Nursing Therapeutics IV

Ms Ivy WONG & Mr Edmond TONG

Continuous assessment & Exam

 Examination 50%

 PBL 50%

 Online discussion x 4 20%

 Group presentation x 1 30%

 Assessment criteria
 Attendance: 80% (Lecture) 100% (Lab + SPS)

 Online discussion: see Blackboard

 Group project and presentation: see Blackboard

 Student must pass all components

Integumentary System
 Skin
 Hair
 Scalp
 Nail
- Diagnostic tests: as in NT II & III
- Eczema / Atopic dermatitis: Allergy and emergency
- Skin Cancer: Primary prevention and screening
- Psoriasis: Impaired body image and stigma
- Genetic disorders: rare
- Rx: Antibiotics / Anti-virals / Anti-mycotics
 Neisseria gonorrhoeae  Gonorrhoea

 Chlamydia trachomatis  Chlamydial infections

 Treponema pallidum  Syphilis

Common viral infections &
Parasitic organisms
 Human immunodeficiency virus AIDS
 Herpes simplex virus type 2 genital herpes
 Human papillomavirus HPV and Ca Cervix
 Hepatitis B virus (HBV)
 Cytomegalovirus (CMV) causes inflammation in a
number of organs including the brain, the eye, and the
bowel
 Trichomonas vaginalis (causes vaginal trichomoniasis)
 Candida albicans (causes vulvovaginitis)
Did you missed sexuality in your last history
taking? Intentional or unintentional
 Unprepared
 Ill at ease
 Embarrassed
 “nurses expect clients to initiate discussion
about sexuality while clients want nurses to
introduce the topics” Waterhouse & Metcalfe in Sharkey, 1997
Facts
 Patient always appreciated
 Be holistic
 Any omission is a negligence
 sexual abuse, child abuse, erecticle
dysfunction
 Be prepared in developing interpersonal
skills and aware of the assessment
procedure and environment
Sharkey, 1997
Relevance
- STI, HIV, Cancers, infertility, HT, DM…..
- Always open up the discussion
Sexuality training
- No personal bias, prejudice or moral judgement
- Fear of arousal and stir up sexual issues
- Awkwardness with sexual language
Embarrassment and Fear of offending
- Be sensitive and ask gender neutral questions
- ask simple questions first / focus medical concern
- let the information revealed guide the discussion
- Changing sexual behaviour may reduce risk
Warner et al, 1999
Principles
 Ensure privacy and confidentiality
 Be professional
 Be open minded and non-judgmental
 Recognise non-verbal cues
 Ask only appropriate questions
 Explain procedures and treatment thoroughly
 Use the time to promote risk reduction and sexual
health
Jones & Barton, 2004
 Structured approach
1. When did you last have sexual intercourse?
2. With a man or a woman?
3. Were they a casual or regular partner?
4. Where were they come from?
5. In which country did you have sex?
6. What kind of sex did you engage in?
- anal / oral / vaginal
- use of condom / LMP / contraceptives
7. Does your partner has any symptoms?
8. Have you had any other partners in the last 6 weeks/ (return to Q.2)
9. Did you have pain during or after intercourse?
10.. Have you ever had any previous STIs (information giving and
counselling?
11. Have you ever had a sexual health check up before (explain and offer)?
12. Have you ever had an HIV/hepatitis/syphilis test before (explain VCT)?
13. Have you ever vaccinated against Hep A / B or have you ever had
hepatitis (assess risk and offer if appropriate)
Jones & Barton, 2004
Countering stigma in Sexual Health Care
Settings

“ If you do something as natural breathing, you risk

getting influenza virus, and if you do something
as natural as having sex, you risk getting Human
papilloma virus”

“…New Practitioners need to consider the work

involves a professional commitment to the rights
of women to reproductive choice, to sexual
diversity and to sexual health care for minors…”
White & Mortensen, 2005
White & Mortensen, 2005
Stigma is about beliefs and attitudes.

Discrimination relates to actions.

