NCP Dermatitis

Dermatitis

Contact Dermatitis; Atopic Dermatitis; Eczema

Dermatitis is a descriptive term used for a group of diseases characterized by inflammation of the skin, with pruritus, redness, and various skin lesions. Contact dermatitis is a generic term applied to acute or chronic inflammatory reactions that are due to substances that come in contact with the skin. The reaction is localized to the area of the skin where contact occurs. Contact dermatitis is subdivided into irritant or allergic. Irritant contact dermatitis is a localized reaction to outside agents such as chemicals, cleaning agents, or cold air. Allergic contact dermatitis is a reaction to an allergen, which elicits an immunoglobulin (Ig) E-mediated hypersensitivity reaction. Poison ivy is an example of this type of reaction. Atopic dermatitis is associated with a personal or family history of atopy such as atopic dermatitis, asthma, hay fever, or allergic rhinitis. This form of dermatitis occurs most often in infants and children. Initial adult onset of atopic dermatitis is rare.

Nursing Diagnosis

Impaired Skin Integrity

Common Related Factor	Defining Characteristics
Contact with irritants or allergens	Inflammation Dry, flaky skin Erosions, excoriations, fissures Pruritus, pain, blisters
Common Expected Outcome Patient maintains optimal skin integrity within limits of the disease, as evidenced by intact skin.	NOC Outcomes Knowledge: Treatment Regimen; Tissue Integrity: Skin and Mucous Membranes NIC Interventions Skin Care: Topical Treatments; Skin Surveillance; Teaching: Procedure/Treatment

Ongoing Assessment

Actions/Interventions	Rationale
Assess skin, noting color, moisture, texture, temperature; note erythema, edema, tenderness.	Specific types of dermatitis may have characteristic patterns of skin changes and lesions.
Assess the skin systematically. Look for areas of irritant and allergic contact.	Flexural areas (elbows, neck, posterior knees) are common areas affected in atopic dermatitis.

Assess skin for lesions. Note presence of excoriations, erosions, fissures, or thickening.	Open skin lesions increase the patient’s risk for infection. Thickening occurs in response to chronic scratching (lichenification).
Identify aggravating factors. Inquire about recent changes in use of products such as soaps, laundry products, cosmetics, wool or synthetic fibers, cleaning solvents, and so forth.	Patients may develop dermatitis in response to changes in their environment. Extremes of temperature, emotional stress, and fatigue may contribute to dermatitis.
Identify signs of itching and scratching.	The patient who scratches the skin to relieve intense itching may cause open skin lesions with an increased risk for infection. Characteristic patterns associated with scratching include reddened papules that run together and become confluent, widespread erythema, and scaling or lichenification
Identify any scarring that may have occurred.	Long-term scarring may result in body image disturbances.

Therapeutic Interventions

Actions/Interventions	Rationale
Encourage the patient to adopt skin care routines to decrease skin irritation:	One of the first steps in the management of dermatitis is promoting healthy skin and healing of skin lesions.
·     Bathe or shower using lukewarm water and mild soap or nonsoap cleansers.	Long bathing or showering in hot water causes drying of the skin and can aggravate itching through vasodilation.
·     After bathing, allow the skin to air dry or gently pat the skin dry. Avoid rubbing or brisk drying.	Rubbing the skin with a towel can irritate the skin and exacerbate the itch-scratch cycle.
·     Apply topical lubricants immediately after bathing.	Lubrication with fragrance-free creams or ointments serves as a barrier to prevent further drying of the skin through evaporation. Moisturizing is the cornerstone of treatment. Over-the-counter moisturizing lotions include Eucerin, Lubriderm, and Nivea. Lotions are lighter and less emollient than creams. If more moisturizing is required than a lotion can provide, a cream is recommended. These include Keri cream, Cetaphil cream, Eucerin cream, and Neutrogena Norwegian formula. Ointments are the most emollient. Vaseline Pyre Petroleum Jelly or Aquaphor Natural Healing Ointment may be beneficial.
Apply topical steroid creams or ointments.	These drugs reduce inflammation and promote healing of the skin. The patient may begin using over-the-counter hydrocortisone preparations. If these are not effective, the physician may include prescription corticosteroids for topical use. Usual application is twice daily, thinly and sparingly. Do not use with an occlusive dressing, because this potentiates the action and systemic absorption of the steroid. Usual duration of use of topical steroids is up to 14 days in adults.
Apply topical immunomodulators (TIMs): ·     Tacrolimus (Protopic) ·     Pimecrolimus (Elidel)	Tacrolimus (Protopic) has recently been approved for the treatment of atopic dermatitis. TIMs alter the reactivity of cell-surface immunological responsiveness to relieve redness and itching. In 2005, the Food and Drug Administration advised a potential cancer risk with long-term use of pimecrolimus and tacrolimus based on animal studies.
Prepare the patient for phototherapy or photochemotherapy.	This treatment modality uses ultraviolet A or B light waves to promote healing of the skin. The addition of psoralen, which increases the skin’s sensitivity to light, may benefit patients who do not respond to phototherapy alone.
Encourage the patient to avoid aggravating factors.	Some change in lifestyle may be indicated to reduce triggers.

