Integumentary- CD

GIL P. SORIANO, RN, MHPED

55
Topic Outline
Leprosy
German measles (Rubella)
Measles (Rubeola/Morbilli)
Chickenpox (Varicella)
Leprosy (Hansens disease, Hansenosis)

Leprosy is a chronic systemic infection

characterized by progressive cutaneous lesions.

Etiologic Agent
Mycobacterium leprae is an acid-fast bacillus that attacks cutaneous tissues and
peripheral nerves, producing skin lesions, anesthesia, infection and deformities.
Contrary to popular belief, leprosy is not highly contagious and actually has
low infectivity.
INCUBATION PERIOD

The incubation period of leprosy ranges from five-

and-a-half months to eight years.

MODE OF TRANSMISSION

1. The disease can be transmitted through respiratory

droplets.

2. Inoculation through the skin break and mucous

membranes may also be a mode of transmission.
 Leprosy occurs in three forms
1. Lepromatous leprosy (multibacillary)

This is the most serious type and is considered to be the

most infectious.

It causes damage to the respiratory tract, eyes and testes,

as well as the nerves and the skin.

Lepromin test is negative but the skin lesion contains

large amounts of Hansens bacillus.
1. Lepromatous leprosy (multibacillary)

There is gradual thickening of the skin with the

development of a granulomatous condition.

The lesions frequently appear as macules and become

nodular in character (leproma).

There is slow involvement of the peripheral nerves,

with some degree of anesthesia and loss of sensation
and gradual destruction of the nerves.
1. Lepromatous leprosy (multibacillary)

There is atrophy of the skin and muscles and eventual

melting or absorption of small bones, primarily those of
the hands and feet.

There is ulceration of the mucous membrane of the nose.

Because of the melting or absorption of small bones and

ulceration, natural amputation may occur.
2. Tuberculoid leprosy

It affects the peripheral nerves and sometimes the

surrounding skin, especially on the face, eyes and testes, as
well as the nerves and the skin.

Lepromin test is positive, but the organism is rarely

isolated from the lesions.
2. Tuberculoid leprosy

Macules are elevated, with clearing at the center, and are

more clearly defined than in the lepromatous form.

Anesthesia is present, and involvement of the peripheral

nerves occurs more rapidly than in the lepromatous form.
3. Borderline (dimorphous) leprosy
has the characteristics of both lepromatous and
tuberculoid leprosy. Skin lesions of this type of
leprosy are diffused and poorly defined.
PATHOLOGY

1. M. leprae attacks the peripheral nerves, especially the

ulnar, radial, posterior-popliteal, anterior-tibial and facial
nerves.

2. When the bacilli damage the skins fine nerves, they

cause anesthesia, anhidrosis and dryness.

3. If they attack a large nerve trunk, motor nerve damage,

weakness and pain occur, followed by peripheral anesthesia,
muscle paralysis and atrophy.
 Clinical Manifestation
1. Neural involvement
The earliest manifestations of the disease in most
cases are the result of nerve damage, as characterized by;

a. Atrophy of the muscles of the hands which extends to the

thenar, the hypothenar, and the forearm muscles,
resulting in clawhand.

b. Nerves often involved are the ulnar, median, readial,

lateral popliteal and facial.
1. Neural involvement

c. Paralysis and peripheral anesthesia can occur either

independently or concurrently.

d. Secondary consequences of nerve involvement

include malperforant, clawhand and ocular
complications incident to corneal insensitivity or
paralysis of the eyelids.
2. Skin
Lepromatous and tuberculoid leprosy differ greatly in their cutaneous
manifestations:

a. In lepromatous disease, early lesions are multiple,

symmetrical and erythematous, sometimes appearing as
macules or papules with smooth surfaces.

b. Later, these lesions enlarge and form plaques or nodules

on the earlobes, nose, eyebrows and forehead, giving the
patient a leonine appearance.
2. Skin
c. Eventually, there is the loss of eyebrows and eyelashes.

d. The loss of function of the sweat and sebaceous glands makes affected skin
appear dry and hairless.