Both are based on negative views of people

simply because they are seen as belonging
to a particular group. HIV and AIDS is
commonly associated with stigma and
discrimination. This may be because HIV
can be associated with issues such as death,
sex and drug use.
The process of destigmatisation is the process that nurses use to
manage sexual health care. Through interactions with clients,
colleagues and communities, sexual health nurses learn the symbolic
meaning of work that is involved with sexuality. Sexually transmitted
infections are a social attribute as much as they are health
problem.

The experience of an STD STI is feeling socially and physically

contaminated. The management of sexual health involves the
treatment of infection and of the social impact of such infections.

Destigmatisation is a conscious process of the reversal of the

negative cultural messages about STDs. Nurses daily are engaged in
counteracting shame, fear and anxiety among sexual health clients.
Destigmatising is a concept for care that is based on the human
rights and dignity of each individual in health care. A positive
experience of health care with a stigmatised disease can alter client
self-perception and self-esteem.
Price, B. (2005). Practical guidelines on sexual lifestyle and risk.19(27), 46-55.
Viral Infections : Varicella (Chickenpox)
Varicella Zoster Virus (VZV)

 highly infectious

 airborne + droplets + contact

transmission

 latent infection in a sensory nerve

ganglia of a dermatome 
Shingles

 Incubation Period - 2 Weeks

Prodromal S/S - (2-3 Days)
- low grade fever & chills
- malaise & anorexia
- arthralgias & myalgias
Acute / Cutaneous Lesions -
- Erythematous Maculopapules
- Small Vesicles on a Erythematous Base
- pustules
- Crusted Lesions
- Extreme Pruritus
Complications -
- Scarring
- Reye’s Syndrome (with administration of Aspirin)
Viral Infections : Varicella Zoster Virus (VZV)
Prevention :
Live Attenuated Varicella Vaccination x 2 doses
(by GP in HK & free from SN)
70 - 90% protection
Contraindications -
Hx of anaphylactoid reaction to Neomycin
Immunocompromised / Immunosuppressed Patients
Poor morbidity
Pregnancy & Breast Feeding
Blood Transfusion within the preceding 5 Months
Rx: Varicella-Zoster Immune Globulin (VZIG)
Herpes Zostser (Shingles)
 Following initial infection (varicella), VZV establishes
permanent latent infection in dorsal root and cranial nerve
ganglia
 Years to decades later VZV reactivates and spreads to skin
through peripheral nerves causing pain and a unilateral
vesicular rash in a dermatomal distribution
 ~1 million cases in the U.S. annually
 Lifetime risk of developing zoster: about 30%
 Less infectious than Chickenpox
 Tzanck Smear for diagnosis
CDC, 2010
Herpes Zostser (Shingles) :
Initial Symptoms -
Pain & Paresthesia in the affected Dermatome
Classical Presentation -
Grouped Vesicles on an Erythematous Base
Unilateral or Bilateral Dermatome Eruptions
Constant or Intermittent Intense Burning Pain
Complete Lesions Resolution: resolves in 10-15 days  2-3 / 52
Scarring
Postherpetic Neuralgia (PHN)
Itchiness
Contralateral hemiparesis (eye), multifocal vasculopathy (TIA),
VZV encephalitis (face) and retinal necrosis (months)
Treatment :
Antiviral Therapy e.g. Forscarnet, Acyclovir, Valacyclovir (O)
- starts within 2- 3/7
- for immuno-compromised hosts
e.g. HIV, kids & elderly; Herpes Ophthalmoticus
Symptomatic Therapy
- Narcotic analgesia x pain control
- Antihistamine for Pruritus
- Cool Compress
Topical Zostrix (Capsicum) cream: Capsaicin  Red pepper
Prevent & Treat Secondary Infection
- Systemic Corticosteroid Therapy
- Tricyclic Antidepressant e.g. Amitriptyline
- Gabapentine (Antiepileptic drug) for PHN
 Herpes Simplex Virus
Herpes Simplex:
Recurrent Systemic Viral Infection
Herpes Simplex I - Cold Sores
Herpes Simplex II - Sexually Transmitted Infection (STI)
Complications -
Aseptic Meningitis
Transverse Myelitis
Spontaneous Abortion
Predisposition to CA Cervix
Herpes simplex virus:
positive Tzanck smear
Human papillomavirus (HPV)
 Common Warts / Verruca vulgaris
 in hands and foot + genitals/ (STI)
 30/100 are sexually transmitted
 Latent period: months to years
 Rx: Imiquimod cream + surgery
 Prevention by vaccination vs 6/11/16/18

