Nursing care of the child with an alteration in tissues integrity/Integumentary disorder

Acne neonatorum:

Acne neonatorum occurs as a response to the presence of maternal androgens or to transient androgen production in the newborn. It may be present immediately after birth but often occurs between 2 and 4 weeks of age.

Acne vulgaris:

Acne vulgaris affects about 85% of adolescents, beginning as early as age 7 to 10 years between the ages of 12 and 16 years, and endogenous androgens play a role in its development. It occurs most frequently on the face, chest, and back. Risk factors for the development of acne vulgaris include preadolescent or adolescent age, male gender (due to the presence of androgens), an oily complexion, Cushing syndrome, or another disease process resulting in increased androgen production.

Acne:

Acne, is a common skin condition in childhood , is a disorder that affects the pilosebaceous unit. It affects males and females, as well as all ethnic groups. Acne that persists past the usual course of time for infantile or adolescent acne may be caused by endocrine abnormalities.

Nursing management:

Administer antibiotics topically or systemically as prescribed. Teach the family about antibiotic administration and care of the lesions or rash. Soak impetiginous lesions with cool compresses or Burow solution to remove crusts before applying topical antibiotics. Though impetigo is considered a contagious disorder among vulnerable populations, removal from school or day care is not necessary unless the condition is widespread or actively weeping. Prevent transmission of nosocomial MRSA by appropriately isolating children according to the institution's policy when the child is hospitalized. For periorbital cellulitis, apply warm soaks to the eye area for 20 minutes every 2 to 4 hours. Administer intravenous antibiotics as prescribed. Instruct parents to call the physician or nurse practitioner or have the child evaluated again if the child is not improving, the child cannot move his eye, proptosis occurs, or if perceived visual acuity lessens. Teach families the importance of completing the entire course of oral antibiotic treatment at home. Educate the family about prevention of bacterial skin infections. Stress the importance of cleanliness and hygiene. Teach the family to keep the child's fingernails cut short and to clean the nails with a nail brush at bath time. When a skin disruption such as a cut, scrape, or insect bite occurs, teach the family to clean the area well to prevent the development of cellulitis. Folliculitis may be prevented with diligent hygiene and avoidance of occlusive emollients.

Atopic dermatitis:

Atopic dermatitis (AD; also called eczema) is one of the disorders in the atopy family (along with asthma and allergic rhinitis). Atopic dermatitis affects 12.5% to 20% of U.S. children. Atopic dermatitis is often associated with food allergies, allergic rhinitis, and asthma, though not all children with AD will develop one of those other disorders. The chronic itching associated with atopic dermatitis causes a great deal of psychological distress. The child's self-image may be affected, particularly if the rash is extensive. Difficulty sleeping may occur because of the itching. The child is irritable and has difficulty concentrating, and family life is disrupted. Parents' stress related to the child's condition may increase the child's anxiety and lead to an increase in itching and scratching. The child may outgrow atopic dermatitis, its severity may decrease as the child approaches adulthood, or the child may continue to have difficulties into the adult years. Bacterial superinfection may occur as a complication.

What is the pathophysiologic for atopic dermatitis?

Atopic dermatitis is a chronic disorder characterized by extreme itching and inflamed, reddened, and swollen skin. It has a relapsing and remitting nature. The skin reaction occurs in response to specific allergens, usually food (especially eggs, wheat, milk, and peanuts) or environmental triggers (e.g., molds, dust mites, and cat dander). Other factors, such as high or low ambient temperatures, perspiring, scratching, skin irritants, or stress, may contribute to flare-ups.

Auscultation:

Auscultate the lungs for wheezing (commonly found in the associated condition of asthma).

