Description: An overview of preparation of wet dressings and therapeutic baths describing the purpose and different types of treatment and looking directly at dressings.

A dressing may be rinsed in the appropriate solution before application this is the preferable procedure if warmth is desired, or the solution may be added for example, with an Asepto syringe after it is in place. Care must be taken lest the dressings become excessively soaked and the solution runs over into normal areas. Sterile towels hold the dressings in place; they may be protected further by plastic film secured with bandage, if necessary. So arranged, the temperature of the dressing can be maintained for several hours. The use of external heating appliances is not only unnecessary but undesirable, because the danger of burning the skin is very real.

A stocking may be converted into a convenient wet dressing for the leg, and a glove similarly prepared for the hand. Face lesions should be dressed with gauze fashioned into a mask and applied in several thicknesses. If wet dressings are required to cover extensive areas of the body, flannel pajamas soaked in the solution serve as a useful form of dressing. The full bath may be used as a total wet dressing if it is desfrabje to treat the whole skin surface, care being observed to avoid chilling.

Remoistening of the dressing may be accomplished by removing the protective cloaks and pouring solution over the gauze, or the gauze may be removed completely, immersed again in the solution and then reapplied. If the remoistening is done without removal of the gauze, applications of sterile water are alternated with those of solution, particularly if the solution contains a metallic salt, which becomes continuously more concentrated through evaporation. If an exudate is present, the dressing should, of course, be changed completely at frequent intervals.

Baths are useful as a means of applying medications to large areas of the skin, removing crusts and scales and relieving itching that accompanies acute dermatoses. Usually the temperature of the water is 35 to 38° C. (95 to 1000 F.). Caution the patient against slipping in the tub, especially after emollient preparations have been used. Dermatologic Medications and Dressings Medications in the form of powders, lotions, creams and ointments are used to treat skin lesions. In general, lotions and emulsions are used for the more acute dermatoses when large areas of skin are involved. Lotions exert a cooling action through water evaporation; they also have a protective effect and are applied easily with a soft paintbrush. Powders are dusted on the skin with a shaker or with cotton sponges. Although their medical action is brief, powders absorb moisture and reduce friction between the skin and the bedding. Pastes are mixtures of powders and ointments and are used in inflammatory conditions. Ointments retard water loss and are preferred in the more chronic or localized skin conditions. Pastes and ointments are applied with a wooden tongue depressor. The patient should be taught to apply them gently but thoroughly.

Many of these topical applications are greasy and require a covering with dressings to prevent soilage of clothing. If it is to be satisfactory, a dressing must be comfortable as well as protective. Plastic film is advantageous because it is thin and adapts itself readily to anatomic structures of all shapes and sizes. Stretchable cotton dressings (Surgitube, Tubegauze) likewise are excellent covering materials.

Corticosteroids are being widely used in the treatment of many dermatologic conditions. Topical steroids frequently are used to suppress inflammation, thus relieving pain and itching. Instruct the patient to use only small quantities of steroid cream and to rub it in thoroughly. If the area covered by the steroid cream is wrapped with an occlusive dressing, the humidity under the dressing rises and increases the penetration of the steroid. Plastic film occlusion thus increases the efficacy and reduces the expense of topical steroid treatment. Corticosteroids are also used in intralesional therapy and are given systemically.

Disposable polyethylene gloves make acceptable coverings for patients who require finger and hand dressings. When large body areas require covering, disposable diapers are useful. The plastic side is placed next to the skin and the diaper is held in place by being pinned to the underclothing. These plastic covers are useful as occlusive dressings to keep local creams, ointments or soaks moist and effective for prolonged periods.

The patient with a dermatologic problem has to take an active part in his treatment. He must be able to apply and remove his medications and dressings. Therefore, he must be indoctrinated fully regarding treatment techniques and the observations he is expected to report to his physician. In short, he participates in his own therapy as an assistant to the physician and the nurse.

Description: An overview of a nurses responsibilities and explaining these responsibilities also clinical observations of the skin and reactions and which ones cause a break in the skin.

The nurse should accustom herself as quickly as possible to the less attractive aspects of dermatologic disease and overcome as completely as possible her personal and natural sense of repugnance when in close proximity to dermatologic patients. Conscious effort in that direction will make such contact progressively easier. She must never betray a reluctance to touch her patient, which would only add to his anxiety, frustration and humiliation, but must cultivate an attitude that promotes a sense of security and tends to restore optimism.

