Pediatrics: Chapter 23
Cold injury
"frostbite"- implies freezing of the tissues described on a continuum from first to fourth degree when a child is in an extremely cold environment, changes in cutaneous circulation help to maintain the core body temp -because circulation is shunted to the core, the most peripheral body parts are those at highest risk for frostbite local damage occurs when the tissue temp drops to 32 F (0 C) -initially, skin sensation is lost, the vasculature constricts, and plasma leakage occurs -ice crystals develop in the extracellular fluid, and eventually vascular stasis leads to endothelial damage, necrosis, and sloughing of dead tissue
Tinea vesicolor: usual treatment
-apply selenium sulfide shampoo all over body (from face to knees) and allow to stay on skin overnight, rinsing in the morning, once a week for 4 weeks (this may cause skin irritation) -topical antifungals in the imidazole family may be used instead
Promoting appropriate body image: interventions and rationale
-assess child or teen for feelings about alteration in skin to determine baseline -acknowledge feelings of anger or depression related to skin changes to provide an outlet for feelings -encourage the child or teen to participate in skin care to give some sense of control over what is occurring -help the child or teen to accept self as the perception of self is tied to knowing oneself and identifying self-values
Promoting fluid balance: interventions and rationale
-assess fluid volume status at least every shift, more frequently if disrupted, to obtain baseline for comparison -strictly monitor intake and output to detect imbalance or need for additional fluid intake -weight the child daily on the same scale, at the same time, in the same amount of clothing as changes in weight are an accurate indicator of fluid volume status in children -provide IV fluid resuscitation in initial period, followed by encouragement of oral fluid intake in the burned child, to compensate for fluid loss through burned areas
Restoring skin integrity: interventions and rationale
-assess site of skin impairment to determine extent of involvement and plan care -monitor skin impairment every shift for changes in color, warmth, redness, or other signs of infection to identify problems early -determine the child's and family's skin care practices to establish need for education related to skin care -individualize the child's skin care regimen depending on the child's particular skin condition to most appropriately care for skin in light of the child's disorder -in the immobile child, use a risk assessment tool (Norton or Braden Q scale) to identify risk for skin breakdown -position the child on the opposite side of the skin impairment to avoid further skin breakdown -encourage appropriate nutritional intake as adequate nutrition are necessary for appropriate immune function and skin healing -consult the wound and stony care nurse specialist to determine the best approach for individualized wound care -provide dressing change and wound care as prescribed to promote wound or burn healing
Emergency assessment of the burned child: primary survey
-assess the child's airway, nothing whether it is patent, maintainable, or unmaintainable -suspect airway injury from burn or smoke inhalation if any of following are present: burns around the mouth, nose or eyes; carbonaceous (black-colored) sputum; hoarseness or stridor -evaluate the child's skin color, respiratory effort, symmetry of breathing, and breath sounds -determine the pulse strength, perfusion status, and heart rate; note extent and location of edema
Promoting nutrition: interventions and rationale
-assess the child's food preferences and ability to eat to provide a baseline for planning nursing care -consult the nutritionist because nutritional needs are increased related to altered metabolic state as a result of burns -collaborate with the nutritionist, child, and parents to plan meals that appeal to the child to increase the child's intake -administer vitamin and mineral preparations as prescribed to supplement nutrients -provide smaller, more frequent meals and snacks to promote increased intake -weigh the child daily to determine progress
Atopic dermatitis: promoting skin hydration
-avoid hot water and skin or hair product containing perfumes, dyes, or fragrance -bathe child twice daily in warm (not hot) water -use a mild soap to clean only the dirty areas (unscented dove, dove for sensitive skin, tone, caress, oil of Olay, cetaphil, aquanil) pat dry child after bath, do not rub the skin with the towel leave the child moist apply prescribed topical ointments or creams (corticosteroids, immune modulators) moisturizer (eucerin, moisturel, curel, aquaphor, vaseline, crisco)
Acne vulgaris: nursing management
-avoid oil-based cosmetics and hair products, as their use may block pores, contributing to noninflammatory lesions -look for cosmetic product labeled as noncomedogenic -headbands, helmets, and hats may exacerbated the lesions by causing friction -dryness and peeling may occur with acne treatment, so encourage the child to use a humectant moisturizers -mild cleansing with soap and water twice daily is appropriate -avoid excessive scrubbing and harsh chemical or alcohol-based cleansers -avoid picking or squeezing the lesions -using noncomedogenic sunscreen with an SPF of 30 or higher is recommended -teach adolescents that the prescribed topical meds must be used daily and that it may take 4-6 weeks to see results -avoid use of OTC preparations because they are irritating and aggravate the drying effect of prescription acne treatments -instruct boys to shave gently and avoid using dull razors, so as not to further irritate the condition -adolescent girls taking isotretinoin who are sexually active must be on pregnancy prevention program because the drug causes defects in fetal development -if severe, depression may occur as a result of body image disturbances -provide emotional support to adolescents undergoing therapy -refer teens for counseling if necessary
Diaper dermatitis: prevention and management