e. Tuberculoid leprosy may be purely neural or may simultaneously affect the skin.

f. Raised, large erythematous plaques appear on the skin with clearly defined
boarders. As they grow, they become rough, hairless and hypopigmented, leaving
an anesthesia scar.
3. Eye
a. Specific ocular manifestations are found only in lepromatous and borderline
leprosy.

b. The conjunctiva, sclera, cornea and iris are affected, sparing the retina and optic
nerve.

c. Photophobia, conjunctivitis and iridocyelitis frequently occur. Opacity of the

cornea, insensitivity and ulceration can lead to blindness.
4. Upper respiratory tract

a. The nose, mouth, pharynx, larynx, trachea and

esophagus are often involved in lepromatous
leprosy.

b. Epistaxis, ulceration of the uvula and tonsils, septal

perforation and nasal collapse are also present.
5. Visceral leprosy

Apart from the skin and nerves, the heaviest

concentration of lesions is in the organs representing
the reticuloendothelial system, the lymph system
and the liver.

Testicular damage occurs in almost all moderately

advanced cases of lepromatous leprosy.
DIAGNOSTIC PROCEDURES

1. Identification of the signs and symptoms

2. Tissue biopsy

3. Tissue smear

4. Blood tests show increased RBC and ESR; and

decrease serum calcium, albumin and cholesterol levels.
MODALITIES OF TREATMENT

1. Sulfone therapy

2. Rehabilitation, recreational and occupational therapy

3. Multiple drug therapy (MDT)

a. The drugs used in MDT are combinations of rifampicin,

clofazimine and dapsone for multibacillary leprosy, and
rifampicin and dapsone for the pausibacillary type.
b. Among these, rifampicin is the most important anti-
leprosy drug and is therefore included in the treatment of
both types of leprosy.

c. Treatment of leprosy with only one anti-leprosy drug will

always result in the development of drug resistance.

d. Treatment of leprosy with dapsone or any anti-leprosy

drug used as monotherapy should be considered as an
unethical practice.
e. For multibacillary leprosy, rifampicin 600 mg is given once
a month; dapsone 100 mg daily; and clofazimine 50 mg
daily for a 12-month duration.

f. For paucibacillary leprosy, give rifampicin 600 mg once a

month, dapsone once daily; duration of treatment is 6
months.

g. Clofazimine causes brownish black discoloration and

dryness of the skin. However, this disappears within a few
months after stopping the treatment. This should be
explains to patients starting the MDT regimen for MB
leprosy.
h. MB and PB patients should have fixed-duration
treatment, which means:

for MB patients after taking 12 monthly doses of MDT,

the person is considered cured and should be removed
from the register;

for PB patients after taking 6 monthly doses of MDT, the

person is considered cured and should be discharged.
NURSING MANAGEMENT

1. If the patient is admitted to the hospital, isolation and

medical asepsis should be carried out.

2. Moral support and encouragement are necessary.

3. Diet should be full, wholesome and nutritious.

4. Special attention should be given to personal hygiene.

5. Terminal disinfection should be carried out.

COMMON NURSING DIAGNOSES

1. Impaired skin integrity

2. Social isolation

3. Ineffective coping

4. Knowledge deficit

5. Anxiety

6. Impaired body image

PREVENTION

1. Report all cases and suspects of leprosy.

2. Newborn infants should be separated from leprous

mothers.

3. BCG vaccine may be protective if given during the

first 6 months of life.

4. Health education should be given, with particular

focus on the mode of transmission.
German measles
(rubella/three-day measles)
An acute contagious disease characterized by mild constitutional
symptoms and a rose-colored macular eruption

It has a teratogenic effect on the fetus.