Jordon, 2008
 Efficacy of Quadrivalent HPV
Vaccine in Men
 Randomized, double-blind, placebo controlled trial of Quadrivalent
(6/11/16/18) HPV vaccine
• 3 doses (0, 2, 6 months)
 3,463 men ages 16-23; 602 MSM ages 16-26
• 1-5 partners in past year
• No history of genital warts
Per protocol analysis*
% 95%
Population, endpoint Quad vaccine Placebo Efficacy CI
Cases Rate Cases Rate
All subjects, external genital
3/1397 0.1 31/1,408 1.1 90.4 69.2, 98.1
lesions
MSM, 6/11/16/18-related AIN 5/299 1.3 24/299 5.8 77.5 39.6, 93.3
MSM, persistent HPV 0.6 per 4.1 per
15 101 85.6 73.4, 92.9
6/11/16/18 DNA 100 PY 100 PY

AIN = anal intraepithelial neoplasia

* Completed 3 injection series within time windows, endpoint after month 7.

Jessen H, et al. 18th IAC; Vienna, July 18-23, 2010; Abst. THLBB101.
Bacterial Infections : Impetigo
 Common in Children
 Group A -hemolytic Streptococci (GAS)
 Staphylococcus Aureus  Bullous form
 Non Bullous form
 Risk Factors :
 Crowding / regionalised
 Poor hygiene
 Pre-existing dermatoses e.g. Atopic Dermatitis
Bacterial Infections : Impetigo
Clinical Manifestations :
- Vesicles or pustules
- “Honey-Coloured” crust
- pruritus
Common Occurrences
- face
- extremities
- periorificial locations
- regional lymphadenopathy
- large flaccid bullae
Non bullous impetigo & bullous impetigo

AAFP, Mar 15 2007

 Bacterial Infections : Impetigo
Complications : rare
Glomerulonephritis  ? Streptococcal
Rheumatic Fever

Treatment :
resolves on its own within 2-3 Weeks
topical Bactroban (mupirocin calcium 2 %)
Oral antibiotics: Augmentin, cephalosporins, macrolides
 Candidiasis (Yeast) 酵母菌
 Candidia Albicans -
An Opportunistic Yeast-like Fungus
 Commonly Affected Areas :
 Oral & Genital mucosa
 Intertriginous body folds
 Diaper area
 Paronychium (nail border)
 Predisposing Factors :
 Immunodeficiency
 Antimicrobial medications
 Systemic diseases
Clinical Manifestations :
Oral Candidiasis (Thrush)
Cutaneous Candidiasis
Candidal Paronychia (infected nail
folds)

Candidal onychomycosis (infected

nails)
Systemic Candidiasis
Chronic Mucocutaneous
Candidiasis - Rare
Fungal Infections : Tinea (mold) 癬
 Spread by direct or indirect contact

 Dermatophytes grow in the non living cornified

layer of keratinized tissue

 Trichophyton rubrum (T. rubrum), T.

Mentagrophytes Var. interdigitale and
Epidermophyton floccosum are the commonest
causative organisms
Tinea Capitis
- Well-delineated patch hair loss
- Scales
- Folliculitis
- inflammation and/or Kerion*
Fungal Infections : Tinea
Clinical Manifestations : Tinea Corporis
Tinea Corporis
- pink to red annular rings with
central clearing and scale
Tinea Cruris (jock itch)
- red lesions with raised borders
- sharp margins
Tinea Unguium
- Most common invade from the distal end
- thickened & crumbling Nail
- Subungual debris
Tinea Unguium Dermatology Nursing (1995)
Wood’s lamp:
fungal infections
 Interdigital Tinea Pedis

Clinical Manifestations:
 Tinea Pedis
 Pain
 Diffuse Scaling Fleischer et al (2000)