-change diapers frequently; change stool-soiled diapers as soon as possible -avoid rubber pants -gently wash the diaper area with a soft cloth, avoiding harsh soaps -use baby wipes in most children but avoid wipes that contain fragrance or preservatives once a rash has occurred, follow all the prevention tips above and add the following: -allow the infant or child to go diaper less for a period of time each day to allow the rash to heal -blow-dry the diaper area/rash with the dryer set on the warm (not hot) setting for 3-5 minutes
Minor injuries: nursing management
-cleanse the wound with mild soap and water or with an antibacterial cleanser -wet gauze helps to scrub away fine and large sand particles -remove pieces of loose skin with sterile scissors, foreign particles with sterile forceps, and raid tar with petroleum -small abrasions and minor, well-approximated cuts may be left open to the air -apply a small amount of antibacterial ointment and cover large abrasions with a loose dressing -change the dressing 12 hours later and redress after cleaning the wound; leave it open to air after 23 hours have passed from the time of injury -assess the wound daily for signs of infection, which include purulence, warmth, edema, increasing pain, and erythema that extends past the margin of the cut or abrasion
Human and animal bites: therapeutic management
-cleansing and irrigating the wound -wound suturing or stapling if necessary -administering topical and/or systemic antibiotic therapy -rabies prophylaxis is indicated if the rabies status of the dog is unknown -secondary bacterial infection of the bite wound with streptococci, staphylococci, or pasteurella multocida may occur
Sunburn: nursing management
-cool compresses may help to cool the burn -aloe vera gel applied topically may provide significant soothing (rarely are adverse effects reported) -administer NSAIDs (ibuprofen) -discourage hot showers or baths -instruct child to wear loose clothing and to ensure that burned areas are covered when going outside (until they are healed) -if skin flaking occurs, discourage the child from peeling the flaked skin in order to prevent further injury
Emergency assessment of the burned child: secondary survey
-determine burn depth -estimate burn extent by determining the percentage of body surface area affected -use a chart for estimation or rapidly estimate by using the child's palm size, which is equivalent to about 1% of the child's body surface area -inspect the child for other traumatic injuries (children who have jumped or fallen from the house fire may suffer cervical spine or internal injuries)
Human and animal bites: nursing assessment
-determine history of the attack and whether it was provoked -determine the child's tetanus vaccination status -inspect the bite to determine the extent of laceration, avulsion, or crushing injury
Seborrhea: nursing assessment
-determine onset and progression of skin and scalp changes -note réponse to treatments used so far -in the infant, inspect the scalp and forehead, behind the ears, and the neck, trunk, and diaper area for thick or flaky greasy yellow scales -in the adolescent, note mild flakes in the hair with yellow greasy scales on the scalp, forehead, and eyebrows; behind the ears; or between the scapulae
Erythema multiforme: nursing management
-discontinue medication or food if it is identified as the cause -ensure that treatment of mycoplasma is instituted if present -encourage oral hydration -administer analgesics and antihistamines as needed to promote comfort -if oral lesions are present, encourage soothing mouthwashes or use of topic oral anesthetics in the older child or teen -oral lesions may be derided with hydrogen peroxide
Frostbite: prevention
-dressing warmly in layers, and keeping warm and dry -avoid exertion -not playing outside when wind chill advisories are in effect, and locking doors with high locks to prevent toddlers from going outside
Psoriasis: nursing management
-exposure to sunlight may promote healing, but take care not to allow the child to become sunburned -apply skin moisturizers or emollients daily to prevent dry skin and flare-ups -apply topical anti-inflammatory creams as prescribed during flare-ups -apply tar shampoos or skin preparations -use mineral oil and warm towels to soak and remove thick plaques
Psoriasis: nursing assessment
-family history -onset and progression of rash -treatments used and the response -ask child about pruritus (usually absent) -inspect the skin for erythematous papules that coalesce to form plaques, most frequently on the scalp, elbows, genital area, and knees -facial plaques may also occur and are more common in children than adults -plaques have silvery or yellow-white scale and sharply demarcated borders -layers of scale may be present, which, when removed, results in pinpoint bleeding (Auspitz sign) -plaques on the scalp may result in alopecia -examine palms and soles, noting fissures and scaling -skin biopsy (rarely needed for diagnosis) will show hyper plastic epidermis, with thinning of the papillary dermis
Atopic dermatitis: risk factors
-family history of atopic dermatitis, allergic rhinitis, or asthma -child's history of asthma or allergic rhinitis -food or environmental allergies
Bacterial skin infections: staphylococcal scalded skin syndrome- skin findings
-flattish bullae that rupture within hours -red, weeping surface is left, most commonly on face, groin, neck, and axillary region
Diaper dermatitis: nursing assessment
-from history, determine if the infant or child wears diapers -ask about onset and progression of the rash, as well as any treatments and response -inspect the skin in the diaper area for erythema and maceration -usually starts as a flat red rash in the convex skin creases -may appear red and shiny and may or may not also have papules -untreated, may become more widespread or severe -some cases are caused by overgrowth of C. albicans
Sebaceous and sweat glands
-function immaturely at birth sebum secreted serves to lubricate the skin and hair -sebum production increases in the preadolescent and adolescent years, which is why acne develops at that time the infant's eccrine sweat glands are somewhat functional and will produce sweat as a response to emotional stimuli and heat -they become fully functional in the middle childhood years -until then, temp regulation is less effective compared to older children and adults apocrine sweat glands are small and nonfunctional in the infant -they mature during puberty, at which time body odor develops in response to the fluid secreted by these glands