Infectious Agent
Rubella virus (Family-Togaviridae;Genus-Rubivirus)

Incubation Period
From exposure to the appearance of the rash, the incubation period is usually 14to 21
days

Period of Communicability
The virus is communicable approximately one week before and four days after the onset
of the rash, but is at its worst then the rash is at its peak. Highly communicable infants
with congenital rubella may shed virus for months after birth.
Mode of transmission
1.Direct contact with nasopharyngeal secretions
2.Air droplets
3.Transplacental transmission in congenital rubella
4.Rubella with congenital rubella shed large quantities of the virus
through their pharyngeal secretions and urine, which serve as a source
of infection to other contacts.
 Clinical manifestation
1. Prodomal period
Low-grade fever
Headache
Malaise
Mild coryza
Conjunctivitis
Post-articular, sub-occipital, and posterior cervical lymphadenopathy which occurs
on the 3rd to the 5th days after onset

2. Eruptive period
A pinkish rash on the soft palate (Forcsheimers spot), an exanthematous rash that
appears first on the face, spreading to the neck, the arms, truck, and legs.
Eruption appears after the onset of adenopathy
Children usally present less or no constitutional symptoms.
The rash may last for one to five days and leaves no pigmentation nor desquamation.
Testicular pain in young adults
Transient polyarthralgia and polyarthritis may occur in adults and occasionally in
children.
Treatment
Very little treatment is necessary; treatment is essentially symptomatic.

Complications
1.Encephalitis
2.Neuritis
3.Arthritis
4.Artharalgias
5.Rubella syndrome, manifested by:
Microcephaly
Mental retardation
Cataract
Deaf-mutism
Heart disease
Risk of congenital
malformation
1.100 percent- when maternal infection occurs on the first trimester of
pregnancy or first month of gestation
2.4 percent- in the second and third trimesters of pregnancy
3.90 percent of congenital rubella cases excrete the virus at birth and are
rare therefore infectious
4.10 percent- the virus remains contagious until the first year of age of
the infected child.
Clinical manifestation
(congenital Rubella)
1.Classic congenital rubella syndrome
Intrauterine growth retardation; infant has low birth weight
All manifestations of congenital rubella syndrome
Thrombocytopenic purpura known as blueberry muffin skin
Lethargy and hypothermia

2.Intrauterine infection
May result in spontaneous abortion
Birth of a live child who may have one or multiple birth anomalies such as:
a.Cleft palate, hare lip, talipes, and eruption of teeth
b.Cardiac defects (patent ductus arteriosus, atrial septal defect)
c.Eye defects (deafness usually bilateral, abnormally-shaped ears)
d.Neurologic (microcephaly, mental retardation, psychomotor retardation,
behavioral disturbances, vasomotor instability)
Nursing management
1.The patient shouls be isolated
2.The patient should be advised to rest in bed until fever subsides
3.The patientss room must be darkened to avoid photophobia
4.The patient must take a mild liquid but nourishing diet.
5.The petients eyes should be ittigated with warm noraml saline to relieve
irritation
6.The ears must be taken care of. Do not apply hear or cold compress unless
ordered
7.Good ventilation is necessary
8.The spread of infection must be prevented
9.The occurence of complications must also be prevented
10.Encourage increased fluid intake
 Common Nursing Diagnosis
Impaired social interaction
Knowledge deficit
Impaired physical mobility
Pain
High risk of infection

Prevention
1.Administration of live attenuated vaccine (MMR)
2.Pregnant women should avoid exposure to patients infected with the rubella virus
3.Administration of immun serum globlin one week after exposure to rubella
4.Prevent spread of infection by minimizing contact with visitors
Measles (Rubeola/Morbilli)
is an acute, contagious, exanthematous disease that usually affects
children who are susceptible to upper respiratory tract infection (URTI).
This may be one of the most common and most serious of all childhood
diseases

Etiologic Agent
Measles virus which belongs to the genus Morbilivirus of the family
Paramyxoviridae is the agent of measles.

The measles virus is rapidly inactivated by heat, ultraviolent light and

extreme degrees of acidity and alkalinity.
Incubation period
1. The incubation period is from ten to
twelve days (the longest is 20 days and the
shortest is 8 days).