Patients with skin disease frequently are embarrassed and self conscious as a result of unattractive or disfiguring lesions or because of the necessary display of conspicuous dressings. Also, they may be depressed and frustrated by the protracted course of the disease and being constantly scrutinized by people who might be repelled by and fearful of the disease. These psychological aspects of dermatologic practice require expert management on the part of the attending nurses, who must exhibit an understanding and unending patience and offer tireless encouragement to their patients. Persistent pruritus, with resultant sleeplessness, may be a potent contributing factor to an anxiety state, which in turn inevitably reinforces discomfort and fatigue.

Many systemic conditions may be accompanied by dermatologic manifestations. In fact, any patient hospitalized with a medical or surgical condition may suddenly develop itching and a rash. The nurse must be able to describe the dermatosis Abnormal condition of the skin clearly and in detail. The following questions are pertinent: What is the color of the lesion? Is there redness, heat, pain or swelling? Is the eruption macular, papular, scaling or oozing? How large an area is involved? When did the patient first notice the eruption? How does he describe his sensations? Are there itching, burning, tingling or crawling sensations, or is there a loss of sensation? Was the appearance of the eruption related to the intake of food? What drugs is the patient receiving that might possibly have caused this reaction?

Primary lesions that do not produce a break in the skin include the following: Macule—a spot on the skin that is not raised or depressed Papule—a solid elevation of the skin Vesicle—a small elevation of the skin that is filled with clear fluid Pustule—an elevation in the skin that contains pus Wheal—an area of transitory edema in the skin Secondary lesions that break the skin include scales, crusts, excoriations, fissures and ulcers. Care of the Skin.

Description: An overview of the serum disease, defining it and describing it’s features then looking at treatment of this disease and certain measures of prevention.

Serum disease is an acute malady that not uncommonly follows the injection of a serum usually an antiserum prepared from horse or rabbit blood. Also, it develops occasionally after a course of penicillin injections. Its characteristic features, which appear after an incubation period of 6 to 12 days, include urticaria, enlargement of the regional lymph nodes, mild fever and pain in the joints symptoms that disappear entirely in a few days to 3 weeks. In severe cases the skin rash is purpuric in character, the temperature for a week or 10 days ranges irregularly from 39.4° C. (103° F.) to 400 C. (104° F.), the lymphadenitis is general, the spleen is enlarged, and the joints are as red and swollen as in acute rheumatic fever.

Other features often present are headache, abdominal pain, vomiting, diarrhea, proteinuria and cylindruria. This is potentially a serious complication, not to be regarded as a mere annoyance. Not only does it share many of the clinical characteristics of rheumatic fever and periarteritis nodosa, but it is also known to produce pathologic lesions very similar to those found in the two conditions.

One of the rarer consequences of serum sickness, which can produce permanent disability, is peripheral neuritis. The nerves most often involved are components of the brachial plexus. Their damage results in atrophy and weakness of muscles in the shoulder and the upper arm (Erb’s palsy). It may affect the muscles of respiration, with potentially fatal results.

Serum sickness, with all of its manifestations, including neuritis, if present, responds promptly to the administration of the steroid hormones. The speediest recovery can be anticipated after the parenteral administration of hydrocortisone in doses of 200 to 300 mg. or dexamethasone, 8 to 12 mg. given intravenously over periods of 12 to 24 hours. Mild cases, exhibiting merely urticaria and arthralgia, may respond satisfactorily to one of the antihistaminic drugs, supplemented by aspirin and codeine.

Avoidance of allergic phenomena following the administration of horse serum is possible to a large extent if each prospective recipient is questioned closely regarding the possibility of sensitivity to horse dander, and if a skin test is carried out with horse serum. If either yields positive results, it still may be feasible to employ the antiserum if the patient first can be desensitized by a series of small injections.

When contemplating the inoculation of a virus or rickettsial vaccine, it must be borne in mind that the materials incorporate egg yolk and, therefore, are a source of grave danger to individuals who are sensitive to eggs.

Description: An overview of antihistaminics and hormones in allergy, and explaining about treatment and skin tests also the administration of steroids.

It is of the utmost importance that the nurse become familiar with certain general concepts regarding therapy in allergic diseases, since she is very apt to find herself an active participant in their treatment and will almost certainly be in the position of advisor to patients who are potential candidates for one or another of these procedures.