Atopic dermatitis: therapeutic management
-good skin hydration -application of topical corticosteroids or immune modulators -oral histamines for sedative effects -antibiotics if secondary infection occurs
Integumentary disorders: nursing assessment
-health history -physical exam -lab and diagnostic testing
Steven-Johnson syndrome and toxic epidermal necrolysis
-high fever and flu-like symptoms for 1-3 days prior to rash appearing -rash is characteristic with the addition of inflammatory bullae on at least two types of mucosa (lips, oral mucous, bulbar conjunctivae, or anogenital region) -mortality rate of 10% -treatment: hospitalization, isolation, fluid and electrolyte support, treatment of secondary infection of the lesions -ophthalmologic consult to determine if corneal ulceration, keratitis, uveitis, or panophthalmitis is present
Acne vulgaris: nursing assessment
-history of onset of acne lesions -family history -medication use (certain meds may hasten onset or worsen it) -note use of corticosteroids, androgens, lithium, phenytoin, and isoniazid -document history of an endocrine disorder, particularly one that results in hyperandrogegism -girls not worsening symptoms 2-7 days before the start of her period -inspect skin lesions (especially face, upper chest, back) -note presence, distribution, and extent of noninflammatory lesions (open and close comedones) and inflammatory lesions (papules, pustules, nodules, or cysts) -examine skin for hypertrophic scarring resulting from inflammatory lesions -note oily skin and oily hair, which result from increased sebum production -determine remedies that have been used and the extent of success of those treatments -assess the child's or teen's feelings about the disorder
Urticaria: nursing management
-identify and remove trigger -discontinue antibiotics -administer antihistamine, corticosteroids, and topical antipruritics as prescribed -inform the child and family that the episode should resolve within a few days -if it lasts up to 6 weeks, the child should be reevaluated -advise family to obtain a medical alert bracelet for the child if the reaction is severe
Nursing diagnoses
-impaired skin integrity -risk for infection -risk for fluid volume deficit -altered nutrition -disturbed body image -pain -interrupted family processes -risk for caregiver role strain
Bacterial skin infections: therapeutic management
-includes topical or systemic antibiotics -appropriate hygiene
Signs of child abuse-induced burns
-inconsistent history given when caregivers are interviewed separately -delay in seeking treatment by caregiver -uniform appearance to the burn, with clear delineation of burned and non burned area (as with a hot object applied to the skin) -in the case of scaled-induced burn, lack of spattering of water but evidence of so-called "porcelain-contact sparing," where the portion of the child's skin that was in contact with the tub or sink is not burned (commonly seen with a forced immersion in extremely hot water used as punishment) -flexor-sparing burns or burns that involve the dorm of the hand -a stocking/glove pattern on the hands or feet (circumferential ring appearing around the extremity, resulting from a caregiver forcefully holding the child under extremely hot water)
Differences in the skin between children and adults
-infant's epidermis is thinner than adult's -the blood vessels lie closer to the surface because there is a decreased amount of subcutaneous fat > infant loses heat more readily through the skin's surface than the older child or adult does -thinness of the skin also allows substances to be absorbed through the skin more readily than they would be in an adult -bacteria can gain access via the infant's and younger child's skin more readily than they can through the adult's skin -the infant's skin contains more water than the adult's, and the epidermis is loosely bound to the dermis > means that friction may easily cause separation of the layers, resulting in blistering or skin breakdown -infant's skin is less pigmented than that of the adult (in all races), placing the infant at increased risk of skin damage from ultraviolet radiation -over time, the infant's skin toughens and becomes less hydrated and therefore is less susceptible to microorganism invasion -skin thickness and characteristics reach adult levels in the late teenage years
Acne neonatorum: nursing management
-instruct parents to avoid picking or squeezing the pimples; to do so places the infant at risk for secondary bacterial infection and cellulitis -teach parents to wash the affected areas daily with clear water -avoid using fragranced soaps or lotions on the area with acne -inform the parents that as the newborn's hormones stabilize over time, the disorder will usually resolve without additional intervention
Burn prevention
-keep hot water heater temp lower than 120 F -test bath water temp before bathing children -keep children away from open flames, stoves, and candles -cook with pots on the inside of the stove with the handles turned in -keep children away from the stove while cooking -place hot liquids out of reach of children -avoid drinking hot beverages while holding a child -keep curling irons out of reach of children -teach older children how to safely get out of the house in case of fire -practice fire drills -teach children to "stop, drop, and roll" if their clothes catch on fire
Bacterial skin infections: nonbullous impetigo- usual treatment
-limited amount: treat topically with mupirocin ointment -if numerous lesions, oral first-generation cephalosporin is indicated -clindamycin may be needed for MRSA -remove honey-colored crust with cool compresses twice daily
Bacterial skin infections: cellulitis- skin findings
-localized reaction: erythema, pain, edema, warmth at site of skin disruption
Bacterial skin infections: cellulitis- usual treatment
-mild cases are usually treated with cephalexin or amoxicillin/ clavulanic acid -more severe cases and periorbital or orbital cellulitis require IV cephalosporins
Bacterial skin infections: staphylococcal scalded skin syndrome- usual treatment