Nursing management for acne vulgaris:

Avoid oil-based cosmetics and hair products, as their use may block pores, contributing to noninflammatory lesions. Look for cosmetic products labeled as noncomedogenic. Headbands, helmets, and hats may exacerbate the lesions by causing friction. Dryness and peeling may occur with acne treatment, so encourage the child to use a humectant moisturizer. 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 a noncomedogenic sunscreen with an SPF of 30 or higher is recommended. Teach adolescents that the prescribed topical medications must be used daily and that it may take 4 to 6 weeks to see results. Avoid the use of over-the-counter 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 a pregnancy prevention program because the drug causes defects in fetal development

Bacterial infections:

Bacterial infections of the skin include bullous and nonbullous impetigo, folliculitis, cellulitis, and staphylococcal scalded skin syndrome. These bacterial skin infections are often caused by Staphylococcus aureus and group A β-hemolytic streptococcus, which are ordinarily normal flora on the skin. Folliculitis, infection of the hair follicle, most often results from occlusion of the hair follicle. It may occur as a result of poor hygiene, prolonged contact with contaminated water, maceration, a moist environment, or use of occlusive emollient products. Periorbital cellulitis is a bacterial infection of the eyelids and tissue surrounding the eye. The bacteria may gain entry to the skin via an abrasion, laceration, insect bite, foreign body, or impetiginous lesion. Staphylococcal scalded skin syndrome results from infection with S. aureus that produces a toxin, which then causes exfoliation. It has an abrupt onset and results in diffuse erythema (reddening of the skin) and skin tenderness CA-MRSA most commonly occurs as a skin or soft tissue infection, such as cellulitis or an abscess. Risk factors for CA-MRSA are turf burns, towel sharing, participation in team sports, or attendance at day care or outdoor camps. If the child presents with a moderate to severe skin infection or with an infection that is not responding as expected to therapy, it is important to culture the infected area for MRSA.

Pathophysiology of burns:

Burned tissue begins to coagulate after the injury, and direct coagulation and microvascular reactions in the adjacent dermis may extend the burn. The blood vessels demonstrate increased capillary permeability, resulting in vasodilatation. This leads to increased hydrostatic pressure in the capillaries, causing water, electrolytes, and protein to leak out of the vasculature and result in significant edema. Edema forms very rapidly in the first 18 hours after the burn, peaking at around 48 hours. Capillary permeability then returns to normal between 48 and 72 hours after the burn and the lymphatics can reabsorb the edema fluid.

Burns

Burns are a common preventable mechanism of injury among children and adolescents. Young children are at highest risk for burns and the mortality rate from burns is highest in children younger than 5 years of age. Most pediatric burn-related injuries do not result in death, but injuries from burns often cause extreme pain and extensive burns can result in serious disfigurement. In young children, 60% to 80% of burns are scald burns. Fires in the home are often related to cooking, cigarette or other smoking materials. Carbon monoxide poisoning often occurs in conjunction with burns as a result of smoke inhalation, and infants and children are at greater risk for carbon monoxide poisoning than adults. Great advances have been made in the care of children with serious burns.

Types of burns:

Burns are classified according to the extent of injury and the terminology used to describe each type includes superficial (formerly first degree), partial thickness (second degree), deep partial thickness (second degree), and full thickness (third and fourth degree). Superficial burns involve only epidermal injury and usually heal without scarring or other sequelae within 4 to 5 days. In partial-thickness burns, injury occurs not only to the epidermis but also to portions of the dermis. These burns usually heal within about 2 weeks and carry a minimal risk of scar formation. Deep partial-thickness burns take longer to heal, may scar, and result in changes in nail and hair appearance as well as sebaceous gland function in the affected area. They may require surgical intervention. Full-thickness burns result in significant tissue damage as they extend through the epidermis, dermis, and hypodermis. Extensive scarring results, as hair follicles and sweat glands are destroyed. Full-thickness burns require a significant time to heal. If underlying tendons and/or bone are involved, the burn may be termed fourth degree.

common laboratory diagnositic:

CBC: infection or inflammatory process. ESR: infection or inflammator process. Poassium hydroxide: to identify fungal infection. Cultue of wond or skin drainage: identificaiton of specific organism Immunoglobulin: atopic determititis. Patch or skin testing: Atopic or contact dermatitis.

Minor injuries

Children suffer minor injuries very frequently. Because of their 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. Minor injuries include minor cuts and abrasions, as well as skin penetration of foreign bodies such as splinters or glass fragments.

