NURSING PROCESS:CARE OF THE PATIENT WITH PSORIASIS
The nursing assessment focuses on how the patient is coping with the psoriatic skin condition, appearance of the normal skin, and appearance of the skin lesions, as described previously. The notable manifestations are red, scaling papules that coalesce to form oval, well-defined plaques. Silver-white scales may also be present. Adjacent skin areas show red, smooth plaques with a macerated surface. It is important to examine the areas especially prone to psoriasis: elbows, knees, scalp, gluteal cleft, fingers, and toenails (for small pits).
Psoriasis may cause despair and frustration for the patient; ob-servers may stare, comment, ask embarrassing questions, or even avoid the person. The disease can eventually exhaust the patient’s resources, interfere with his or her job, and make life miserable in general. Teenagers are especially vulnerable to the psychological effects of this disorder. The family, too, is affected, because time-consuming treatments, messy salves, and constant shedding of scales may disrupt home life and cause resentment. The patient’s frustrations may be expressed through hostility directed at health care personnel and others.
The nurse assesses the impact of the disease on the patient and the coping strategies used for conducting normal activities and interactions with family and friends. Many patients need reas-surance that the condition is not infectious, not a reflection of poor personal hygiene, and not skin cancer.
Based on the nursing assessment data, the patient’s major nurs-ing diagnoses may include the following:
· Deficient knowledge about the disease process and treat-ment
· Impaired skin integrity related to lesions and inflammatory response
· Disturbed body image related to embarrassment over ap-pearance and self-perception of uncleanliness
Based on the assessment data, potential complications include the following:
· Psoriatic arthritis
Major goals for the patient may include increased understanding of psoriasis and the treatment regimen, achievement of smoother skin with control of lesions, development of self-acceptance, and absence of complications.
The nurse explains with sensitivity that, although there is no cure for psoriasis and lifetime management is necessary, the condition can usually be controlled. The pathophysiology of psoriasis is re-viewed, as are the factors that provoke it—irritation or injury to the skin (eg, cut, abrasion, sunburn), current illness (eg, pharyn-geal streptococcal infection), and emotional stress. It is empha-sized that repeated trauma to the skin and an unfavorable environment (eg, cold) or a specific medication (eg, lithium, beta-blockers, indomethacin) may exacerbate psoriasis. The patient is cautioned about taking any nonprescription medications because some may aggravate mild psoriasis.
Reviewing and explaining the treatment regimen are essential to ensure compliance. For example, if the patient has a mild con-dition confined to localized areas, such as the elbows or knees, ap-plication of an emollient to maintain softness and minimize scaling may be all that is required. However, if the patient uses anthralin, the dosage schedule, possible side effects, and problems to report to the nurse or physician should be explained.
Most patients need a comprehensive plan of care that ranges from using topical medications and shampoos to more complex and lengthy treatment with systemic medications and photo-chemotherapy, such as PUVA therapy. Patient education materials that include a description of the therapy and specific guidelines are helpful but cannot replace face-to-face discussions of the treat-ment plan.
To avoid injuring the skin, the patient is advised not to pick at or scratch the affected areas. Measures to prevent dry skin are en-couraged because dry skin worsens psoriasis. Too-frequent wash-ing produces more soreness and scaling. Water should be warm, not hot, and the skin should be dried by patting with a towel rather than by rubbing. Emollients have a moisturizing effect, providing an occlusive film on the skin surface so that normal water loss through the skin is halted and allowing the trapped water to hydrate the stratum corneum. A bath oil or emollient cleansing agent can comfort sore and scaling skin. Softening the skin can prevent fissures (see Plan of Nursing Care 56-1).
A therapeutic relationship between health care professionals and the patient with psoriasis is one that includes education and sup-port. After the treatment regimen is established, the patient should begin to feel more confident and empowered in carrying it out and in using coping strategies that help deal with the altered self-concept and body image brought about by the disease. Introducing the patient to successful coping strategies used by others with pso-riasis and making suggestions for reducing or coping with stress-ful situations at home, school, and work can facilitate a more positive outlook and acceptance of the chronicity of the disease.