-mild to moderate cases are treated with oral cephalexin, dicloxacillin, or amoxicillin/ clavulanic acid -severe cases are managed similar to burns with aggressive fluid management and IV oxacillin or clindamycin
Animal bites: prevention
-never provoke a dog with teasing or roughhousing -get adult permission before interacting with a dog, cat, or other animal that is not your pet -do not bother an eating, sleeping, or nursing dog -avoid high-pitched talking or screaming around dogs -display a closed fist first for the dog to sniff -keep ferrets away from the face -if a cat hisses or lashes out with the paw, leave it alone
Cold injury: nursing assessment
-note history of cold exposure -inquire about pain or numbness -examine skin for indications of frostbite
Erythema multiforme: nursing assessment
-note history of fever, malaise, and ashiness (myalgia) -determine onset and progression of rash, and presence of pruritus and burning -document child's temp upon assessment -inspect for skin lesions, most commonly occur over the hands and feet and extensor surfaces of the extremities, with spread to the trunk -lesions progress from erythematous macule (flat reddened areas) to papules, plaques, vesicles, and target lesions over a period of days
Pressure ulcers: nursing assessment
-note history of immobility (chronic, related to a condition such as paralysis) or lengthy hospitalization, particularly in intensive care -inspect the skin for areas of erythema or warmth -note ulceration of the skin -use the facility's wound assessment scale to document the extent of the ulcer -take photo of ulcer if possible
Acne neonatorum: nursing assessment
-note oily face or scalp -examine the face (especially the cheeks), upper chest, and back for inflammatory papules and pustules -document the absence of fever
Urticaria: nursing assessment
-obtain detailed history of new foods, medications, symptoms of a recent infection, changes in environment, or unusual stress -inspect skin, noting raised, edematous hives anywhere on the body or mucous membranes -hives are pruritic, blanch when pressed, and may migrate -angioedema may also be present and is identifiable as subcutaneous edema and warmth, occurring most frequently on the extremities, face or genitalia -carefully assess airway and breathing, as hypersensitivity reactions may affect respiratory status
Sunburn: nursing assessment
-obtain health history, noting recent sun exposure -determine length of exposure whether any type of sunscreen or sun block product was used -note redness of the skin on the exposed areas -more severe areas will have a darker red, slightly purple hue -blisters may be noted with more severe sunburn
Insect stings and spider bites: nursing assessment
-obtain history of the bite or sting -children are usually acutely aware when they have been stung by an insect, but spiders are generally not observed before the bite -inspect the bite or sting, noting an urticarial wheal or papular reaction -a large local reaction may be mistaken for cellulitis -note whether a stinger remains present -assess the child's work of breathing to determine if a systemic reaction or anaphylaxis is occurring
Minor injuries: nursing assessment
-obtain the history from the child or caregiver to determine whether dirt or a foreign object may be present in the wound -inspect the wound, noting depth of injury, a foreign body, and bleeding
Bacterial skin infections: bullous impetigo- usual treatment
-oral first-generation cephalosporin -good hygiene
Tinea capitis: usual treatment
-oral griseofulvin for 4-6 weeks -selenium sulfide shampoo may be used to decrease contagiousness (adjunct only) -no school or daycare for 1 week after treatment initiated
Bacterial skin infections: nonbullous impetigo- skin findings
-papules progressing to vesicles, then painless pustules with a narrow erythematous border -honey-colord exudate when the vesicles or pustules rupture, which forms a crust on the ulcer-like base
Criteria for referral to specialized burn unit
-partial thickness burns greater than 10% of total body surface area -burns that involve the face, the hands and feet, genitalia, perineum, or major joints -full-thickness burns of any size -chemical or electrical burns (including lightning injury) -inhalation injury -burn injury in children who have pre-existing conditions that might affect their care -persons with burns and traumatic injuries -persons who will require special social, emotional, or long-term rehabilitative care -burned children in a hospital without qualified personnel or equipment for the care of children
Tinea capitis: skin findings
-patches of scaling in the scalp with central hair loss -risk of kerion development (inflamed, boggy mass that is filled with pustules)
Pressure ulcers: nursing management
-position child to alleviate pressure on the area of the ulcer -use specialized beds or mattresses to prevent further pressure areas from developing -perform prescribed wound care meticulously, noting the formation of granulation tissue as the ulcer begins to heal -prevent ulcers in the child who is hospitalized for long periods of time by turning the child frequently, assessing the entire surface of the child's skin at least every shift, using pressure-alleviating beds and mattresses, and maintaining the child's nutritional status
Burns: nursing management
-promoting oxygenation and ventilation -restoring and maintaining fluid volume -preventing hypothermia -cleansing the burn -preventing infection -managing pain -treating infected burns -providing burn rehabilitation -preventing burns and carbon monoxide poisoning -providing burn care at home
Human and animal bites: nursing management
-provide rabies immunoprophylaxis and tetanus booster vaccination if indicated -thoroughly cleanse the wound with soap and water or a povidone-iodine solution -irrigate the wound well with normal saline after cleansing -if the animal may be rabid, cleanse the wound for at least 10 minutes with a vircucidal agent such as povidone-iodine -administer antibiotics as prescribed -never leave a child younger than 5 alone with a dog -contact the local humane society for a dog bite prevention program that is appropriate for school-age children -children may suffer significant emotional distress after being bitten; help child through this period by talking about the incident or reading books about this type of event