Nursing Diagnosis

Risk for Impaired Skin Integrity

Common Risk Factors
Severe pruritus Scratches skin frequently Dry skin
Common Expected Outcome Patient reports increased comfort level and skin remains intact.	NOC Outcome Tissue Integrity: Skin and Mucous Membranes NIC Interventions Skin Surveillance; Skin Care: Topical Treatments

Ongoing Assessment

Actions/Interventions	Rationale
Assess severity of pruritus.	Patients with dermatitis may develop an itch-scratch cycle. The extreme itchiness of the skin causes the person to scratch, which in turn worsens the itching. Many patients report the itching to be worse at night, thus disrupting their sleep.
Assess skin for excoriations and lichenification.	Scratching and rubbing the skin in response to the itching increases the irritation of the skin. When papules are scratched, they may break open, causing excoriations that become crusty and infected. Over time, constant rubbing and scratching cause the skin to become thick and leathery (lichenification).

Therapeutic Interventions

Actions/Interventions	Rationale
Encourage the patient to avoid triggering factors.	Contact with factors that stimulate histamine release will increase itching. Because irritants vary from one patient to another, each patient needs to determine substances and situations that aggravate the dermatitis.
Maintain hydration of stratum corneum.	Application of lubricating creams and ointments serve as a barrier to water evaporation from the skin.  Moist skin is less likely to experience pruritus.
Use cool compresses on pruritic areas of the skin.	Cool, moist compresses help relieve pruritus and itching. Additionally, cool baths with colloidal oatmeal (e.g., Aveeno) can provide relief.
Encourage the patient to keep fingernails trimmed short.	Long fingernails used for scratching are more likely to cause skin trauma and aggravate itching.
Administer antihistamine drugs.	Antihistamines such as hydroxyzine will help relieve itching and promote comfort. These drugs can be taken at bedtime. Their sedative effect may also help promote sleep. During the daytime, nonsedating antihistamines may increase the efficacy of pruritus control. Loratadine is an over-the-counter medication.
Apply topical antipruritic agents if indicated.	These may be used alone or combined with oral antihistamines. Over-the-counter products include Sarna lotion, Prax lotion, and Itch-X gel. Prescription Cetaphil with menthol may also help.
Apply topical steroid creams if indicated.	Do not apply on the face. Use thinly and sparingly, up to a maximum of 14 days. Do not use with occlusive dressings.
Administer oral steroids.	Short-term low-dose oral steroids may be ordered for severe cases. Oral steroids are not indicated for long-term use despite their efficacy.

Nursing Diagnosis

Risk for Infection

Common Risk Factors
Impaired skin integrity Severe inflammation Excoriation
Common Expected Outcome Patient remains free of secondary infection.	NOC Outcomes Risk Detection; Risk Control; Tissue Integrity: Skin and Mucous Membranes NIC Interventions Skin Surveillance; Infection Control; Infection Protection

Ongoing Assessment

Actions/Interventions	Rationale
Assess skin for severity of skin integrity compromise.	The skin is the body’s first line of defense against infection. Disruption of the integrity of skin increases the patient’s risk of developing an infection or of scarring.
Assess for signs of infection.	Patients with dermatitis are at highest risk for developing skin infections caused by Staphylococcus aureus. Purulent drainage from skin lesions indicates infection. With severe infections, the patient may have an elevated temperature.

Therapeutic Interventions

Actions/Interventions	Rationale
Apply topical antibiotics.	Topical antibiotics may be used to treat infections that occur with dermatitis.
Administer oral antibiotics.	Oral antibiotics may be more effective in treating infections on the skin.
Encourage the patient to use appropriate hygiene methods.	Keeping the skin clean, dry, and well lubricated reduces skin trauma and risk of infection.

Nursing Diagnosis

Disturbed Body Image

Common Related Factor	Defining Characteristics
Visible skin lesions	Verbalizes feelings about change in body appearance Verbalizes negative feelings about skin condition Fear of rejection or reactions of others
Common Expected Outcome Patient verbalizes feeling about lesions and continues daily activities and social interactions.	NOC Outcome Body Image NIC Intervention Body Image Enhancement

Ongoing Assessment

Actions/Interventions	Rationale
Assess the patient’s perception of changed appearance.	The nurse needs to understand the patient’s attitude about visible changes in the appearance of the skin that occur with dermatitis.
Assess the patient’s behavior related to appearance.	Patients with body image issues may try to hide or camouflage their lesions. Their socialization may decrease based on anxiety or fear about the reactions of others.

Therapeutic Interventions

Actions/Interventions	Rationale
Assist the patient in articulating responses to questions from others regarding lesions and contagion.	Patients may need guidance in determining what to say to people who comment about the appearance of their skin. Dermatitis is not a contagious skin condition.
Allow patients to verbalize feelings regarding their skin condition.	Through talking, the patient can be guided to separate physical appearance from feelings of personal worth.
Assist patients in identifying ways to enhance their appearance.	Clothing, cosmetics, and accessories may direct attention away from the skin lesions. The patient may need help in selecting methods that do not aggravate the skin lesions.