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

The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing action is priority? The nurse follows contact precautions. The nurse soaks the skin with warm water. The nurse applies elbow restraints to the infant. The nurse applies topical antibiotics to the lesions.

The nurse follows contact precautions. RATIONALE: Impetigo is highly contagious and can spread quickly. The nurse should follow contact (skin and wound) precautions, including wearing a cover gown and gloves. The nurse will soak the crusts with warm water, apply topical antibiotics, and apply elbow restraints, but these are not as high a priority as trying to prevent the spread of the infection by following contact precautions.

An adolescent is to receive topical retinoid therapy for his moderately severe acne. The nurse would instruct the adolescent about which adverse effects? Select all that apply. flu-like symptoms photosensitivity headache dryness burning

photosensitivity dryness burning RATIONALE: Adverse effects associated with topical retinoid therapy include burning, dryness, and photosensitivity. Flu-like symptoms and headache are associated with topical immune modulators.

The nurse is providing education to an adolescent client diagnosed with tinea pedis. Which statement will the nurse include in the teaching? "Keep your feet moist and open to the air as much as possible." "Be sure to dry the area between your toes really well." "Avoid applying soap to the affected area until healed." "You need to wear nylon or synthetic socks every day."

"Be sure to dry the area between your toes really well." RATIONALE: Keeping the feet clean and dry is key for the adolescent with tinea pedis. This includes rinsing the feet with water or a water/vinegar mixture and drying them well, especially between the toes. The adolescent should wear cotton socks and shoes that allow the feet to breathe. The client should clean the area with soap daily to reduce the risk of infection.

A nurse is assessing a 6-month-old girl with an integumentary disorder. The nurse notes three virtually identically sized, round red circles with scaling that are symmetrically spaced on both of the girl's inner thighs. What should the nurse ask the mother? "Do you change her diapers regularly?" "Tell me about your family history of allergies." "Has she been exposed to poison ivy?" "Does she wear sleepers with metal snaps?"

"Does she wear sleepers with metal snaps?" RATIONALE: Small round red circles with scaling, symmetrically located on the girl's inner thighs, point to nickel dermatitis that may occur from contact with jewelry, eyeglasses, belts, or clothing snaps. The nurse should inquire about any sleepers or clothing with metal snaps. The girl does not have a rash in her diaper area. It is unlikely that an infant this age would have her inner thighs exposed to a highly allergenic plant. Discussing family allergy history is important, but the nurse should first inquire about any clothing with metal that could have come into contact with the girl's skin when she displays a symmetrical rash.

The nurse is teaching parents about the care of diaper rash. The nurse would be concerned about the parents' level of understanding if they made which statement? "I need to wash and rinse clothes thoroughly to be sure all of the detergent is washed out." "I should be certain to use fabric softener in the care of the infant's clothes." "I should not overdress the infant." "I should only use ointments and creams as instructed by the health care provider."

"I should be certain to use fabric softener in the care of the infant's clothes." RATIONALE: Fabric softeners should be avoided because their use can result in skin irritation in the infant. Clothing and other baby items should be washed and rinsed thoroughly. Overdressing should be avoided as sweating irritates the rash, and only ointments and creams that are recommended by health care personnel should be used on the infant.

The clinic nurse is assessing a 12-year-old client. The client reports having dandruff and asks the nurse what can be done for it. Which response by the nurse is best? "Wash your hair with a gentle shampoo daily." "Wash your hair vigorously twice a day for one week." "Apply warm baby oil to your scalp once a day for a few days." "I will let your primary health care provider know you need prescription shampoo."

"Wash your hair with a gentle shampoo daily." RATIONALE: In the older child and adolescent, a gentle shampoo should be used daily to control scaling caused by dandruff. A medicated shampoo may be indicated if shampooing with a gentle formula shampoo does not provide relief. Washing hair vigorously twice a day is not recommended. Warm baby oil is recommended for infants with cradle cap (seborrhea).

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 need to develop ways to prevent him from scratching." "We should keep his fingernails short and clean." "We should avoid tight clothing and heat." "We should avoid using petroleum jelly."

"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 nurse is discussing dermatitis with the parents of an affected child. When addressing nonpharmacologic options for managing the condition what information can be included? Select all that apply. "Wearing breathable fabrics such as cotton is recommended." "Avoid use of perfumes." "Apply moisturizers throughout the day." "Avoid irritating fabrics such as wool." "Vigorously towel dry to increase blood flow to affected areas."