Providing burns rehabilitation:

Children who have suffered a significant burn injury face myriad physical and psychological challenges that extend well beyond the acute injury phase. Burned children most often exhibit anxiety and attention or behavioral problems. Extensive burns may also result in the need for pressure garments to decrease the risk of extensive scarring. Pressure garments are not comfortable, and they must be worn continuously for at least 1 year, sometimes 2, but they have been shown to be very effective in reducing hypertrophic scarring resulting from significant burn injury. Nurses play a key role in smoothing the transition from the acute care phase of life-saving interventions and frequent dressing changes to normal activities such as school and play. Body image considerations may have a significant impact on the child when he or she returns to school and should be addressed. Children with altered body image as a result of a burn might benefit from regular counseling and group therapy.

What are the differences in dark-skinned children?

Children with dark skin tend to have more pronounced cutaneous reactions compared to children with lighter skin. Hypopigmentation or hyperpigmentation in the affected area following healing of a dermatologic condition is common in dark-skinned children. This change in pigmentation may be temporary (a few months following a superficial skin disorder) or permanent (following a more involved skin condition). Dark-skinned children tend to have more prominent papules (rounded, nonpustular elevation on the skin), 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.

Injuries

Children, by their inquisitive natures, developmental immaturity, and skin's properties, are prone to experience a variety of skin injuries. Pressure ulcers are most likely to occur in hospitalized or otherwise immobile children. Typical healthy, active children are likely to suffer cuts, abrasions, foreign-body penetration, burns and other thermal injuries, bites, and stings.

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 road tar with petrolatum. 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.

Contact dermatitis:

Contact dermatitis is a cell-mediated response to an antigenic substance exposure. The first exposure is the sensitization phase. The antigen attaches to cells that migrate to regional lymph nodes and have contact with T lymphocytes, where recognition of antigen is developed. During the second phase, elicitation, contact with the antigen results in T-lymphocyte proliferation and release of inflammatory mediators. An allergic response occurs within 24 to 48 hours after contact with the substance. Direct or indirect contact with the plant's oleoresin found in the leaves, stems, and roots results in an allergic reaction. Even contact with dormant plants or plants perceived to be dead may cause an allergic response. The rash is extremely pruritic and may last for 2 to 4 weeks; lesions continue to appear during the illness. Contact dermatitis is not contagious and does not spread either to other parts of the affected child's skin or to other people. Scratching does not spread the rash, but it may cause skin damage or secondary infection. Complications of contact dermatitis include secondary bacterial skin infections and lichenification or hyperpigmentation, particularly in dark-skinned people. Therapeutic management is directed toward management of itching and the use of topical corticosteroids.

Nursing management for burns:

Cool compresses may help to cool the burn. Aloe vera gel applied topically may provide significant soothing. Rarely are adverse effects reported with the use of aloe vera gel. Administer a nonsteroidal antiinflammatory such as ibuprofen. Discourage hot showers or baths. Instruct the child to wear loose clothing and to ensure that burned areas are covered when going outside

Maintaining skin integrity and preventing infection:

Cut the child's fingernails short and keep them clean. Avoid tight clothing and heat. Use 100% cotton bed sheets and pajamas. In addition to keeping the child's skin well moisturized, it is extremely important to prevent the child from scratching. Scratching causes the rash to appear and further scratching may lead to secondary infection. Antihistamines given at bedtime may sedate the child enough to allow him or her to sleep without awakening because of itching. A handheld clicker or counter may help to identify the scratching episode for the child, thus raising awareness. The use of diversion, imagination, and play may help to distract the child from scratching.

Diaper dermatitis:

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. It is a nonimmunologic response to a skin irritant that results in skin cell hydration disturbance. Prolonged exposure to urine and feces may lead to skin breakdown.

Nursing assessment for diaper dermititis

Determine from the history whether the infant or child wears diapers. Ask about the onset and progression of the rash, as well as any treatments and response. Inspect the skin in the diaper area for erythema and maceration. Ordinary diaper dermatitis does not usually result in a bumpy rash but starts as a flat red rash in the convex skin creases.

