mcg (Ortho Tri-Cyclen).
iii.
Ethinyl estradiol 20 mcg/drospirenone 3 mg
(Yaz).
i.
Spironolactone may be used in females who fail topical
and oral antibiotics and contraceptives. Use spironolactone
50 to 100mg/d, split into two divided doses. Medical history should be evaluated for comorbidities such as heart disease, renal disease, and other medications/risks of causing
hyperkalemia since spironolactone is a potassium-sparing
drug. Levels may be checked prior to starting medication
and periodically while on the medication.
3.
Severe: Medications such as isotretinoin should be pre-
scribed by the dermatologist.
4.
Underlying disorders: Females with hyperandrogen-
ism should be evaluated and treated for underlying endocrine disorders. Mild cases can be treated with hormone
therapy (oral contraceptive agents).
ii.
Begin contraception 1 month before start-
ing the medication and continue contraception 1
month after nishing the medication.
iii.
Safe antibiotics to use during pregnancy include
oral/topical erythromycin, topical clindamycin, or
azelaic acid.
B.
Teens/Adults:
1.
Review risk factors prior to using oral contraceptives
for treatment of acne. Avoid use in clients who may have
an increased risk of deep vein thrombosis.
2.
Contraceptives with progestin only and/or high
androgenic properties should be avoided due to worsening acne in these clients.
BIBLIOGRAPHY
Acmaz, G., Cınar, L., Acmaz, B., Aksoy, H., Kafadar, Y. T., Madendag, Y.,
Ozdemir, F., Sahin, E., & Muderris, I. (2019). The effects of oral
isotretinoin in women with acne and polycystic ovary syndrome.
BioMed Research International, 1–5. https://doi.org/10.1155/2019/
2513067 2019
Brackenbury, J. (2016). Recommended topical treatments for managing
adult acne in women. Nurse Prescribing, 14(3), 126–129. https://doi.
org/10.12968/npre.2016.14.3.126
Graber, E. (2019). Treatment of acne vulgaris. UpToDate. https://www-uptodate-
com.ckmproxy.vumc.org/contents/treatment-of-acne-vulgaris?
search=acne%20vulgaris§ionRank=3&usage_type=default&
anchor=H40&source=machineLearning&selectedTitle=1~150&
display_rank=1#H40
Kang, A., Lyons, A., Herrmann, J., & Moy, R. (2019). Treatment of
moderate-to-severe facial acne vulgaris with solid-state fractional
589/1,319-nm laser. Journal of Clinical & Aesthetic Dermatology, 12(3), 28–31.
Radley, K. (2015). The management and treatment of acnes. Primary Health
Care, 25(4), 34–41. https://doi.org/10.7748/phc.25.4.34.e9 96
Zito, P. M., Murgia, R. D., & III. (2019). Complementary alterna-
tive therapies: Green tea avonoids in acne vulgaris. Journal of the
Dermatology Nurses’ Association, 11(2), 91–92. https://doi.org/10.
1097/JDN.0000000000000453
FOLLOW-UP
A.
See clients every 6 to 8 weeks for evaluation.
1.
Mild: Adjust dose depending on local irritation.
2.
Moderate (oral and topical medications):
a.
Adjust dose according to irritation.
b.
Taper oral antibiotics with discretion and/or con-
tinue topical medications.
c.
Oral antibiotics may be tapered and discontinued
when inammatory lesions have resolved.
3.
Severe: Recommend referral to dermatology and
follow-up with the specialty.
B.
A minimum of 3 to 6 months should be trialed before
switching to another alternative.
CONSULTATION/REFERRAL
A.
Consult with a physician if treatment is unsuccessful after
10 to 12 weeks of therapy or if acne is severe.
B.
The client may need dermatology consultation.
INDIVIDUAL
A.
Pregnancy:
1.
2.
CONSIDERATIONS
Acne may are up or improve during pregnancy.
Medications preferred during pregnancy are topical
retinoids.
a.
Teratogens include tretinoin, tetracycline, and
minocycline.
i.
When using teratogenic medications, contra-
ception must be used. Teratogenic medications may
cause severe fetal malformations in utero and pregnancy prevention is imperative to avoid this risk.
ANIMAL
BITES, MAMMALIAN
DEFINITION
A.
Bites of any mammalian animal to humans can be poten-
tially dangerous. Human bites are included.
INCIDENCE
A.
There are approximately 4.5 million animal bites in the
United States each year. Of these, 90% are dog bites and 20%
of these bites become infected.
B.
There are approximately 400,000 cat bites per year in the
United States, accounting for 10% of the total animal bites and
up to 50% of these bites become infected.