 Overgrowth of Various Bacteria

 Vesiculobullous Infections
 Maceration in the Interdigital Space
Rx: Clotrimazoles cream as candida x 2/52
Griseofulvin p.o. body, palm, sole: 2-6/52;
finger, toe nail:  8-12/12
Rx: Fungal Infections & Candidiasis
Antifungals / Antimycotics
1. Polyene
- Nystatin: Candida only
- Amphotericin B IVI in severe infections
2. Imidazole: both Candida and tinea
- Clotrimazole L.A. b.d. x 2-3/52
3. Triazole: both
- Fluconazole IVI - side effects: hepatitis, Prolong QT interval
and avoid use in breast-feeding mothers
4. Others
- Griseofulvin p.o. skin 2-4/52, 4-6/52 scalp, 4-8/52 foot, 3-4/12
fingernail & 4-6/12 toenail (less popular)
Lamisil (Terbinafine)
 Squalene monooxygenase inhibitor
 Terbinafine inhibits the production of ergosterol in such a
way as to lead to the build up of the ergosterol precursor
known as squalene. Having the wrong structural
components disrupts the function of the cell wall as a
barrier. Without the protection of its outer armor (the cell
wall), the fungal cell will die.

Itraconazole works by inhibiting the fungal enzymes

that produce “ergosterol,” an important component of the
fungal cell wall. Without adequate ergosterol, the fungal
cell becomes weak, leaky and ultimately dies.
Amphotericin B liposome
Indications:
- Empirical therapy for presumed fungal infection in febrile,
neutropenic patients.
- Cryptococcal Meningitis
- Aspergillus species
- Candida species and/or Cryptococcus species infections
- visceral leishmaniasis
Dosage: 3-6 mg/Kg/Day x 5 days and weekly dose up to 21-
38 days; q.d. x 2-4 weeks *
Side effects: N/V/D, abdominal pain, chills, hypertension,
hypotension, tachycardia, hypoxia, hypo-kalemia/Mg, and
various events related to decreased renal / liver function,
ARDS…
Administration: diluted in water only and infused with D5%
after filtered with 5 micron filter, infuse over 2 hr
 AmBisome

Amphotericin B Liposome Inj. 50mg/bot and 5 micron filter

Particles of 5 to 20 microns size and larger have the capability of
obstructing blood flow through pulmonary capillaries, which could
lead to complications such as pulmonary embolism
 Patient teaching
 Instruction regarding medications, use of oral
and topical agents, and shampoos
 Instructions regarding hygiene: use clean towels
and washcloths every day
 Do not share towels, combs, etc.
 Keep skin folds and feet dry
 Wear clean, dry, cotton clothing including
underwear and socks; avoid synthetic
underwear, tight-fitting garments, wet bathing
suits, and plastic shoes
 Avoid excessive heat and humidity
 Hair loss associated with tinea capitus is
temporary
Brunner & Saddarth, 2012
www.psoriasis.org
Psoriasis
Are they infectious and chronic?
Will it affect joints and nails?
Is it caused by allergy?
Is it curable?
Psoriasis
- Acanthosis: epidermal thickening
- Parakeratosis: retention of nuclei in the stratum
corneum
- Supra-papillary thinning: only a few layers of epidermal
cells are noted above the dermal papillae
- Increased prominence of papillary vasculature
- Chronic inflammation cell infiltrate in the dermis
Characteristics: erythema, induration (hardening),
desquamation with oval-shaped plague
Triggers: Beta blockers, NSAIDs, antimalarial drugs and
streptococcal URTI and the withdrawal of long term
steroid
Jackson, 2002
Wagner, E. F. et al. (2010) Psoriasis:
what we have learned from mouse
models
Nat. Rev. Rheumatol.
doi:10.1038/nrrheum.2010.157
Psychological impact:
- low self esteem, distorted self-perception, depression and
anxiety.
- Social and Sexual relationships might be difficult to
establish or maintain if the patient lacks confidence or
fears rejection
- Social isolation e.g. avoid swimming, hair-dressing and
sun-bathing
- Assess Quality of Life and Psychosocial disability,
individual coping mechanism and family support
- Assess signs and symptoms of Depression
- Assess stressors at work and any effects on daily life
- Assess compliance to treatment and side effects of Rx
Jackson, 2002
 Treatment
Anti-proliferative, anti-inflammatory drugs and keratolytics
Local application:
- Coal tar (0.5-5%): burning sensation & staining of clothes
- Dithranol (0.1-6%): burning and brown purplish
discolouration
Systemic application:
- Steroid
- Vitamin D3 analogue: block T cell proliferation
- Methotrexate / Cyclosporin
Second line treatment
- Phototherapy (narrow band UVB (NBUVB) x 3 in 1/52)
- Photochemotherapy PUVA (Psoralen + UVA)
Before treatment:
1) Written consent after explanation of the procedures
2) Take clinical photograph
3) Ensure the patient and operators having eye-protection
e.g. Novesin eye drop, eye shield
4) Prepare local anaesthetics if necessary
Lignocaine (without adrenaline) or
EMLA cream (1 hour before Rx with Tegederm
occlusion
5) Lock the door and turn on the warning lamp
After treatment:
1) Apply antiseptic cream (Ag sulphadiazine, fucidin) or
aqueous cream
2) Arrange follow-up appointment
Skin Cancer: Squamous / Basal
 Sun exposure: UV
 BCC / SCC / Melanoma***
 UVA: aging of skin
 UVC absorb by the ozone layer
 Environmental exposure in SCC
 X ray radiation
 Tar, mineral oils, soots, arsenic ingestion,
chemical, virus
 Non healing ulcers in SCC
A = Asymmetry: One half is unlike the other half.