Assessment: health history

Determine the child's or parent's chief complaint, which is most often related to pruritus (sensation of itching), scaling (dry, flaky skin), or a cosmetic disruption. Document the history of the present illness, noting onset, location, duration, characteristics, other symptoms, and relieving factors, particularly as related to a rash or lesion. Also ask about the quantity and quality of any discharge from the rash or lesions. Document accompanying symptoms. Note the child's general state of health, history of chronic medical conditions, recent surgeries, hospitalizations, medications, or immunizations. Has there been a recent change in the child's food intake or environment? Is there a family history of chronic or acute skin conditions? Does anyone in the home have a similar concern at this time? Does the family have pets that go outdoors? Does the child play in the woods or garden? Note usual skin care routines, as well as types of soaps, cosmetics, or other skin care products used.

Nursing manamgent for bites:

Determine the 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.

Nursing management for eryhtema multiforme:

Discontinue the medication or food if it is identified as the cause. Ensure that treatment for Mycoplasma is instituted if present. Encourage oral hydration. Administer analgesics and antihistamines as needed to promote comfort.

Preventing hypothermia:

Due to the loss of the protective dermis, children who are burned are at high risk for hypothermia and secondary infection. Therefore, take care to keep the child warm. Warm intravenous fluids before administration. Maintain a neutral thermal environment and monitor the child's temperature frequently.

Nursing assessment for health history:

Elicit a description of the present illness and chief complaint. Common signs and symptoms reported during the health history might include: Wiggling or scratching Dry skin Scratch marks noticed by the parents Disrupted sleep Irritability Explore the child's current and past medical history for risk factors such as: Family history of atopic dermatitis, allergic rhinitis, or asthma Child's history of asthma or allergic rhinitis Food or environmental allergies

Nursing assessment for uticardia:

Elicit the health history, determining onset and progression of skin and scalp changes. Note response to treatment 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.

Nursing assessment for fungal infection:

Elicit the health history, noting exposure to another person with a fungal infection or exposure to a pet (fungi are often carried by pets). Note onset of the rash and whether it is itchy. Determine if the child has recently visited the barber (tinea capitis). Note contact with damp areas such as locker rooms and swimming pools, use of nylon socks or nonbreathable shoes, or minor trauma to the feet (tinea pedis). Document a history of wearing tight clothing or participating in a contact sport such as wrestling (tinea cruris). Inspect the skin and scalp, noting the location, description, and distribution of the rash or lesions.

Nursing assessment for contact dermatitis:

Elicit the health history, noting onset, description, location, and progression of the rash, which may be intensely pruritic and vesicular if caused by allergenic plant exposure. Examine the skin, noting rash that may vary from maculopapular in nature to an erythematous papulovesicular rash at the site of contact. Some lesions may be weeping; others may erupt and form a crust. The lesions are often distributed in an asymmetric linear pattern on exposed body parts if caused by allergenic plant exposure. If the child's shirt came in contact with the plant and then the shirt was removed by pulling it over the head, there may be widespread lesions over both sides of the face. Lesions near the eyes often cause significant eyelid edema.

Physical examination for burns:

Emergency examination of the burned child consists of a primary survey followed by a secondary survey. The primary survey includes evaluation of the child's airway, breathing, and circulation. Classify the burn according to its severity. Superficial burns are painful, red, dry, and possibly edematous. Partial-thickness and deep partial-thickness burns are very painful and edematous and have a wet appearance or blisters.

Erythema multiforme:

Erythema multiforme, though uncommon in children, is an acute, self-limiting hypersensitivity reaction. It may occur in response to viral infections, such as adenovirus or Epstein-Barr virus; Mycoplasma pneumoniae infection; or a drug (especially sulfa drugs, penicillins, or immunizations) or food reaction. Stevens-Johnson syndrome and toxic epidermal necrolysis are the most severe forms of erythema multiforme and most often occur in response to certain medications or to Mycoplasma infection

Nursing management for Psorias:

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 antiinflammatory creams as prescribed during flare-ups. Apply tar shampoos or skin preparations. Use mineral oil and warm towels to soak and remove thick plaques.