C.
Human bites account for 250,000 bites annually and 10%
of these bites become infected.
D.
Children and older adults are more prone to bites.
PATHOGENESIS
A.
Mechanical trauma and break in the skin and/or underly-
ing structures.
B.
Infection from transmission of bacteria:
1.
Pasteurella multocida is primarily associated with cat
bites but may also be associated with dog bites.
2.
Staphylococcus aureus, S. epidermidis, and Enterobacter
species can be transmitted by dog and cat bites.
3.
Streptobacillus moniliformis can be transmitted by rat
and mouse bites.
4.
Streptococcus, Staphylococcus, and Eikenella can be trans-
mitted by human bites.
5.
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Human bites can transmit diseases such as actinomy-
cosis, syphilis, tuberculosis, hepatitis B, and potentially
HIV.
C.
Rabies, an acute viral infection, may be transmitted by
means of infected saliva or by an infected animal licking
mucosa of an open wound. It is rarely contracted by means of
airborne transmission, but this has been reported to occur in
bat-infested caves.
PREDISPOSING
A.
Entering an animal’s territorial space and/or surprising an
FACTORS
animal.
COMMON
A.
B.
C.
D.
OTHER
A.
COMPLAINTS
Bitten.
Pain.
Redness.
Swelling.
SIGNS AND SYMPTOMS
Normal: mild redness and swelling, serosanguinous ooz-
ing, and discomfort.
B.
Abnormal: erythema, fever, pus, red streaks, pain, loss of
sensation.
SUBJECTIVE
A.
What person or type of animal bit the client?
B.
Was this a provoked or an unprovoked attack?
C.
Did the client identify and contact the owner of the animal?
DATA
ANIMAL BITES, MAMMALIAN
D.
What was the behavior of the animal: unusual, strange, or
ill-appearing?
E.
How much time has elapsed from being bitten to seeking
treatment?
F.
Did the client start any self-treatment?
G.
What is the client’s tetanus immunization status?
H.
Review history for any prior rabies immunizations.
I.
Does the client know if the animal was a domestic animal?
Is the animal’s vaccination status known?
J.
If the bite is of human origin, determine if it is a closed-st
injury or a plain bite.
PHYSICAL
A.
Check blood pressure, pulse, and respirations, and observe
EXAMINATION
overall respiratory status.
B.
See Table 4.1.
DIAGNOSTIC
A.
Refer to Table 4.1.
DIFFERENTIAL
A.
Animal bite: dog, cat, human, and so forth:
1.
2.
TESTS
DIAGNOSES
Cat bites more frequently become infected.
Bites on the hand have the highest infection rates. Bites
on the face have the lowest infection rates.
B.
Cellulitis and abscesses.
C.
High-risk potential for rabies from the following:
1.
Skunks, foxes, raccoons, and bats are primary carriers.
75
TABLE
4.1 EXAMINATION AND TESTING FOR BITES
Animal Signs and Symptoms Physical Examination
Dog Crush injury, lacerations, and
abrasions
Inspect site, underlying structures, and
distal neurovascular, motor, and
sensory functions.
a
Diagnostic Tests
If infected—laboratory: CBC,
culture, and sensitivity for
anaerobes and aerobes
Palpate area. If wound is more than
24 hours old, check for any signs of
cellulitis or lymphangitis.
Cat Puncture wounds, may be deep Determine depth and extent of wound. If sepsis suspected—laboratory:
CBC, culture, and sensitivity of
Check for foreign bodies.
abscess/tissue site
If wound is more than 24 hours old,
check for any signs of cellulitis or
lymphangitis.
Rat and squirrel Laceration, abrasions; more
superficial in nature
Check for signs of infection if wound is
more than 24 hours old. Check for
any signs of cellulitis or lymphangitis.
Human Crush injury, laceration; wound
in the hands
Check for signs of infection if wound is
more than 24 hours old.
If infected—laboratory: CBC,
culture, and sensitivity
(closed-fist wound)
Check for any signs of cellulitis or
lymphangitis. Also, examine for
An x-ray film of structures
underlying the bite
fractures, air in the joint, subchondral
bone defects, and osteomyelitis.
a
For all animal bites, check the client’s temperature.
CBC,
complete blood count.
Examine for full range of interphalangeal
and metacarpophalangeal joints.
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4: DERMATOLOGY GUIDELINES
2.
Rabbits, squirrels, chipmunks, rats, and mice are sel-
dom infective for rabies.
3.
Properly vaccinated animals are seldom infective.
PLAN
A.
General interventions:
1.
Control bleeding.
2.
Perform wound care.
a.