B = Border: An irregular, scalloped or poorly defined

border.

C = Color: Is varied from one area to another; has shades

of tan, brown or black, or is sometimes white, red, or
blue.

D = Diameter: Melanomas are usually greater than

6mm (the size of a pencil eraser) when diagnosed, but
they can be smaller.

E = Evolving: A mole or skin lesion that looks different

from the rest or is changing in size, shape or color.
 Basal cell carcinoma: curable*

- caused by sun exposure and burns

- originated from Basal cells
- commonest skin cancer
- raised pearly edge and telangiectasia
Squamous cell carcinoma

-appeared as non-healing lesions

-affects keratinocytes of the epidermis
-Metastasis through LN
Malignant Melanoma
 Most fatal and serious among fair skin
people
 arised from melanocytes (pigment originally
as a natural protection of UV)
 uncontrolled growth of visible lesions are
seen
 Tumours < 0.76mm deep are in situ tumours
and are potentially curable and > 2mm deep
has less favourable prognosis
(Buchanan, 2001)
 Primary prevention
 National health education on UV protection from
exposure

 Secondary prevention
 Early diagnosis and treatment
 Size / shape / colour / sensation / bleeding, oozing
and crusting
 ABCDE & Subungal melanoma
Other laboratory investigations
DERMATOPATHOLOGY
SEROLOGY
Search for hepatitis-associated antigen, assessment of the
complement system, assessment of specific IgE antibodies
by radioallergosorbent test (RAST), anti-Fc RI
autoantibodies (Human IgE receptor). Serology for lupus
and Sjögren's syndrome.
HEMATOLOGY
LFT / RFT / Thyroid function tests / Fe / Diabetes
COMPLEMENT STUDIES: decreased serum complement
(C3 and C4) levels indicate active SLE
USG: biliary obstruction in cholestasis (with elevated alk PO4)
PARASITES: stool specimen for presence of parasites.
Chan & Tang, 2003
 Pruritus
- Rule out primary cause with Ix e.g. environment, stress
and fabrics
- Irritations, inflammation and underlying diseases
- Cycle: itch  scratch  itch
- Dry skin: warm bath + emollient
- Cool the surroundings, wear light clothes and apply cool
lotions and cream
- Antihistamine (H1 receptor antagonists), steroid as 2nd
line for eczema, bullous pemphigoids
- TENS
- Phototherapy (PUVA) + UVB
- Ondansetron (5HT3 receptor antagonist), Naloxone
(Opiate antagonist) x Cholestasis
Chan & Tang, 2003
Topical preparations
 Ointment: more occlusive (to retain moisture)
 Cream: easy to apply
 Gels and lotions: apply on scalp
 Solution
 Powder
 Tincture e.g. iodine tincture (alcohol base)