Promoting skin hydration for atopic dermatitis

First and foremost, avoid hot water and any skin or hair product containing perfumes, dyes, or fragrance. Bathe the child twice daily in warm (not hot) water. Use a mild soap to clean only the dirty areas. Recommended mild soaps or cleansing agents include: Unscented Dove or Dove for sensitive skin Tone Caress Oil of Olay Cetaphil Aquanil Slightly pat the child dry after the bath, but do not rub the skin with the towel. Leave the child moist. Apply prescribed topical ointments or creams such as corticosteroids or immune modulators.

Nursing assessment for atopic dermatitis:

For a full description of the assessment phase of the nursing process, refer to the nursing process overview section earlier in the chapter. Assessment findings pertinent to atopic dermatitis are discussed below.

Fungal infections:

Fungi also cause infections on children's skin. Tinea is a fungal disease of the skin occurring on any part of the body. The part of the body affected determines the second word in the name. Examples of tinea infections occurring on various parts of the body include: Tinea pedis: fungal infection on the feet Tinea corporis: fungal infection on the arms or legs Tinea versicolor: fungal infection on the trunk and extremities Tinea capitis: fungal infection on the scalp, eyebrows, or eyelashes Tinea cruris: fungal infection on the groin. Therapeutic management of fungal infections involves appropriate hygiene and administration of an antifungal agent.

Nursing assessment for uticardia

Identify and remove the offending trigger. Discontinue antibiotics. Administer antihistamines, 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.

Health history for burns:

If the burn is severe or there is a potential for respiratory compromise, obtain a brief history while simultaneously evaluating the child and providing emergency care. If the burn does not appear to pose an immediate life-threatening risk, obtain an in-depth history. Elicit a description of how the burn occurred, noting date, time, and cause. Determine if smoke inhalation or an associated fall may have occurred. Inquire about what caused the burn and if the event was witnessed by anyone. Spatter-type burns resulting from the child pulling a source of hot fluid onto himself or herself usually yield a nonuniform, asymmetric distribution of injury. In contrast, intentional scald injuries usually yield a uniform "stocking" or "glove" distribution when the child's extremity is held under very hot water as punishment

Laboratory and diagnnostic tests:

In the child with more extensive burns, electrolytes and complete blood count are used to measure fluid and electrolyte balance and to determine the possibility of infection, respectively. If wound infection is suspected, culture of the drainage will determine the particular bacteria. Nutritional indices such as albumin, transferrin, carotene, retinol, copper, cholesterol, calcium, thiamine, riboflavin, pyridoxine, and iron may be evaluated when the child has severe or extensive burns.

Signs of child abuse induced burns:

Inconsistent history given when caregivers are interviewed separately. • Delay in seeking treatment by caregiver. • Uniform appearance of the burn, with clear delineation of burned and nonburned area (as with a hot object applied to the skin). • In the case of a scald-induced burn, lack of spattering of water but evidence of the 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 dorsum 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).

Infectious disorders:

Infectious disorders of the skin include those caused by viral, bacterial, or fungal infection.

Inflammatory skin conditions:

Inflammatory skin conditions (dermatitis) may be either acute or chronic. Acute hypersensitivity reactions may cause diaper dermatitis, contact dermatitis, erythema multiforme, and urticaria. Atopic dermatitis is a chronic hypersensitivity disorder. Seborrhea and psoriasis are chronic inflammatory skin disorders that do not occur as a result of hypersensitivity.

Cleansing the burn:

Initially, it is very important to stop the burning. Therefore, remove charred clothing. Wash and rinse the burn thoroughly with mild soap and cool water from the tap. Never apply ice. Children who are burned with tar require special care. Remove tar with cool water and mineral oil. Do not routinely remove blisters because they provide a protective barrier; however, debridement is recommended in certain cases where large blisters impede wound care. commended in certain cases where large blisters impede wound care. Wounds that are open require debridement. Debridement involves the removal of loose skin and eschar (dead, charred skin). This procedure is usually performed with sterile scissors and a pair of forceps or with a gauze sponge. Gently cleanse the burned area; there is no advantage to aggressive scrubbing, and this technique only makes the pain more intense for the child.