Bacterial skin infections: bullous impetigo- skin findings
-red macule and bullous eruptions on an erythematous base -size may be from a few millimeters to several centimeters
Bacterial skin infections: folliculitis- skin findings
-red, raised hair follicles
Insect stings and spider bites: nursing management
-remove jewelry or constrictive clothing if the sting is on an extremity -cleanse the wound with mild soap and water -if the stinger is present, scrape it away with your fingernail or a credit card -apply ice intermittently to decrease pain and edema -administer diphenhydramine as soon as possible after the sting in an attempt to minimize the reaction -prevent insect stings and spider bites by wearing protective clothing and shoes when outdoors -use insect repellants (with max concentration of 30% n,n-diethyl-meta-tolumaide [DEET] in infants and children older than 2 months) -teach children never to disturb a bee or wasp nest or an ant hill
Atopic dermatitis: lab and diagnostic tests
-serum IgE levels: may be elevated -skin prick allergy testing: may determine the food or environmental allergen to which the child is sensitive
Tinea vesicolor: skin findings
-superficial tan or hypopigmented oval scaly lesions, especially on upper back and chest and proximal arms -more noticeable in the summer with tanning of unaffected areas
Differences in dark-skinned children
-tend to have more pronounced cutaneous reactions compared to children with lighter skin -hypopigmentation or hyper pigmentation in the affected area following healing of a dermatologic condition is common > change in pigmentation may be temporary (a few months) -tend to have more prominent papules, follicular responses, lichenification, and vesicular or bullous reactions than lighter skinned children with the same disorder -hypertrophic scarring and keloid formation occur more often in dark-skinned children
Tinea pedis (athlete's foot): usual treatment
-topical anti fungal cream, powder, or spray -appropriate foot hygiene
Diaper candidiasis (monilial diaper rash): usual treatment
-topical nystatin with diaper changes for several days -see section on diaper dermatitis for additional information
Bacterial skin infections: folliculitis- usual treatment
-treat with aggressive hygiene: warm compresses after washing with soap and water several times a day -topical mupirocin is indicated; occasionally oral antibiotics are required
CA-MRSA: risk factors
-turf burns -towel sharing -participation in team sports -attendance at daycare or outdoor camps
Preventing infection: interventions and rationale
-use appropriate hand hygiene to decrease transmission of infectious organisms -assess the skin impairment site for increased warmth, redness, discharge, or new purulence to identify infection early -assess temp every 4 hours or more frequently if needed as children develop fever quickly in response to infection -note WBC count and culture results, reporting unexpected values to the physician or NP so that appropriate treatment may be started -follow prescribed therapies for skin alteration to maintain skin moisture and prevent further breakdown, which may lead to infection -encourage appropriate nutritional intake as adequate nutrients are necessary for appropriate immune function and skin healing
Contact dermatitis: treatment
-wash lesions daily with mild soap and water -mildly decried crusted lesions -tepid baths (colloidal oatmeal such as Aveeno) are helpful to decrease itching -avoid hot baths or showers, as they aggravate itching -apply corticosteroid preparations topically as directed (if using high-potency preparations, do not cover with an occlusive dressing) -weeping lesions may be wrapped lightly; avoid occlusion -Burrow or Domeboro solutions with a dressing applied twice daily for 20 minutes may help to dry weepy lesions -OTC preparations such as calamine lotion or Ivy Rest may reduce itching and help the lesions to dry -do not use topical antihistamines, benzocaine, or neomycin because of the potential for sensitization
Seborrhea: nursing management
-wash or shampoo the affected areas with a mild soap -apply anti-inflammatory cream to skin lesions if prescribed -in the infant, apply mineral oil to the scalp, massage it well with a washcloth, and then shampoo 10-15 minutes later, using a brush to gently lift the crusts; do not forcibly remove the crusts -if needed, selenium sulfide shampoo may safely be used on the infant, following the aforementioned procedure -adolescent may require daily shampooing with antidandruff shampoo
Contact dermatitis: prevention
-wear long sleeves and long pants on outings in the woods -identify and remove offending plants in the yard by using a commercial weed or underbrush killer -vinyl gloves (not rubber or latex) are an effective barrier -the plant's oil residue may be on clothes, pets, garden, and sports equipment, and toys; wash those well with soap and water -if contact occurs, wash vigorously with soap and water within 10 minutes of contact -Zanfel and Tecnu Oak-N-Ivy Outdoor Skin Cleanser (both soap mixtures) may prevent rash if used to wash the skin soon after exposure -Ivy Block (an organoclay) is the only US FDA approved preventative treatment related to poison ivy, oak, or sumac; it is applied to the skin before possible exposure
Cellulitis: periorbital
a bacterial infection of the eyelids and tissue surrounding the eye bacteria may gain entry to the skin via an abrasion, laceration, insect bite, foreign body, or impetiginous lesion may also result form a nearby bacterial infection, such as sinusitis staphylococcus, aureus, streptococcus pyogenes, and streptococcus pneumonia are the most commonly implicated bacteria bacteria produce either an enzyme or endotoxins that initiate the inflammatory response -redness, swelling, and infiltration of the skin by the inflammatory mediators occur
Tinea
a fungal disease occurring on any part of the body
Lesion descriptions: morbilliform
a rosy, maculopapular rash
Insect stings and spider bites