Immediately wash wound copiously with soap and
water.
b.
Irrigate wound with saline using a 20-gauge or
larger catheter.
c.
Use 150 to 1,000 mL of solution.
d.
Apply direct saline stream on the entire wound
surface.
e.
Scrub entire surrounding area.
f.
Debride all wounds.
g.
Trim any jagged edges to prevent cosmetic and/or
functional complications.
h.
Cover with dry dressing.
3.
Do not suture wounds at high risk of infection.
a.
Hand bites and closed-st injuries.
b.
Bites older than 12 hours (greater than 24 hours on
the face).
c.
Deep, crush, or puncture wounds.
d.
Bites with extensive injury of the surface or underly-
ing structures.
4.
Implement rabies control measures.
a.
Consult with the local health department regarding
the risk of rabies in the area.
b.
The domestic animal should be identied, caught,
and conned for 10 days of observation. If the animal
develops any signs of rabies, it should be destroyed
and its brain tissue should be analyzed. No treatment
is necessary if results are negative.
c.
The wild animal should be caught and destroyed
for brain tissue analysis. No treatment is necessary if
results are negative.
d.
If the bat or wild carnivore cannot be found, rabies
prophylaxis is instituted.
B.
Client teaching:
1.
Stress the importance of keeping the site free from
infection. Instruct the client on how to keep the site free
from infection, such as teaching cleaning techniques, good
handwashing, and using medications as prescribed.
2.
Discuss symptoms to report to the provider if signs
of infection begin (erythema, swelling, drainage, and
tenderness).
C.
Pharmaceutical therapy:
1.
Antibiotic prophylaxis:
a.
Antibiotic prophylaxis is controversial, but is gen-
erally recommended for wounds involving subcutaneous tissues and deeper structures. Prophylaxis may
be prescribed 3 to 5 days and antibiotic treatment for
established infection is 5 to 14 days.
i.
Prescribe amoxicillin/clavulanic acid
(Augmentin) 875mg Q12H; for children, prescribe
25 to 45mg/kg/dose in two divided doses for 3 to
7 days. Available as 200mg/5 mL and 400mg/5 mL
liquid
ii.
For adults allergic to penicillin, pre-
scribe doxycycline 100 mg BID for 3 to 7 days;
trimethoprim-sulfamethoxazole 1 tab BID, or
uoroquinolone (ciprooxacin 500–750 BID or levooxacin 750 mg daily) PLUS metronidazole 500 mg
TID or clindamycin 300 to 450mg TID OR moxioxacin 400mg daily monotherapy.
iii.
For children allergic to penicillin, prescribe
clindamycin 7.5 to 10mg/kg divided every 6 to 8 hours
PLUS trimethoprim/ sulfamethoxazole 4 to 6 mg/kg
(trimethoprim component) divided Q12H for 3 to 7
days.
2.
Tetanus prophylaxis:
a.
Tetanus toxoid-containing vaccine should be given
for any wound (minor or major) if vaccination status is
unknown or if less than three doses have been received
in the past. For major wounds, human tetanus immune
globulin should also be given to anyone of unknown
status or has received less than three doses in the past.
Tetanus toxoid-containing vaccine should be given to
anyone who has received more than three doses in the
past if the last dose is more than 10 years for clean/
minor wounds and more than 5 years for all other
major wounds. Human tetanus immuno globulin is not
recommended to anyone who has received more than
three previous doses of tetanus toxoid.
3.
Rabies prophylaxis:
a.
Active immunization: Human diploid cell vaccine
(HDCV), 1 mL, is given intramuscularly (IM) on the
rst day of treatment, and repeat doses are administered on days 3, 7, 14, and 28.
b.
Passive immunization: Rabies immunoglobulin
(RIG; human) should be used simultaneously with the
rst dose of HDCV; the recommended dose of RIG is
20 IU/kg. Approximately one-half of RIG is inltrated
into the wound and the remainder is given IM.
FOLLOW-UP
A.
Evaluate wound and change dressing in 24 to 48 hours.
B.
Reevaluate as indicated. If the client is on immunoprophy-
laxis and has no signs of infection, see them in 1 week.
C.
Instruct the client to return immediately in case of any
signs of infection.
CONSULTATION/REFERRAL
A.
Refer all clients with bites in the ears, face, genitalia, hands,
and feet.
B.
Consult with a doctor if there is suspicion for rabies.
C.
Contact the local health department.
D.
Wounds involving the tendon, joint, or bone require hospi-
talization and surgical consultation.
INDIVIDUAL
A.
Pregnancy:
1.
B.
Pediatrics:
1.
C.
Geriatrics:
1.
