Question

L.M. is a 16-year-old girl who is visiting the dermatologist for acne treatment.

Subjective data States she has had acne on and off for the past 5 years Has tried over-the-counter creams and remedies with no success Enjoys tanning and uses indoor tanning beds Mother present for assessment

Objective data Pustules on forehead, chin, and bilateral cheeks with blackheads scattered throughout Arms and legs bronze color No edema

Questions

What other assessments should be included for this patient?

What risk factors are associated with tanning?

What health promotion teaching should be included for this patient?

From the readings, what is the most probable cause of the acne?

What are three nursing diagnoses?

What should the nurse consider related to the cause of acne?

What interventions might be included in the plan of care for this patient?

Answer 1

1) Assessment

The nursing assessment should include history and physical examination .

Drug history : Acne may be precipitated by drugs like corticosteroids, bromides, lithium, antiepileptics and iodides .

Family history is a risk factor , along with hormonal changes during the menstrual cycle and pregnancy.

Associated medical conditions such as polycystic ovary syndrome, congenital adrenal hyperplasia, and Cushing syndrome may lead to the development of acne.

Examination findings

• Closed comedones (i.e. whiteheads)
• Open comedones (i.e. blackheads)
• Papules, pustules, nodules, cysts
• Primarily appear on the face, shoulders, and upper back.

Biopsy of the lesion is not usually needed, but may be indicated in suspicion of atypical presentation / malignant lesions.

2) Risk factors associated with tanning

• The most common risk of exposure to ultraviolet radiation is sunburn.
• Frequent tanning increases the risk of developing malignant melanoma, the deadliest form of skin cancer.
• UV tanning in particular can cause dryness of the skin, making the skin produce more oil ,which can worsen the acne.  

3) Health promotion teaching  

The patient is instructed to wash the face and other affected areas with mild soap and water twice daily to remove surface oils and prevent obstruction of the oil glands. Alternatively ,she may wash the skin with a gentle skin cleanser twice daily.  

The patient is advised to avoid scrubbing the face, Vigorous washing and scrubbing can irritate the skin and exacerbate acne.

The patient is cautioned to avoid excessive abrasion because it makes acne worse. Excessive abrasion causes minute scratches on the skin surface and increases possible bacterial contamination.

All forms of friction and trauma are avoided, including propping the hands against the face, rubbing the face, and wearing tight collars and helmets.

The patient is instructed to avoid manipulation of pimples or blackheads. Squeezing merely worsens the problem, because a portion of the blackhead is pushed down into the skin, which may cause the follicle to rupture.

Because cosmetics, shaving creams, and lotions can aggravate acne, these substances are best avoided unless the patient is advised otherwise. Use cosmetics, toiletries and sunscreens that do not clog pores ,which may be labelled non-comedogenic or oil-free.

There is no evidence that a particular food can cause or aggravate acne. In general, eating a nutritious diet helps the body maintain a strong immune system.

Instruct the female client to inform her health care provider if she is possibly pregnant. Some medication, such as systemic retinoic acid, have teratogenic effects.

Advise the client that heat, humidity, and perspiration exacerbate acne. Explain that uncleanliness, dietary indiscretions, menstrual cycle, and other myths are not responsible for acne.

Explain that it will take 4 to 6 weeks of compliance with the treatment regimen to obtain results.

Explain that tanning can increase the risk of developing skin cancer. Wrinkles, age spots, and loss of skin firmness tend to appear years earlier in people who tan.

4) Most probable cause of Acne

Hormonal changes in this Age group i.e., Adolescence

During childhood, the sebaceous glands are small and virtually nonfunctioning. These glands are under endocrine control, especially by the androgens.

During puberty, androgens stimulate the sebaceous glands, causing them to enlarge and secrete a natural
oil, sebum, which rises to the top of the hair follicle and flows out onto the skin surface.

In adolescents who develop acne, androgenic stimulation produces a heightened response in the sebaceous glands so that acne occurs when accumulated sebum plugs the pilosebaceous ducts. This accumulated material forms comedones.

5) Nursing diagnosis

• Disturbed Body Image related to biophysical changes associated with skin disorder.
• Ineffective Health management related to insufficient knowledge of therapeutic regimen.
• Impaired Skin integrity related to hormonal changes (adolescence ).

6) Patient education is crucial to improve adherence to treatment.Acne can have a significant adverse impact on quality of life by causing some teens to become more self-conscious and potentially develop a poor body image.

NURSING CARE PLAN FOR ACNE

1) Management of Therapeutic Regimen:  

GOAL	INTERVENTION	RATIONALE	EXPECTED OUTCOME
	Anticipatory Guidance: Preparation of patient for an anticipated developmental and/or situational crisis.		Symptom Control Behavior: Personal actions to minimize perceived adverse changes in physical and emotional functioning
The adolescent will verbalize proper hygiene, nutrition, and treatment of acne.	Teach good skin care: ■ Wash the skin with mild soap and water twice daily. ■ Avoid vigorous scrubbing. ■ Praise good habits. ■ Advise the adolescent to wash hair with anti-seborrheic preparations , and avoid oil-based cosmetics or lotions. ■ Encourage a balanced diet, plenty of fluids, exercise, and adequate rest. ■ Encourage the adolescent to keep a diary of health and diet habit	■ Good hygiene and appropriate skin care reduce surface oils and bacteria, which intensify inflammatory reactions. ■ Positive reinforcement encourages continued effort. ■ Treats seborrhea, which frequently accompanies acne. Oil-based preparations can obstruct sebaceous glands, exacerbating acne. ■ Adequate nutrients, water, and exercise promote healthy skin. ■ A record may help identify associations with flare-ups that can be avoided in the future.
The adolescent will verbalize understanding of treatment regimen.	■ Educate the adolescent about action, side effects, dosage, method of application of medications. ■ Encourage application of tretinoin at night. Encourage use of non-oil sunscreens of at least SPF 15. ■ Educate the adolescent about time needed for response and importance of compliance to treatment.	■ Proper application of medication enhances healing of lesions. ■ Helps reduce sensitivity to sun and avoid sunburn. ■ May take up to 3 months for significant improvement to occur. The adolescent needs a reason to continue with the care plan.	The adolescent implements the treatment regimen as outlined, resulting in a noticeable reduction in lesions.

2) Body Image Disturbance related to biophysical factors

	Body Image Enhancement: Improving a patient’s conscious and unconscious perceptions and attitudes about his/her body		Self-esteem: Personal judgment of selfworth.
The adolescent will demonstrate increased self-confidence and self-esteem.	■ Establish a rapport with the patient. ■ Provide education about the condition and treatment modalities. ■ Encourage the adolescent to be responsible for treatment and follow-up, and give positive reinforcement. ■ Encourage the adolescent to become involved with school activities and peers.	■ A trustful relationship promotes verbalization of concerns and fears. ■ Providing information better enables the adolescent to take control of the condition. ■ Responsibility reinforces a feeling of self-esteem. ■ Involvement in activities helps to enhance  self-esteem and allows the adolescent to explore new experiences and friendships.	The adolescent freely discusses concerns and fears. The adolescent demonstrates active involvement in self care. The adolescent shows increased confidence, as demonstrated by involvement in extracurricular activities.