a systemic or anaphylactic reaction to a Hymenoptera sting may also occur, possibly resulting in airway compromise serious reactions may occur with brown recluse or black widow spider bites local reactions include pruritus, pain and edema a hypersensitivity reaction thought to be mediated by IgE occurs in response to venom bacterial superinfection may occur as a complication and as a result of scratching therapeutic management: antihistamines to decrease itching and in some cases corticosteroids to decrease inflammation and swelling
Common drugs for integumentary disorders: corticosteroids (topical)
actions/indications: -anti-inflammatory effect in atopic dermatitis and certain kinds of contact dermatitis nursing implications: -do not use moderate- or high- potent corticosteroid preparations on the face or genitals -do not cover with an occlusive dressing -absorption is increased in the young infant
Common drugs for integumentary disorders: topical immune modulators (tacrolimus, pimecrolimus)
actions/indications: -antihistaminic effect, results in sedation -indicated for hypersensitivity reactions, atopic dermatitis or contact dermatitis that is severely pruritic nursing implications: -may give three or four times a day unless sedation effect interferes with activities of daily living or school
Common drugs for integumentary disorders: coal tar preparations
actions/indications: -antipruritic and anti-inflammatory effect -useful in psoriasis, atopic dermatitis nursing implications: -may stain fabrics; strong and unpleasant odor -apply at bedtime and rinse off in the morning to improve compliance
Common drugs for integumentary disorders: antibiotics (topical)
actions/indications: -decrease skin colonization with bacteria -indicated for mild acne vulgarisms, impetigo, folliculitis nursing implications: -apply as prescribed to clean skin or a cleansed wound -be alert for neomycin allergy
Common drugs for integumentary disorders: antifungals (topical)
actions/indications: -fungicidal used to treat tine, candidal diaper rash nursing implications: -apply a thin layer as prescribed -comply with length of treatment as prescribed to prevent reemergence of the rash
Common drugs for integumentary disorders: systemic corticosteroids (prednisone, dexamethasone, methylprednisone)
actions/indications: -anti-inflammatory and immunosuppressive action -used in severe contact dermatitis nursing implications: -administer with food to decrease GI upset -may mask signs of infection -monitor BP, urine for glucose -do not stop treatment abruptly or acute adrenal insufficiency may occur -monitor for Cushing syndrome -doses may be tapered over time
Common drugs for integumentary disorders: retinoids (topical)- tretinoin, adapalene, tazarotene
actions/indications: -anticomedogenic activity in moderate to severe acne vulgaris nursing implications: -adverse effects: dryness, burning, photosensitivity -instruct child to use SPF 15 or higher sunscreen
Common drugs for integumentary disorders: silver sulfadiazine 1%
actions/indications: -bactericidal against gram-positive and gram-negative bacteria and yeasts -indicated for burns nursing implications: -cover with occlusive dressing -apply twice daily -do not use in children with sulfa allergy -forms a gel on the burn that is painful to remove -may cause transient neutropenia -do not use on the child's face or on an infant younger than 2 moths of age
Common drugs for integumentary disorders: antibiotics (systemic)
actions/indications: -bactericidal or bacteriostatic against a variety of organisms, depending on the preparation -used for moderate to severe acne vulgarisms, extensive impetigo, cellulitis, scaled skin syndrome nursing implications: -check for medication allergies prior to administration -teach families to finish entire course of antibiotics
Common drugs for integumentary disorders: benzoyl peroxide
actions/indications: -decreases colonization of P. acnes in mild acne vulgaris nursing implications: -available in combination with topical antibiotics -apply sparingly; shake before application -avoid contact with eyes and mucous membranes
Common drugs for integumentary disorders: antifungals (systemic)- griseofulvin, ketoconazole
actions/indications: -kill fungus; bind to human keratin, making it resistant to fungus -indicates for tinea capitis and severe or widespread fungal skin infections nursing implications: -griseofulvin: give with fatty food to increase absorption; requires minimum 4-week course -monitor liver function tests and CBC -may cause photosensitivity -ketoconazole: administer with food to decrease GI upset
Common drugs for integumentary disorders: isotretinoin
actions/indications: -reduces sebaceous gland size, decreases sebum production, and regulates cell proliferation and differentiation -indicated for cystic acne or severe acne that is resistant to 3 months of treatment with oral antibiotics nursing implications: -ensure that the adolescent girl is not pregnant and does not become pregnant -monitor CBC, lipid profiles, liver function tests, and beta-human chorionic gonadotropin monthly -monitor for suicide risk
Erythema multiforme
acute, self-limiting hypersensitivity reaction uncommon in children may occur in response to viral infections (adenovirus, or Epstein-Barr virus), mycoplasma pneumonia infection, or a drug (sulfa drugs, penicillins, immunizations) or food reaction most severe forms: -Steven-Johnson syndrome (results in skin detachment of 10% or less) -toxic epidermal necrolysis (involves 30% skin detachment) treatment is generally supportive because it resolves on its own
Acne vulgaris
affects about 85% of adolescents (beginning a early as age 7-10 years, between the ages of 12-16) endogenous androgens play a role in its development occurs most frequently on the face, chest, and back
Tinea corporis (ringworm): skin findings
annular lesion with raised peripheral scaling and central clearing (looks like a ring)
Lesion descriptions: shape
are they round, oval, or annular
Cellulitis: perioribtal complications
bacteremia and progression orbital cellulitis, which is more extensive infection involving the orbit of the eye
Open comedones
blackheads
Contact dermatitis
