Chapter 45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder

The nurse is speaking with the mother of a child diagnosed with contact dermatitis from poison ivy. Which statement by the mother indicates a need for further education?

"As long as he takes a shower as soon as he gets inside, he shouldn't get this again." Rationale: Prevention of contact dermatitis from poison ivy, poison oak, or poison sumac includes wearing long pants and long sleeves on outings in the wood. If contact occurs, wash vigorously with soap and water within 10 minutes of contact. The plant's oil residue may be on clothes, pets, toys, and other objects, so these must be washed well with soap and water. Ivy Block is the only preventive treatment approved by the US FDA. It is applied to the skin before exposure.

The nurse is interviewing the mother of a 6-month-old being seen at a well-child visit. The mother reports she has used an over-the-counter topical ointment intended for adults on her child for a skin rash. What is the most appropriate response by the nurse?

"Children have thin skin and can absorb medications differently than adults." Rationale: Children have thinner skin than adults. They will absorb topical medications more rapidly than adults. Medications concentrated for adults should not be used on children. It is important to explain this to the parent. It is confrontational to tell her this is dangerous or to tell her to contact the physician. The frequency of use is information that should be obtained but the education is most important in this scenario.

An adolescent is prescribed isotretinoin. Which statement indicates that the adolescent understands the necessary precautions associated with this drug?

"I have to make sure that I do not become pregnant while taking this drug." Rationale: Adolescent girls taking this drug who are sexually active must be on a pregnancy prevention program because the drug causes defects in fetal development. Monthly complete blood counts are required when taking isotretinoin. Isotretinoin is not associated with lung problems, so a chest radiograph is not necessary. Coal tar preparations are associated with staining of the clothing or fabrics. Isotretinoin does not stain clothes or fabrics.

When teaching a group of caregivers of infants, the nurse is discussing the topic of diaper rash. The caregivers in the group make the following statements. Which statement is the most accurate related to the child with diaper rash.

"My child gets diaper rash if I wash her clothes in the same detergent we use for the family." Rationale: Infants may have a sensitivity to some soaps or disposable diaper perfumes, and the use of strong laundry detergents without thorough rinsing can cause diaper rash. Diarrheal stools, prolonged exposure to wet or soiled diapers, use of plastic or rubber pants, infrequently changed disposable diapers, inadequate cleansing of the diaper area (especially after bowel movements), and yeast infections are also causative factors. Exposing the diaper area to the air helps clear up the dermatitis. The use of baby powder when diapering is discouraged because caked powder helps create an environment in which organisms thrive.

The nurse is teaching the parents of a 6-year-old who has sustained a large laceration about providing care to the wound at home. The nurse determines that the parents need additional teaching when they state:

"We need to keep the wound tightly bandaged for at least 3 days." Rationale: If a wound is large, it can be covered by a loose dressing, which is changed in about 12 hours and redressed after the wound is cleaned. The wound is then left open to the air after 24 hours have passed from the time of the injury. A wound that is red and hot looking or one with yellowish drainage or increased pain suggests infection, which needs to be evaluated by the practitioner.

The nurse is providing teaching on ways to maintain skin integrity and prevent infection for the parents of a boy with atopic dermatitis. Which response indicates a need for further teaching?

"We should avoid using petroleum jelly." Rationale: It is important to apply moisture multiple times throughout the day. Petroleum jelly is a recommended moisturizer that is inexpensive and readily available. The other statements are correct.

The parent of a 1-week-old infant is concerned with white scales that have begun to flake off the infant's scalp. The parent asks the nurse what to do to treat this. How should the nurse best respond?

"Your child most likely has cradle cap (seborrhea). You can care for it by cleansing the hair and scalp daily with baby shampoo and applying baby oil." Rationale: Infantile seborrheic dermatitis, better known as cradle cap, usually responds well to cleansing the scalp with a mild shampoo. The thick, scaling lesions on the child's scalp can be treated by applying baby oil, mineral oil, or a corticosteroid gel on the scalp for 10 to 15 minutes. The area is gently massaged with a soft brush to lift the scales then shampooed again. A fine-toothed comb helps rid the hair of scale debris. Antiseborrheic shampoo is not recommended for infants. Infantile seborrheic dermatitis is not a result of poor hygiene and will not resolve without intervention.

The nurse has completed client teaching with a 16-year-old female who has been prescribed isotretinoin for cystic acne. Which statements indicate learning has occurred? Select all that apply.

-"It's important I get my CBC blood test when my doctor orders it." -"This is not a drug to be used for all forms of acne. My sister has minor acne so I told her this wasn't for her." -"If I am sexually active I need to let my doctor know." Rationale: Accutane (isotretinoin) is a powerful medication used for severe forms of acne and cystic acne when other treatment methods are not effective. Sexual activity should be reported to the physician. Some physicians may order monthly pregnancy tests even if the client says she is not sexually active because of the risk of birth defects to a fetus. No matter what form of birth control is used, pregnancy is possible, so monthly pregnancy tests are still necessary. Liver function tests are important regardless of age because of the side effects of the medication. Any labs ordered by the physician, such as the CBC, to monitor the medication's side effects should be obtained.

The nurse is developing the plan of care for a child who has suffered a major burn and has just been admitted to the acute care facility. Which nursing diagnosis would be most appropriate?