Promoting oxygenatino and ventilation:

Institute emergency airway management as needed. If the child requires intubation, make sure that the tracheal tube is taped in a very secure manner, as reintubation in these children will become increasingly difficult as the edema spreads. The burned child's respiratory status warrants vigilant evaluation and reevaluation, as airway edema that is secondary to a burn may not become evident until 2 days after the injury. Administer 100% oxygen via nonrebreather mask or bag-valve-mask ventilation to all children with severe burns.

Preventing burns and carbon monoxide poinsoning:

Instruct parents about prevention of burns. Explain that all homes should have working smoke detectors, and batteries should be changed yearly. Instruct families that all homes should be equipped with fire extinguishers, and adults and older teenagers should be taught how to operate them. Explain that children should sleep in fire-retardant sleepwear, parents should not smoke in the house or the car, and parents should keep lighters and matches out of children's reach. Young children are particularly susceptible to burns that occur in the kitchen, such as scalds from hot liquids and foods and burns from contact with hot burners or oven doors.

Nursing management for acne neonatorum:

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.

Insect stings and spider bites:

Members of the Hymenoptera class of insects sting. This class includes bees, wasps, ants, yellow jackets, and hornets. Spiders inject their venom when they bite. Stings and bites usually result in a local reaction. A systemic or anaphylactic reaction to a Hymenoptera sting may also occur, possibly resulting in airway compromise.

Nursing assessment for Psoriasis

Note family history of psoriasis. Determine onset and progression of rash, as well as treatments used and the response to treatment. Question the child about pruritus, which is usually absent with psoriasis. Inspect the skin for erythematous papules that coalesce to form plaques, most frequently found on the scalp, elbows, genital area, and knee. Facial plaques may also occur and are more common in children than adults. The plaques have a silvery or yellow-white scale and sharply demarcated borders.

Nursing management for cold injury:

Note history of cold exposure. Inquire about pain or numbness. Examine the skin for indications of frostbite. First-degree frostbite results in superficial white plaques with surrounding erythema. Second-degree frostbite demonstrates blistering with erythema and edema. In third-degree frostbite, hemorrhagic blisters occur, progressing to tissue necrosis and sloughing in fourth-degree frostbite.

Nursing assessment for erythema Multifome

Note history of fever, malaise, and achiness (myalgia). Determine onset and progression of rash, and presence of pruritus and burning. Document the child's temperature upon assessment. Inspect the skin for lesions, which most commonly occur over the hands and feet and extensor surfaces of the extremities, with spread to the trunk. Lesions progress from erythematous macules (flat reddened areas) to papules, plaques, vesicles, and target lesions over a period of days (hence the name multiforme)

Pressure ulcers for 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.

Nursing assessment for acne vulgaris:

Note history of onset of acne lesions, as well as family history of acne. Determine medication use; certain medications may hasten the onset of acne or worsen it when already present. In particular, note use of corticosteroids, androgens, lithium, phenytoin, and isoniazid. Document history of an endocrine disorder, particularly one that results in hyperandrogenism. In girls, note worsening of acne 2 to 7 days before the start of the menstrual period. Inspect the skin for lesions (particularly on the face and upper chest and back, which are the areas of highest sebaceous activity). Note presence, distribution, and extent of noninflammatory lesions, such as open and closed comedones, as well as inflammatory lesions such as papules, pustules, nodules, or cysts (open comedones are commonly referred to as blackheads and closed comedones as whiteheads

Nursing assessment for acne noenatorum:

Note oily face or scalp. Examine the face (especially the cheeks), upper chest, and back for inflammatory papules and pustules. Document absence of fever.

Nurisng management for burns:

Nursing management of the child who has been burned focuses first on stabilizing the child. Place the child on a cardiac/apnea monitor, measure the child with the Broselow tape, monitor pulse oximetry, and apply an end-tidal CO2 monitor if the child is ventilated. Further management focuses on cleansing the burn, pain management, and prevention and treatment of infection. Fluid status and nutrition are important components of burn care, particularly in the early stages. Rehabilitation of the child with severe burns is also an important nursing function.