2. A single attack conveys lifelong immunity.

Period of communicability
1. Measles usually last about nine to ten
days, measured from the beginning of the
prodromal symptoms to the fading of the
rash.
2. The disease is communicable four days
before and five days after the appearance of
rashes.
3. The disease is most communicable at the
height of the rash.
Source of infection
The virus has been found in patients blood,
as well as in the secretion from the eyes,
nose, and throat.
Mode of Transmission
1. The disease is transmitted through direct
contact with droplets spread through
coughing or sneezing.
2. It can also be transmitted indirectly
through articles or fomites freshly
contaminated with respiratory secretions of
infected patients.
Pathognomonic sign
Kopliks spots are pathognomonic of measles.
These are inflammatory lesions of the buccal
mucous glands with superficial necrosis.
1. They appear on the mucosa of the inner
cheek opposite to the second molars, or near
the junction of the gum and the inner cheek.
2. They usually appear one to two days before
the measles rash.
Clinical manifestation
1. Pre-eruptive stage
a. Fever
b. Catarrhal symptoms (rhinitis,
conjunctivitis, photophobia, coryza)
c. Respiratory symptoms starts from
common colds to persistent coughing.
d. Enanthem sign (Kopliks spot, Stimsons
line)
2. Eruptive stage
a. A maculo-papular rash usually starts to appear late on the 4th day.
b. The maculo-papular rash appears first on the cheeks, bridge of the
nose, temples, earlobes or along the hairline.
c. The rash is fully developed by the end of the second day and all
symptoms are at their most severe at this time.
d. High-grade fever comes on and off.
e. Anorexia and irritability.
f. Abdominal tympanism, pruritus, and lethargy.
g. The throat is red and often extremely sore.
h. As fever subsides, coughing may diminish, but more often it hangs on
for a week or two and becomes looser and less metallic
Stage of convalescence
a. Rashes fade away in the same manner as
they erupted.
b. The fever subsides as rashes starts to
fade.
c. When the rashes have faded,
desquamation begins.
d. Symptoms subside and appetite is
restored.
Diagnostic procedure
1. Nose and throat swab
2. Urinalysis
3. Blood exams (CBC, leukopenia,
leukocytosis)
4. Complement fixation or hemogglutinin
test
Modalities of treatment
1. Anti-viral drugs (isoprinosine)