"Wearing breathable fabrics such as cotton is recommended." "Avoid use of perfumes." "Apply moisturizers throughout the day." "Avoid irritating fabrics such as wool." RATIONALE: Skin affected with atopic dermatitis is sensitive. Care should be taken to avoid irritants and triggers. Fabrics such as wool and synthetics can be irritating. Cotton is recommended. Moisturizing the skin is beneficial. Using unscented lotion and petroleum jelly can be used. Limit exposure of the skin to perfumes and dyes in skin care and bathing products.

An adolescent experiencing contact dermatitis reports experiencing pruritis. What intervention will the nurse recommend to relieve the itching? Apply calamine lotion if the lesion is weeping. Bathe with a product that is oatmeal-based. Keep the area covered with clothing. Use a fragrance-free moisturizer.

Bathe with a product that is oatmeal-based. RATIONALE: Pruritis is a common problem associated with contact dermatitis. By healing the lesions, the itching will subside. Bathing with oatmeal-based products will accomplish this healing. If the area is too involved, then products like a topical corticosteroid can be used. Calamine lotion is a product that can help with itching, but it is primarily used to dry out weeping lesions. Moisturizers can be applied to the irritated skin, but they must be free of fragrances and dyes. The area should not be covered but allowed to be exposed to air to aid in healing.

An adolescent with tinea versicolor is admitted for treatment of the disorder. Which nursing diagnosis will the nurse identify as having the highest priority for this client? Pain Altered nutrition Disturbed body image Risk for fluid volume deficit

Disturbed body image RATIONALE: Tinea versicolor is a superficial tan or hypopigmented oval scaly lesions, especially on upper back and chest and proximal arms. It may take several months for pigmentation to return to normal; therefore, disturbed body image is going to be a high priority for an adolescent client.

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. Tell the parent that the infant will need to see an endocrine specialist about the problem. Explain that this is because an infant's temperature normally runs lower than an adult's. Make a note to inform the health care provider of the parent's concern.

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? Examine the lips and oral mucosa for cyanosis. Observe the infant's respiratory effort. Determine whether the child is breastfed or formula fed. Question the parent about methods of punishment.

Observe the infant's respiratory effort. 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.

An infant has presented at the clinic with impetigo. Which organism usually causes impetigo in infants? Staphylococcus aureus Methicillin-resistant Staphylococcus aureus (MRSA) Escherichia coli Group A beta hemolytic strep

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 13-year-old client who asks about acne prevention. Which would be most appropriate for the nurse to suggest? Wash the face with abrasive soaps three times a day. Wash the face twice a day with a mild soap then pat dry. Avoid chocolate and greasy foods. Pop the pimples to make them go away.

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.

In working with infants diagnosed with atopic dermatitis, the nurse anticipates that when these children are older they will likely have a tendency to have which disorder? hemophilia otitis media asthma rheumatoid arthritis

asthma RATIONALE: Infants who have atopic dermatitis (infantile eczema) tend to have allergic rhinitis or asthma later in life.

The nurse is caring for a client brought to a pediatric clinic for swelling in the lower extremities with reddened skin that has undefined borders and pits slightly when pressed. What is the most likely diagnosis of the client's skin alteration? cat scratch disease staphylococcal scalded skin syndrome impetigo cellulitis

cellulitis RATIONALE: Cellulitis is characterized by reddened or lilac-colored swollen skin that pits when pressed by the fingertips. Impetigo has superficial lesions that can be bullous or nonbullous. Staphylococcal scalded skin syndrome involves bullae that enlarge and rupture, leaving a red, scalded-looking lesion. Cat scratch disease involves a benign, subacute, chronic course of lymphadenopathy that usually resolves spontaneously in 2 to 3 months.

The nurse is presenting an in-service to a group of nurses who will be working in a dermatology clinic. One participant asks the nurse about a bacterial skin infection that she has seen in children that involves honey-colored crusted lesions. The nurse most likely is referring to: miliaria rubra (heat rash). seborrheic dermatitis. candidiasis. impetigo.

impetigo. RATIONALE: Impetigo is a superficial bacterial skin infection. Impetigo in the newborn is usually bullous (blister-like, fluid filled); in the older child, the lesions are nonbullous and have a honey-colored, crusted appearance.

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." "I can buy a medicine to put on him before he goes out to prevent him from getting this again." "When he plays in the woods again, I will make sure he wears long pants and long sleeves." "I will need to make sure the dog gets a bath if he goes in the woods."