Standard precautions and transmission based precautions

Absorption depends on the skin conditions

e.g. weeping lesions and inflammation
LASER in Dermatology
 PDL (Pulsed dye laser)
 standard for vascular lesions
 lower complications e.g. purpura, pain and erythema
 Intense pulsed noncoherent light: 500-1200nm, train
of pulse 2-25 ms, interval 10-500 ms,
 Quasi CW mode (APTDL, Krypton, KTP)
 Larger calibre vessels (higher fluence 50-75j/cm2)
 Complications:
 Hyper- / Hypo-pigmentation
 Scar formation, Keloid
 Infection
Port wine stain
Advice to patient:
1) Expect a sunburn-like reaction with possible blistering within the first
24-48 hours. Pain is usually minimal and can be relieved with either
Panadol and/or cool soaks with a wash cloth.
2) A crust or scab may occur and should last for 7-14 days. Do not pick
off the scab!! Just let it fall off at its own pace.
3) Keep the area clean and dry until the scab/crust falls off. Wash gently
with soap and water and apply a thin layer of moisturizer or antibiotic
ointment.
4) Once the scab/crust has come off the area may look pink and even
slightly depressed or indented. Both the pinkness and depression
should improve over the next several weeks to months.
5) Avoid direct sunlight or sun exposure to the treated areas for 3-6
months. Use at least an SPF of 15 or greater sunscreen, or wear a hat
or other protective clothing (preferably both). Be aware that
unprotected sun exposure can result in an uneven repigmentation,
producing brown spots that can take months to fade away and in rare
cases may be permanent.
6) Be patient!! It may take up to three months to adequately judge the true
response of your condition to the laser treatment. DON'T
HESITATE TO CALL IF YOU HAVE ANY QUESTIONS OR
PROBLEMS!! Handbook of Dermatology and Venereology, 2006
Drugs in Dermatology
Steroid
- low to high dose < 10 mg prednisone/day
- in different forms e.g. cream / tablets
Antihistmaine & antiallergic
- H1 receptor antagonist: Loratidine (Clarityne TM)
- Chlorphenaramine (piriton)
Antifungals & Antibiotics
Anti-neoplastic / anti-rejection for eczema
e.g. Tacrolimus and cyclosporin in Transplant
Wu, T. C. (2007). Clinical Aspects and Treatment of CA-MRSA
Infection. The Hong Kong Medical Diary. 12 (12), 14-17.
Chapter 41: Management of clients with sexually transmitted infections

Online text: PolyU

Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology
Fitzpatrick's Dermatology in General Medicine
The Electronic Textbook of Dermatology : http://www.telemedicine.org/stamford.htm
http://emedicine.medscape.com/dermatology
Buchanan, P. (1998). Dermatology. Nursing Standard. 12 (40), 48-55.
Chan, L. Y. & Tang, Y. M. W. (2003). Management of Pruritus. HKMA-CME Bulletin.
January, 1-6.
Jackson, K. (2002). Chronic plague psoriasis: an overview. Nursing Standard. 16(51),
45-52, 54-55.
Jordon, K. (2008). Sexually transmitted infections: a major challenges for Advanced
Practice Nurses. Advanced Emergency Nursing Journal. 30(1), 63-74.
Jones, R. & Barton, R. (2004). Introduction to history taking and principles of sexual
health. Postgraduate Med J. 80, 444-446.
Freak, J. (2004). Promoting knowledge and awareness of skin cancer. Nursing
Standard. 18(35), 45-56.
Price, B. (2005). Practical guidance on sexual lifestyle and risk. Nursing Standard.
19(27), 46-52.
Wilson, D. (2014). Herpes zoster: a rash demanding careful evaluation. Nurse
Practitioner. 39(5), 30-36.