The diagnosis of psoriasis, especially when it is accompanied by the complication of arthritis, is usually difficult to make. Psoriatic arthritis involving the sacroiliac and distal joints of the fingers may be overlooked, especially if the patient has the typical psoriatic le-sions. However, patients who complain of mild joint discomfort and some pitting of the fingernails may not be diagnosed with pso-riasis until the more obvious cutaneous lesions appear.
The complaint of joint discomfort in the patient with psoria-sis should be noted and evaluated. The symptoms of psoriatic arthritis can mimic the symptoms of Reiter’s disease and anky-losing spondylitis, and a definitive diagnosis must be made. Treat-ment of the condition usually involves joint rest, application of heat, and salicylates.
The patient requires education about the care and treatment of the involved joints and the need for compliance with therapy. The incidence of psoriatic arthropathy is unknown because the symp-toms are so variable. It is believed, however, that when the psoriasis is extensive and a family history of inflammatory arthritis is elicited, the chance that the patient will develop psoriatic arthritis increases substantially. It is recommended that a rheumatologist be consulted to assist in the diagnosis and treatment of the arthropathy.
Printed patient education materials may be provided to reinforce face-to-face discussions about treatment guidelines and other considerations. For example, the patient and the family caregiver may need to know that the topical agent anthralin leaves a brownish purple stain on the skin but that the discoloration subsides after an-thralin treatment stops. The patient should also be instructed to cover lesions treated with anthralin with gauze, stockinette, or other soft coverings to avoid staining clothing, furniture, and bed linens.
Patients using topical corticosteroid preparations repeatedly on the face and around the eyes should be aware that cataract de-velopment is possible. Strict guidelines for applying these med-ications should be emphasized because overuse can result in skin atrophy, striae, and medication resistance.
Photochemotherapy (PUVA), which is reserved for moderate to severe psoriasis, produces photosensitization, which means that the skin is sensitive to the sun until methoxsalen has been ex-creted from the body in about 6 to 8 hours. Patients undergoing PUVA treatments should avoid exposure to the sun. If exposure is unavoidable, the skin must be protected with sunscreen and clothing. Gray- or green-tinted, wraparound sunglasses should be worn to protect the eyes during and after treatment, and oph-thalmologic examinations should be performed on a regular basis. Nausea, which may be a problem in some patients, is lessened when methoxsalen is taken with food. Lubricants and bath oils may be used to help remove scales and prevent excessive dryness. No other creams or oils are to be used except on areas that have been shielded from ultraviolet light. Contraceptives should be used by sexually active women of reproductive age, because the teratogenic effect of PUVA has not been determined. The patient is kept under constant and careful supervision and is encouraged to recognize unusual changes in the skin.
If indicated, referral may be made to a mental health profes-sional who can help to ease emotional strain and give support. Be-longing to a support group may also help patients acknowledge that they are not alone in experiencing life adjustments in re-sponse to a visible, chronic disease. The National Psoriasis Foun-dation publishes periodic bulletins and reports about new and relevant developments in this condition.
Chart 56-4 is a Home Care Checklist for the patient with psoriasis.
Expected patient outcomes may include the following:
1) Demonstrates knowledge and understanding of disease process and its treatment
a) Describes psoriasis and the prescribed therapy
b) Verbalizes that trauma, infection, and emotional stress may be trigger factors
c) Maintains control with appropriate therapy
d) Demonstrates proper application of topical therapy
2) Achieves smoother skin and control of lesions
a) Exhibits no new lesions
b) Keeps skin lubricated and soft
3) Develops self-acceptance
a) Identifies someone with whom to discuss feelings and concerns
b) Expresses optimism about outcomes of treatment
4) Absense of complications
a) Has no joint discomfort
b) Reports control of cutaneous lesions with no extension of disease
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