"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 caring for a mother and newborn on a postpartum unit. The mother asks if it OK to use baby powder on newborns. Which response by the nurse would be most appropriate? "Baby powder should not be used on newborns because of the risk of aspiration upon application." "Baby powder can be used anytime with no concerns." "Baby powder should not be used because so many people are allergic to the ingredients in it." "Baby powder may be used if sprinkled on your hand away from the baby to prevent aspiration."

"Baby powder may be used if sprinkled on your hand away from the baby to prevent aspiration." RATIONALE: The use of baby powders containing talc or known as "talcum powder" can cause accidental aspiration, pneumonia, and death. Aspiration is predominantly caused when the baby receives a "puff of smoke" when the powder is shaken from the container directly onto the baby's skin. In addition, the use of talcum powder is abrasive and is considered to contribute to the pathogenesis of diaper dermatitis.

The parents of a child recently diagnosed with atopic dermatitis voice concern to the nurse that their child may develop asthma at some point. How should the nurse respond? "If your child starts having respiratory difficulties, be sure to let your health care provider know." "I am not sure why you think a skin disorder would lead to asthma?" "I can understand your concern. We will closely monitor your child for asthma development." "All children with atopic dermatitis develop both asthma and hay fever, so we will monitor your child for both conditions."

"I can understand your concern. We will closely monitor your child for asthma development." RATIONALE: Atopic dermatitis (eczema) is one of the disorders in the atopy family (along with asthma and allergic rhinitis [hay fever]). About 30% to 35% of children who have atopic dermatitis will also develop allergic rhinitis (hay fever) and/or asthma. Therefore, the child will be monitored for the development of asthma.

The nurse is caring for a 12-year-old child who comes to the pediatric clinic for a well-child checkup. The child reports embarrassing dandruff and asks the nurse what can be done for it. A quick scalp assessment confirms the presence of dandruff. Which response by the nurse would be most appropriate when addressing the child's concern? "Wash your hair vigorously twice a day for 1 week." "Wear light-colored clothing so the flakes aren't noticeable." "Apply a corticosteroid cream to your scalp at night." "Wash your hair with an antiseborrheic shampoo daily."

"Wash your hair with an antiseborrheic shampoo daily." RATIONALE: In the older child and adolescent, an antiseborrheic shampoo should be used daily to control scaling caused by dandruff. Low-potency corticosteroid creams can be applied two to four times a day for severe cases. Washing hair vigorously twice a day is not recommended. Light-colored clothing is a good suggestion; however, it is not an intervention to control the prevalence of dandruff.

Which assessment finding by the nurse would warrant immediate action? A child with cellulitis has a temporal temperature of 101°F (38.3°C). A child with impetigo has honey-colored drainage noted on the skin area. A child has a red, warm, edematous area over an old spider bite. A child with periorbital cellulitis reports changes in vision and pain with eye movement.

A child with periorbital cellulitis reports changes in vision and pain with eye movement. RATIONALE: In a child with periorbital cellulitis, the nurse musty notify the health care provider immediately if signs of progression to orbital cellulitis occur, such as conjunctival redness, change in vision, pain with eye movement, eye muscle weakness or paralysis, or proptosis. This assessment finding warrants immediate action. In nonbullous impetigo, a honey-colored exudate when the vesicles or pustules rupture may be noted on the skin. This assessment finding would be expected. A localized cellulitis will present with erythema, pain, edema, and warmth at the site of the skin disruption (such as a cut or spider bite). This assessment finding warrants further follow-up but not immediate attention. Fever may occur with bullous impetigo or cellulitis and is common with scalded skin syndrome; therefore, this assessment finding also warrants further, but not immediate, follow-up.

The nurse is discussing acne vulgaris with a group of adolescents. The teenagers make the following statements regarding the topic. Which statement is the most accurate regarding acne vulgaris? "There is a new immunization that you can get to keep from having acne." "My next door neighbor told me that acne was caused by a fungus." "Sometimes I get acne when I use my sister's makeup." "My mom says I have acne because I eat too much chocolate."

"Sometimes I get acne when I use my sister's makeup." RATIONALE: Irritation and irritating substances, such as vigorous scrubbing and cosmetics with a greasy base, can cause acne vulgaris. Increased hormone levels, hereditary factors, and anaerobic bacteria can cause acne vulgaris as well. Eating chocolate and fatty foods does not cause acne, but a well-balanced, nutritious diet does promote healing.