cell-mediated response to an antigenic substance exposure -first exposure is the sensitization phase -an allergic response occurs within 24-48 hours after contact with the substance may occur as result of allergy to nickel or cobalt found in clothing hardware and dyes, and chemicals found in many hygiene products and cosmetics
Minor injuries
children suffer frequently -because of developmental immaturity and inquisitive nature, children often attempt tasks they are not yet capable of or take risks that an adult would not, often resulting in a fall or other accident include: -minor cuts and abrasions -skin penetration of foreign bodies (splinters, glass fragmentS) break in the skin allows an entry point for bacteria, and the complication of cellulitis may occur treatment is directed at cleaning the wound and preventing infection
Seborrhea
chronic inflammatory dermatitis that may occur on the skin or scalp in infants, it occurs most often on the scalp and is commonly referred to as cradle cap infants can also manifest on nose or eyebrows, behind the ears, or in the diaper area usually resolves over a period of weeks to months adolescents manifest on the scalp (dandruff) and on the eyebrows and eyelashes, behind the ears, and between the shoulder blades a thought to be an inflammatory reaction to the fungus pityrosporum oval and is worsened by sebaceous involvement related to maternal hormones in the infant and androgens in the adolescent therapeutic management: -treating the skin lesions with corticosteroid creams or lotions -antidandruff shampoos containing selenium sulfide, ketoconazole, or tar are used to treat the scalp
Psoriasis
chronic inflammatory skin disease with periods of remission and exacerbation; control is possible with conscientious therapy only affects about 2% of adult population -30-45% of all cases are diagnosed in childhood hyper proliferation of the epidermis occurs, with a rash developing at sites of mechanical, thermal and physical trauma therapeutic management: -skin hydration with emollient creams -use of tar preparations -topical steroids -ultraviolet light -narrow band ultraviolet light has been used with some success in children with severe forms
Classification of acne: moderate
comedones plus inflammatory lesions such as papules or pustules (localized to face or back)
Acne
common skin condition in childhood that affects the pilosebaceous unit affects males and females, and all ethnic groups can be caused by endocrine abnormalities (when it lasts past the usual course of time for infantile or adolescent types) may occur in repose to use of certain types of drugs (corticosteroids, androgens, phenytoin, others)
Impetigo: bollous
demonstrates a sporadic occurrence pattern and develops on intact skin, resulting for toxin production by s. aureus
Frostbite: second-degree
demonstrates blistering with erythema and edema
Common medical treatments: wet dressing
dressing moistened with lukewarm water (sterile water may be required in certain cases) indications: in the presence of itching, crusting or oozing- helps to remove crusts nursing implications: -may use Burow, Domeboro, or saline solutions in certain cases -provide atraumatic care by giving premedication before dressing change
Scaling
dry, flaky skin
Tinea cruris: skin findings
erythema, scaling, maceration in the inguinal creases and inner thighs (penis/scrotum spared)
Diaper candidiasis (monilial diaper rash): skin findings
fiery red lesions, scaling in the skin folds, and satellite lesions (located further out from the main rash)
Cellulitis: periorbital- treatment
focuses on IV antibiotic administration during the acute phase followed by completion of the course with oral antibiotics
Tinea corporis
fungal infection on the arms or legs
Tinea pedis
fungal infection on the feet
Tinea cruris
fungal infection on the groin
Tinea capitis
fungal infection on the scalp, eyebrows, or eyelashes
Tinea vesicular
fungal infection on the trunk and extremities
Impetigo: nonbollous
generally follows some type of skin trauma or may arise as a secondary bacterial infection of another skin disorder, such as atopic dermatitis
Frostbite: third-degree
hemorrhage blisters occur
Contact dermatitis: common causes
highly allergenic plants: -poison ivy (toxicodendron radicans) -eastern poison oak (toxicodendron quercifolium) -western poison oak (toxicodendron diversilobum) -poison sumac (toxicodendron vernix)
Atopic dermatitis: nursing assessment
history: -wiggling or scratching -dry skin -scratch marks noticed by the parents -disrupted sleep -irritability current and past medical history risk factors onset of rash: -location -progression -severity response to treatments used so far medications used to treat the rash, as well as other medications child is taking
Lesion descriptions: linear
in a line
Common lab and diagnostic tests: CBC
indications: infection or inflammatory process nursing implications: -normal values vary according to age and gender -WBC differential is helpful in evaluating source of infection -may be affected by myelosuppressive drugs -eosinophils may be elevated in the child with atopic dermatitis
Folliculitis
infection of the hair follicle most often results from occlusion of the hair follicle may occur as a result of poor hygiene, prolonged contact with contaminated water, maceration, a moist environment, or use of occlusive emollient products
Classification of acne: sever
lesions similar to moderate, but more widespread, and/or presence of cysts or nodules associated more frequently with scarring
Lesion descriptions: target lesions
like a bull's eye
Cellulitis
localized infection and inflammation of the skin and subcutaneous tissues and is usually preceded by skin trauma of some sort
Common medical treatments: sunscreen
lotion, gel or cream with sun-protective factor (SPF) indications: all children older than 6 months of age nursing implications: -use a fragrance-free, para-aminobenzoic acid (PABA)- free preparation with an SPF of 15 or higher -apply at least 30 min prior to sun exposure; reapply at least every 2 hours while exposed (every 60-80 min while in the water) -sweat and water-resistant preparations are available yet still require reapplication as noted above -use daily in summer and in warm climates, even on overcast and cloudy days
Common lab and diagnostic tests: Immunoglobulin E (IgE)