The commonest method of treatment employs the serial injection of one or more antigens which are Selected in each particular case on the basis of skin tests. Skin testing entails the simultaneous intradermal inoculation (or superficial application), at separate sites, of several solutions containing individual antigens, comprising an assortment of those allergens deemed most likely to be implicated in the patient’s disease. A positive reaction, evidenced by the appearance of an urticarial wheal or by localized erythema in the area of inoculation or contact, is regarded as evidence of sensitivity to the corresponding antigen. Skin tests lend important weight to other evidence obtained from the patient’s history, indicating which of several antigens are most likely to provoke his symptoms and providing some clue to the intensity of his sensitization. (On the other hand, it should be recognized that the skin test is a test of skin reactivity, and any deduction that might be drawn from it relative to allergic phenomena in other tissues, such as the respiratory or gastrointestinal mucosa, is largely a matter of correlation and conjecture.) A positive skin test may be regarded as an indication for a series of desensitizing (hyposensitizing) injections, a course involving the repeated inoculation of the suspected allergen in graded doses and at regularly spaced intervals. The value of such injections has been fairly well established in those cases of hay fever and asthma that are clearly due to sensitivity to one of the common pollens or molds or to house dust. Although referred to as a “desensitization” procedure, the effects are very probably attributable to the opposite process, i.e., immunization, for it appears to stimulate the production of a new antibody with the capacity of neutralizing the allergy-provoking properties of the responsible antigen.

One approach to the symptomatic treatment of allergic disorders has been the administration of certain chemical agents called “antihistaminic drugs.” These, most of which are derivatives of aminoethanol and ethylenediamine, are capable of neutralizing histamine, a substance that is liberated in the course of tissue antigen antibody reactions and has been considered to be responsible, in part at least, for the symptoms of allergic reactions. In actual practice, the effectiveness of these drugs is sharply limited to certain cases of hay fever, vasomotor rhinitis, urticaria and mild asthma; they are rarely effective in other conditions or in severe conditions of any sort.

Administration of the steroid hormones dramatically eliminates any allergic phenomena that happen to be in progress at the time. The reason for their effectiveness in allergic disorders appears to be related to their inhibiting effect on inflammatory reactions in general. In this sense, their beneficial effect in allergic patients must be classed as nonspecific, bearing no relation to any specific antigen-antibody reaction that may be responsible for the disorder. Certain circumstances justify the administration of these hormones.

Description: An overview of urticaria and angioneurotic edema, the characters and factors of it and also treatment and gastrointestinal allergy.

Urticaria (hives) is an allergic affection of the skin characterized by the sudden appearance of pinkish edematous elevations, variable in size and shape, which itch and smart. They may involve any part of the body, including the mucous membranes, especially those of the mouth, the larynx (occasionally with serious results) and the gastrointestinal tract. Each hive remains for a few minutes to several hours, then disappears. For hours or days, crops of these lesions may come, go and return in a most capricious manner. If this sequence continues indefinitely, the condition is called chronic urticaria; if the individual lesions themselves persist for several days, it is known as urticaria perstans.

The swellings of angioneurotic edema vary in size from a few millimeters in diameter to several centimeters. On occasion, one may be seen that covers the entire back. The skin over them may appear normal, but often it has a reddish hue. It does not pit on pressure as ordinary edema does. The regions most often involved are lips, eyelids, cheeks, hands, feet, genitalia and tongue; also, the mucous membranes of the larynx, the bronchi and the gastrointestinal canal, particularly in cases of the hereditary type. An eye may be completely closed; one lip may become so large that eating is impossible; one hand may become so huge that the fingers cannot be flexed.

These swellings may appear suddenly in a few seconds or minutes, or slowly, in 1 or 2 hours. In the latter case, their appearance often is preceded by itching or burning sensations. Seldom does more than a single swelling appear at one time, although one may develop while another is disappearing. Only infrequently do they recur in the same region. The individual lesions usually last frOm 24 to 36 hours. On rare occasions they recur with a remarkable periodicity at intervals of 3 or 4 weeks. The swellings of angioneurotic edema along the gastrointestinal canal may cause acute crises of pain with vomiting, which suggest acute appendicitis, acute cholecystitis, renal colic or intussusception; those in the throat, edema of the glottis; those in a primary bronchus, massive pulmonary collapse.

Many patients are relieved by antihistamine drugs; others require injections of epinephrine. Corticosteroids usually give rapid resolution. Tracheotomy becomes necessary if laryngeal edema threatens to obstruct the glottis.

To a few persons, certain common foods are veritable poisons. There are those who cannot eat strawberries or shellfish without an attack of urticaria; or pork, or cheese, no matter how well disguised these foods may be, without vomiting promptly; or, if the food is retained, without diarrhea often accompanied by considerable pain (owing, it is surmised, to urticanal lesions along the gastrointestinal mucosa). Often asthma and urticaria result as well.