A topical corticosteroid is prescribed for a child with contact dermatitis. Which statement by the mother would indicate the teaching was successful? "I should use the highest-potency steroid cream I can find." "I should not cover the area with plastic wrap after applying the cream." "I should apply the medicine at bedtime and rinse it off in the morning." "I need to shake the preparation before using it."

"I should not cover the area with plastic wrap after applying the cream." RATIONALE: An occlusive dressing such as plastic wrap over the area should not be used with topical corticosteroids. High-potency preparations should not be used. There is no need to shake topical corticosteroids. Benzoyl peroxide requires shaking before use. Applying the medication at night and rinsing off in the morning is used for coal tar preparations.

A newborn has a generalized rash on the skin, which the nurse identifies as erythema toxicum neonatorum. Which information would the nurse include when explaining the condition to the newborn's parent? "What you see on your newborn's skin is erythema toxicum neonatorum. It is an extensive skin condition that is rare in newborns. You will need to treat the infant as soon as possible to prevent its spread." "What you see on your newborn's skin is erythema toxicum neonatorum. It is a common newborn skin condition that typically resolves on its own in about 1 week. There is nothing special you will need to do for this." "This is a normal newborn rash; do not be so worried." "What you see on your newborn's skin is erythema toxicum neonatorum. It is a common newborn skin condition. You will need to apply a topical cream twice a day until it disappears."

"What you see on your newborn's skin is erythema toxicum neonatorum. It is a common newborn skin condition that typically resolves on its own in about 1 week. There is nothing special you will need to do for this." RATIONALE: Erythema toxicum neonatorum (ETN), or neonatal erythema, is one of the more well-known benign, self-limiting skin eruptions in the newborn period. Incidence estimates range from 50% to 70% of all healthy newborns. The rash usually remits within 1 week with no treatment. It is never appropriate to tell a mother not to be so worried.

A nurse completes an assessment on an 8-month-old infant seen in the pediatrician's office for a well-child visit. The nurse notes that the infant's buttocks, perineum and inner thighs are covered in a thick coating of white ointment. When questioned, the parent says the infant has a diaper rash and the ointment is to protect the infant's skin. What is the best action for the nurse to take? Tell the parent that he or she has used too much ointment. Commend the parent on addressing the infant's diaper rash. Explain that frequent diaper changes will prevent diaper rash. Provide instruction on how to care for a diaper rash.

Provide instruction on how to care for a diaper rash. RATIONALE: The best action for the nurse to take is to provide instruction on how to care for a diaper rash. This would include changing diapers frequently to prevent a rash, how to apply rash ointment, and how using too much ointment can cause the infant's skin to absorb the ointment. It is important to praise parents on taking good care of their child, but the best action is to provide instruction on the correct way to do so.

An adolescent girl is going to be treated for a severe case of acne vulgaris. A pregnancy test should be done prior to the adolescent starting treatment with: tretinoin. isotretinoin. benzoyl peroxide. erythromycin.

isotretinoin. RATIONALE: Isotretinoin is a drug used to treat cystic acne after at least 3 months of antibiotic therapy has not been successful. Isotretinoin is a pregnancy category X drug. It must not be used at all during pregnancy because of serious risk of fetal abnormalities. Tretinoin is used to treat severe acne vulgaris. Instruction for the use of this medication include using sunscreen. Benzoyl peroxide can be used for mild acne and can be used with topical antibiotics. Erythromycin is an antibiotic that has no pregnancy contraindications. It is used for many skin infections.

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 cruris tinea faciei tinea capitis Ttnea corporis

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 child with a prescription for PO prednisone. Which statement by the child's mother would indicate a need for further education? "I will have to watch my child closely for signs of infection." "My child should take the entire prescription as prescribed by the health care provider." "Since my child has type 1 diabetes, I will need to monitor my child's blood sugar levels closely while on this medication. "I will give it to my child at least 1 hour before all meals."

"I will give it to my child at least 1 hour before all meals." RATIONALE: Systemic corticosteroids such as prednisone should be administered with food to decrease gastrointestinal upset. These medications may mask signs of infection. This medication may increase blood sugar levels. Corticosteroid doses should be tapered and should not be stopped abruptly.