CONSIDERATIONS
Use appropriate antibiotic management.
Children are more prone to animal bites.
The elderly population is more prone to animal bites.
BIBLIOGRAPHY
Aziz, H., Rhee, P., Pandit, V., Tang, A., Gries, L., & Joseph, B. (2015). The
current concepts in management of animal (dog, cat, snake, scorpion)
and human bite wounds. Journal of Trauma and Acute Care Surgery,
78(3), 641–648. https://doi.org/10.1097/TA.0000000000000531
Bula-Rudas, F. J., & Olcott, J. L. (2018). Human and animal bites. Pediatrics
in Review, 39(10), 490–500. https://doi.org/10.1542/pir.2017-0212
BENIGN
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SKIN LESIONS
DEFINITION
A.
A benign skin lesion is a cutaneous growth with no harm-
ful effects to the body. Benign lesions must be distinguished
from the following:
1.
Basal cell carcinoma: nodular tumor with pearly sur-
face, telangiectasia on surface, and depressed center or
rolled edge.
2.
Squamous cell carcinoma: irregular papule, with scaly,
friable, bleeding surface.
3.
Malignant melanoma: asymmetric papule, with irregu-
lar border, of two or more colors, and varied sizes.
INCIDENCE
A.
Benign lesions are common to all races and are seen pri-
marily in the adult and elderly populations.
BENIGN SKIN LESIONS
B.
Dermatosis papulosa nigra: hyperpigmented mole located
77
on face or neck; a pedunculated papule that is symmetric, 1 to
3 mm in diameter.
C.
Cherry angioma: vascular papule, red to purple, located
on trunk in adults; begins in early adulthood; 1- to 3-mm
diameter papules that do not blanch.
D.
Solar lentigines (liver spots): tan maculae on sun-exposed
areas in elders, especially on face and hands; with irregular
border and varied sizes.
E.
Sebaceous hyperplasia: enlarged sebaceous glands that
appear as yellow papules on sun-exposed areas, especially on
the face in elders; papules have central umbilication and with
varied sizes.
F.
Seborrheic keratosis: waxy papules with a stuck-on
appearance seen in adults; appear symmetric, 0.2 to 3.0 cm
in size, with a well-demarcated border and a variety of colors
(tan, black, and brown).
PATHOGENESIS
B.
The course varies, depending on the specic type of lesion.
PREDISPOSING
A.
Sun exposure in the adult and elderly populations.
B.
Dermatosis papulosa nigra: common in African Americans
FACTORS
and Asians.
COMMON
A.
OTHER
A.
COMPLAINT
New lesion on the skin.
SIGNS AND SYMPTOMS
Actinic keratosis (Figure 4.3): rough, scaly patch on the
skin that develops from years of exposure to the sun; most
commonly found on the face, lips, ears, back of the hands,
forearms, scalp, or neck; areas should be monitored closely as
they can become cancerous.
SUBJECTIVE
A.
Identify when the client rst discovered the lesion.
B.
Determine whether the lesion has changed in size, shape,
DATA
or color.
C.
Ask if the client has discovered more lesions.
D.
Elicit information regarding a family history of skin lesions
or cancer.
PHYSICAL
A.
Inspect:
EXAMINATION
1.
Observe skin; note all lesions and evaluate each for
asymmetry, border, color, diameter, evolving changes,
and/or elevation change.
2.
Note the client’s skin type.
DIAGNOSTIC
A.
Benign lesions do not require any tests.
B.
If unsure regarding possible malignancy, a biopsy is
TESTS
recommended.
DIFFERENTIAL
A.
Seborrheic keratosis.
B.
Dermatosis papulosa nigra.
C.
Cherry angioma.
D.
Solar lentigines.
E.
Senile sebaceous hyperplasia.
F.
Keratoacanthoma.
DIAGNOSES
FIGURE
4.3 Example of actinic keratosis.
Source:
Reproduced from Lyons, F., & Ousley, L. (2015).
Dermatology for the advanced practice nurse. Springer
Publishing Company, Figure III.48.
PLAN
A.
General interventions:
1.
Reassure the client that lesions are benign. No treat-
ment is required unless the client chooses to have the
lesion removed for cosmetic purposes.
2.
Benign skin lesions may be removed using cryother-
apy if they are bothersome to the client.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Skin Care Assessment.”
C.
Pharmaceutical therapy:
1.
Medications are not recommended for treatment.
FOLLOW-UP
A.
Routine skin examinations should be performed yearly.
CONSULTATION/REFERRAL
A.
Immediately refer the client to a dermatologist if malig-
nancy is suspected or conrmed by biopsy.
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