Acute pain related to thermal injuries and procedures Rationale: Management of acute pain is crucial for the client with a burn. Knowledge of the daily procedures at the acute care setting is not a priority for this client. A child with a burn would most likely experience fluid volume deficit due to the fluid loss associated with burns. Risk for aspiration would not be an appropriate nursing diagnosis.

The nurse is caring for a child admitted with second-degree (partial-thickness) burns. What is most characteristic of this type of burn?

Blisters appear. Rationale: In first-degree (superficial) burns, the injury is only to the epidermis. The burns are very painful, red, and dry. In second-degree (partial-thickness) burns, the injury is to the epidermis and part of the dermis. These burns are painful, edematous, have a wet appearance and form blisters. In third-degree (full-thickness ) burns, the dermis, epidermis and hypodermis are all involved. There may or may not be pain. These burns are red and edematous and may have peeling, charred skin. Muscle damage can occur.

A parent brings an infant to the clinic for a well child visit. During the assessment, the parent asks the nurse why the infant never seems to sweat. What action should the nurse take?

Explain that this normal mechanism keeps the infant from losing too much water through the skin. Rationale: The sweat glands of an infant are immature and this normal mechanism keeps the infant from losing too much insensible water. Because this is a normal occurrence, there is no reason to make a note to inform the health care provider or to refer the infant to a specialist. An infant's temperature does not run lower than an adult's temperature.

An infant is seen in the emergency department with several raised red welts over the abdomen and lower extremities. The parent states that the symptoms developed suddenly over the past few hours. The infant is fussy and has a low grade temperature. What assessment is most important for the nurse to perform?

Observe the infant's respiratory effort. Rationale: The raised red welts are likely urticaria or hives, an allergic response to a substance (food, drugs, plants, etc.). As such, it is most important to observe the infant's respiratory effort since that reaction can involve the lips, tongue, and airway. Cyanosis would not be visible unless the airway was blocked and then it would be central cyanosis, not just circumoral. Questioning the parent about methods of punishment is unnecessary as the welts are not a sign of trauma. It is appropriate to determine if the infant is breastfed or formula fed because it might be related to the hives, especially if the infant was switched from breast milk to formula. This, however, is not the most important assessment.

Which intervention is the most beneficial for a burn client undergoing a skin graft?

Provide around-the-clock pain medication as soon as pain is reported. Rationale: When the child undergoes a procedure, such as skin grafting, that is known to produce prolonged pain, administer pain medication on a scheduled basis, rather than as needed once pain is reported. Around-the-clock pain medication will serve to diminish peaks and valleys in pain relief. Diversional activities and an egg-crate mattress are not effective treatments for severe pain.

An infant has presented at the clinic with impetigo. Which organism usually causes impetigo in infants?

Staphylococcus aureus Rationale: Staphylococcus aureus is the most common cause of impetigo in infants. MRSA is a hospital-associated infection (HAI), group A beta hemolytic strep is seen in older children, and Escherichia coli is not frequently associated with impetigo.

The nurse is caring for a child with an order for silver sulfadiazine 1% for a burn. What would make the nurse question this order?

The burn is on the child's face. Rationale: Silver sulfadiazine 1% is used for burns. It should not be applied to the face or an infant under 2 months of age. It should not be used in children with a sulfa allergy.

The nurse is caring for a 13-year-old client who asks about acne prevention. Which would be most appropriate for the nurse to suggest?

Wash the face twice a day with a mild soap then pat dry. Rationale: The face should be washed twice per day with a mild soap and lukewarm water then patted dry. Avoiding certain foods will not prevent acne. Popping pimples does not make acne go away and can cause scarring. Washing the face with abrasive soaps can aggravate the acne and cause more flare-ups.

The nurse caring for a child with a skin allergy recognizes that the highest priority in the treatment for skin allergies is aimed at:

reducing swelling and relieving itching. Rationale: Treatment for skin allergies is aimed at reducing the swelling and relieving the itching. With swelling in various parts of the body, the child may have pain, nausea and vomiting, but reducing the swelling would prevent those symptoms from occurring.

A 10-year-old child is brought to the clinic by the parent. Assessment reveals small circular patches of hair loss on the scalp. The nurse suspects which condition?

tinea capitis Rationale: Tinea capitis is a fungal infection of the scalp that causes circular patches of hair loss. Tinea faciei is a fungal infection of the face; tinea cruris is a fungal infection of the inner thighs and inguinal creases; and tinea corporis is a fungal infection located on the entire body.

The nurse is caring for a 10-year-old male in a pediatric clinic with presenting symptoms of small circular patches of hair loss on the scalp. Which skin condition does the child most likely have?

tinea capitis Rationale: Tinea capitis is a fungal infection of the scalp that causes circular patches of hair loss. Tinea faciei is a fungal infection of the face; tinea cruris is a fungal infection of the inner thighs and inguinal creases; and tinea corporis is a fungal infection located on the entire body.

The nursing diagnosis of risk for infection related to a disruption in the protective skin barrier is noted on a child's plan of care. Which action would be of greatest importance?

using appropriate hand hygiene Rationale: Hand hygiene would be the priority because the child's risk for infection is increased and hand hygiene is crucial to preventing the transmission of infectious organisms. Monitoring the child's temperature is important to evaluate for possible fever and infection, but this would not be the most important action. Although nutritional status can influence wound healing, urging adequate nutritional intake would not be the most important action. Although obtaining a culture provides information about the cause of an infection, the child is at risk for infection, so a culture would not provide any information about the risk.