The parents of a child diagnosed with atopic dermatitis ask the nurse, "My child has a skin disorder. I don't understand why a complete blood count (CBC) was ordered?" What is the appropriate response by the nurse? "The complete blood count is a routine test used anytime there is an abnormal condition in the body." "Eosinophils are a type of white blood cell that are often elevated with atopic dermatitis. These are part of the CBC and helps in making the diagnosis." "This is just another tool to help rule out any other disorders that can be causing this skin disorder. There will be other lab tests ordered as well." "This test will help in determining the type of bacteria that is causing this infection."

"Eosinophils are a type of white blood cell that are often elevated with atopic dermatitis. These are part of the CBC and helps in making the diagnosis." RATIONALE: Atopic dermatitis is a type of allergic skin disorder, not a bacterial infection, in which the eosinophil count is often elevated. This is one test that will help in diagnosing the disorder. This explanation addresses the parents' question.

A child has been hospitalized with a diagnosis of severe impetigo. The nurse is interviewing the family. Which question will have the greatest impact on the child's care? "Do you have any concerns about filling the prescriptions?" "Is there anything else you think we should know about your family?" "Does your child have any allergies to medications?" "How long has the child had the infection?"

"Does your child have any allergies to medications?" RATIONALE: Since the child is hospitalized with a severe case of impetigo, the child will likely need intravenous antibiotics, so asking about medication allergies is the question that will have the greatest impact on care. Asking how long the child has had the infection, if the parent has concerns about filling prescriptions, or if there is anything the health care team should know about the family are all appropriate questions that should be asked during an admission interview. However, due to the severity of the infection, asking about medication allergies will impact care the most.

The nurse instructor is reviewing the integumentary system during a presentation to a group of student nurses. Which statement made by the instructor is the most accurate regarding the integumentary system? "The integumentary system is not in place until after the child is born and then takes many years to mature." "The sebaceous and sweat glands are fully functional in the infant." "The largest organ of the body helps regulate body temperature." "One role of the integumentary system is to distribute oxygen to the body cells."

"The largest organ of the body helps regulate body temperature." RATIONALE: The skin is the largest organ of the body. The skin helps regulate the body temperature by heating and cooling. The sebaceous and sweat glands are not fully functional until middle childhood. The major role of the skin is to protect the organs and structures of the body against bacteria, chemicals, and injury. Excretion in the form of perspiration is also a function of the skin glands, called the sweat glands. Sebaceous glands in the skin secrete oils to lubricate the skin and hair. The integumentary system is in place at birth, but the system is immature. A function of the respiratory system is to distribute oxygen to body cells.

A parent expresses a concern about white scales that have begun to flake off the 1-week-old infant's scalp. The parent asks, "What can I do to prevent this?" Which response by the nurse would be most appropriate? "Your child most likely has infantile seborrheic dermatitis, or cradle cap. You can care for it by cleansing the hair and scalp daily with baby shampoo. You can also apply baby oil to the area for 10 to 15 minutes and then rinse away the flakes." "How often do you bathe your infant? The infant should have a thorough shampooing every day to prevent things like this." "Your child most likely has infantile seborrheic dermatitis, or cradle cap. There is no intervention needed and it should resolve in 1 week." "Your child most likely has dandruff. You can treat it with daily with antiseborrheic shampoo, like Head and Shoulders."

"Your child most likely has infantile seborrheic dermatitis, or cradle cap. You can care for it by cleansing the hair and scalp daily with baby shampoo. You can also apply baby oil to the area for 10 to 15 minutes and then rinse away the flakes." RATIONALE: Infantile seborrheic dermatitis 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, salicylic acid in mineral oil, or a corticosteroid gel on the scalp for 10 to 15 minutes. The area is gently massaged with a soft toothbrush; then the scales can be rinsed away. A fine-toothed comb helps rid the hair of scale debris. Antiseborrheic shampoo is not recommended for infants. Accusing a parent of poor hygiene is inappropriate. Infantile seborrheic dermatitis is not a result of poor hygiene.

A child is hospitalized with a diagnosis of severe cellulitis. The nurse is preparing the family for discharge. Which instruction is most important for the nurse to convey to the family? Monitor for signs of worsening condition. Keep follow-up appointments. Complete the prescribed antibiotics. Perform proper hand hygiene.

Complete the prescribed antibiotics. RATIONALE: The instruction that is most important for the nurse to convey is to complete the prescribed course of antibiotics. Many times, once the child feels better, the parent stops the medication; this action, though, can cause a rebound infection. Instructing the family to keep follow-up appointments, perform good hand hygiene, and look out for signs of worsening condition are all appropriate, but the most important instruction is to make sure the child completes the course of antibiotics.