2. Antibiotics if with complication

3. Supportive therapy (oxygen inhalation. IV

fluids)
Nursing management
1. Isolation of the patient is necessary (the room must
be quiet, well-ventilated and must have subdued light)
2. Control the patients high temperature with warm or
tepid sponges.
3. Skin care is of utmost importance. The patient
should have a daily cleansing bed bath. The water
should be comfortably warm.
4. Oral and nasal hygiene is a very important aspect of
the nursing care of a patient with measles.
5. Care of the eyes is necessary. The patient is sensitive
to light. Therefore, position the patient in such a way
that direct glare of light is avoided. Keep eyes free of
secretions.
6. Care of the ears is also important. It is the
responsibility of the nurse to be on the alert for any
signs of early mastoid infection.
7. Daily elimination is important. This can be
accomplished with a mild laxative, as prescribed by
the physician.
8. During the febrile stage, limit the diet to fruit
juices, milk and water. If the patient is vomiting,
give frequent, small servings of iced juices.
9. The patients position should be changed every
three to four hours.
10. Penicillin or other prescribed medications, are
usually given in cases where there is complications.
Complications
1. Bronchopneumonia
2. Otitis media
3. Pneumonia/Bronchitis
4. Nephritis
5. Encephalitis; encephalomyelitis
6. Blindness (seldom)
Unfavorable signals
1. Violent onset with high-grade fever
2. Fading eruption with rising fever
3. Hemorrhagic or black measles
4. Persistence of fever for ten days or more
5. Slight eruptions accompanied by severe
symptoms, especially those of encephalitis.
Common nursing diagnoses
Ineffective airway clearance
Altered nutrition: Less than body requirement
Impaired skin integrity
Activity intolerance
Knowledge deficit
Body image disturbance
Alteration in comfort
Sleep pattern disturbance
Altered body temperature
Preventive measures
1. Immunization with anti-measles at the age of
9 months, as a single dose. The first dose of the
measles-mumps-rubella (MMR) vaccine is given
at 15 months old, with the 2nd dose at 11 to 12
years. The measles vaccine should not be given
to pregnant women or to persons with active
tuberculosis, leukemia, or lymphoma, or those
with depressed immune systems.
2. Avoid crowded places to lessen the chances
or contracting the virus.
Chickenpox (Varicella)
is an acute and highly contagious disease of viral etiology that is
characterized by vesicular eruptions on the skin and mucous membrane
wit mild constitutional symptoms.
Infectious Agent
Herpesvirus varicellae a DNA containing virus.
Human beings are the only source of infection.
This is closely related or identical herpes zoster virus.
Incubation Period
The incubation period is 10 to 21 days
Period of Communicability
The patient is capable of transmitting disease about a day before the
eruptions of the first lesion up to five days after the appearance of the last
crop.
MODE OF TRANSMISSION
1. Direct contact with a patient who sheds the virus from the vesicles.
2. Indirect contact, through linens and fomites.
3. Airborne, or spread by aerosolized droplets from the nasopharynx
of ill individuals.
4. High viral titers are found in the vesicles of chickenpox; thus,
viraltransmission may also occur through the direct contact with
these vesicles, although the risk is lower.
5. Following primary infection there is usually lifelong protective
immunity from further episodes of chickenpox.
CLINICAL MANIFESTATIONS
Pre- eruptive manifestations are mild fever and malaise.
Eruptive stage
a) Rash starts on the trunk (unexposed area), then spreads to other
parts of the body.
b) Initial lesions are distinctively red papules whose contents become
milky and pus-like within four days.
c) In adults and bigger children, the lesions are more widespread and
more severe.
Papule is a lesion that is elevated above the skin
surface with a diameter of about 3mm
Vesicle is a pop-like eruption filled with fluid. The thin-
walled vesicle easily bursts and dries up in three to five
days.
Pustule is a vesicle that is infected or filled with pus. Of
the lesion becomes infected the scar may be big and
wide.
Crust is a scab or eschar. This is a secondary lesion
caused by the secretion of vesicle drying on the skin.
The scars are superficial, dipegmented and take time to
fade out.
Diagnostic Test
1. Determination of the V-Z virus through the complement fixation
test
2. Determination of the V-Z virus through electron microscopic
examination of vesicular fluid
TREATMENT MODALITIES
Oral acyclovir 800 mg 3x a day for five days must
also be given.
Oral antihistamine can be taken to symptomatic
pruritus.
Calamine lotion eases itchiness
Salicylates must not be given.
Antipyretic might be given for fever.
Antihistamine must be given.
NURSING MANAGEMENT
1. Respiratory isolation is a must until all vesicles have crusted.
2. Prevent secondary infection of the skin lesions through
hygienic care of the patient.
3. Attention should be given to nasopharyngeal secretions and
discharges. Linens must be disinfected under the sunlight or
through boiling.
4. Cut fingernails short and wash hands more often to minimize
bacterial infections that may be introduced by scratching.
5. A child must wear mittens
6. Provide activities to keep child occupied to lessen pruritus.
7. Observe oral and nasal care as rashes may appear in the
buccal cavity.
COMPLICATIONS
1. Chicken pox is rarely fatal, although it is generally more severe in adults
than in children.
2. Pregnant women and those with a supressed immune system are at the
highest risk of complications.
3. The most common late complications of chicken poxis shingles, caused by
reactivation of the varicella zoster virus decades after the initial episode of
chicken pox.
4. Secondary infection of the lesions- furuncles, cellulitis, skin abscess,
erysipelas
5. Meningoencephalitis
6. Pnuemonia
7. Sepsis
PREVENTIVE MEASURES
Active immunization with live, attenuated varicella
vaccine is necessary.
Avoid exposure as much as possible to infected
persons.
Patient must be isolated to avoid transmission of
organism to ther members of the family.