measurement of serum IgE indications: atopic dermatitis nursing implications: -often elevated in allergic or atopic disease, through this is a nonspecific finding; may be increased if the child takes systemic corticosteroids
Community-acquried methicillin-resistant s. aureus (CA-MRSA)
most commonly occurs as a skin or soft tissue infection (cellulitis, abscess) if child presents with a moderate to severe skin infection or with an infection that is not responding as expected to therapy, obtain a culture of the area
Common lab and diagnostic tests: patch or skin testing
needle prick testing with allergens indications: atopic or contact dermatitis nursing implications: -have emergency equipment available in the event of anaphylaxis (rare)
Common lab and diagnostic tests: Erythrocyte sedimentation rate (ESR)
nonspecific test used to detect presence of infection or inflammation indications: infection or inflammatory process nursing implications: -send sample to lab immediately > if allowed to stand for longer than 3 hours, may result in falsely low result
Acne neonatorum
occurs as a response to the presence of maternal androgens or to transient androgen production in the newborn may be present immediately after birth but often occurs between 2-4 weeks of age usually no treatment is necessary, but in severe cases, there is risk of scarring > topical preparation may be prescribed
Sunburn
occurs as a result of overexposure to the UV rays of the sun erythema and eventual blisters occur as a result of the skin's blood flow change as well as alterations in cell kinetics and pigment products in response to UV exposures erythema may occur within 4 hours and blisters within 6 hours usually treated with cool compresses, cooling lotions, and oral non steroidal anti-inflammatory agents
Atopic dermatitis (eczema)
onset of symptoms is usually before 2 years of age often associated with food allergies, allergic rhinitis, and asthma phonic itching associated causes a great deal of psychological distress -child's self-image may be affected, particularly if rash is extensive child is irritable and has difficulty concentrating, family life is disrupted -parents' stress related to the child's condition may increase the child's level of anxiety and lead to an increase in itching and scratching child may outgrow the condition, its severity may decrease as the child approaches adulthood, or the child may continue to have difficulties into adulthood bacterial superinfection is a possible complication
Acne vulgaris: risk factors
preadolescent or adolescent age male gender (presence of androgens) oily complexion Cushing syndrome or other disease process resulting in increased androgen production
Classification of acne: mild
primarily noninflammatory lesions (comedones)
Impetigo
readily recognizable skin rash nonbollous, bollous
Tinea pedis (athlete's foot): skin findings
red, scaling rash on soles and between the toes
Dermatitis
refers to an inflammatory reaction of the skin
Diaper dermatitis
refers to an inflammatory reaction of the skin in the area covered by a diaper nonimmunologic response to a skin irritant that results in skin cell hydration disturbance prolonged exposure to urine and feces may lead to skin breakdown diaper wearing increases the skin's pH, activating fecal enzymes that further contribute to skin maceration
Cold injury: nursing management
remove wet or tight clothing avoid vigorous massage to decrease the change of damaging the skin further immerse the affected part in 104 F water for 15-30 min thawing may cause significant pain, so administer analgesics keep the thawed part loosely covered, warm, and dry splinting may be used to help decrease associated edema consult wound care specialist/plastic surgeon for further management
Staphylococcal scaled skin syndrome
results from infection with s. aureus that produces a toxin, which then causes exfoliation has an abrupt onset and results in diffuse erythema and skin tenderness scalded skin syndrome is most common in infancy and rare beyond 5 years of age
Frostbite: first-degree
results in superficial white plaques with surrounding erythema
Common lab and diagnostic tests: Potassium hydroxide (KOH) prep
reveals branching hyphae (fungus) when viewed under microscope indications: to identify fungal infection nursing implications: -place skin scrapings on a microscope slide and add KOH 20% drop
Annular
ring around central clearing
Papules
rounded, nonpustular elevation on the skin
Pruritus
sensation of itching
Pressure ulcers
skin breakdown involves changes in intact skin, which may range from blanch able erythema to deep pressure ulcers refers to damage to the skin resulting in skin loss and development of a crater that may range from mild to deep develop from a combination of factors, including immobility or decreased activity, decreased sensory perception, increased moisture, impaired nutritional status, inadequate tissue perfusion, and the forces of friction and shear common sites in hospitalized children: occiput and toes, sacral or hip area (children in wheelchairs)
Frostbite: fourth-degree
tissue necrosis and sloughing
Tinea corporis (ringworm): usual treatment
topical anti fungal cream is required for at least 4 weeks
Tinea cruris: usual treatment
topical anti fungal preparation for 4-6 weeks
Urticaria
type I hypersensitivity reaction caused by an immunologically mediated antigen-antibody response of histamine release from mast cells -vasodilation and increased vascular permeability; erythema and wheals then occur usually begins rapidly and may disappear in a few days or may take up to 6 weeks to resolve common causes: -foods -drugs -animal stings -infections -environmental stimuli (heat, cold, sun, tight clothes) -stress therapeutic management: -focuses on identifying and removing the cause as well as providing antihistamines or steroids
Common medical treatments: bathing
use of lukewarm water (with or without soap) to bathe indications: itchy and irritating skin conditions nursing implications: -recommended fragrance-free, dye-free soaps such as Dove, Aveeno, Basis, Lubriderm -Colloid (oatmeal baths) are especially helpful -pat the child dry; do not rub the skin; leave the child moist before applying medication, dressing, or moisturizer
Closed comedones
whiteheads