Nursing management: atopic dermatitis

Nursing management of the child with atopic dermatitis focuses on promoting skin hydration, maintaining skin integrity, and preventing infection.

Physica examination: Inspectition and observation

Observe whether the infant is wiggling, or the child is actively scratching. Carefully inspect the skin. Document dry, scaly, or flaky skin, as well as hypertrophy and lichenification. In children younger than 2 years old, the rash is most likely to occur on the face, scalp, wrists, and extensor surfaces of the arms or legs. In older children it may occur anywhere on the skin but is found more commonly on the flexor areas. Note erythema or warmth, which may indicate associated secondary bacterial infection. Document areas of hyperpigmentation or hypopigmentation, which may have resulted from a prior exacerbation of atopic dermatitis or its treatment.

Nursing assesment for uticardia:

Obtain a detailed history of new foods, medications, symptoms of a recent infection, changes in environment, or unusual stress. Inspect the skin, noting raised, edematous hives anywhere on the body or mucous membranes. The 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.

Nursing assesment for sunburn:

Obtain the health history, noting recent sun exposure. Determine length of exposure and 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.

Nursing assessment:

Obtain the history as noted in the nursing process overview section. Note history of skin disruption such as a cut, scrape, or insect or spider bite (nonbullous impetigo and cellulitis). Note body piercing in the adolescent, which can lead to impetigo or cellulitis. Fever may occur with bullous impetigo or cellulitis and is common with scalded skin syndrome. Inspect the skin, noting abnormalities, documenting their location and distribution, and describing drainage if present. Palpate for regional lymphadenopathy, which may be present with impetigo or cellulitis. Blood cultures are indicated in the child with cellulitis with lymphangitic streaking and in all cases of periorbital or orbital cellulitis.

Nursing assessment for minor injuries:

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.

Nursing assesment for insect stings and spider bites:

Obtain the 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.

Managing pain:

Pain management is of the utmost importance, and several options are available for the treatment of burn-related pain. Local anesthesia, sedatives, and systemic analgesics are commonly used. Children who have less severe burns that are managed at home can be given oral medications such as acetaminophen with codeine 30 to 45 minutes before dressing changes. In burns that result in more severe pain, the child should be hospitalized and given intravenous pain control with medications such as morphine sulfate.

Physical examination:

Perform a complete physical examination, noting any abnormalities. Perform a focused and thorough examination of the skin. The best lighting for examination of the skin is natural daylight. Look at the skin in general, noting distribution of any obvious rashes or lesions. Inspect the mucous membranes, noting and describing lesions if present. Examine all surfaces of the skin and scalp carefully. Note temperature, moisture, texture, and fragility of the skin. Provide a description of vascular lesions if present. If lesions are present on the scalp, has hair loss in that region occurred? Describe lesions according to the following criteria: Linear: in a line Shape: are the lesions round, oval, or annular (ring around central clearing)? Morbilliform: a rosy, maculopapular rash Target lesions: like a bull's eye

Nursing management for pressure ulcers:

Position the 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.

Nursing management of diper dermititis:

Prevention is the best management of diaper dermatitis. Topical products such as ointments or creams containing vitamins A, D, and E; zinc oxide; or petrolatum are helpful to provide a barrier to the skin.

Preventing infection:

Prevention of infection is critical to successful outcomes for burned children. If the child's immunization status is unknown or if it has been 5 years or longer since the last tetanus vaccine, administer the tetanus vaccine. If the child has never received tetanus vaccination, also give 250 units tetanus human immunoglobulin intravenously. Apply antibiotic ointment in conjunction with burn dressing changes. Membrane dressings such as biosynthetic, hydrocolloid, and antibiotic-impregnated foam dressings are alternatives to topical antibiotics and sterile dressings. Evaluate the child's wound during dressing changes, looking for wound redness, swelling, odor, or drainage.

Nursing management for bites:

Provide rabies immunoprophylaxis and a 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 virucidal agent such as povidone-iodine solution. Administer antibiotics as prescribed.

Psoriasis:

Psoriasis is a chronic inflammatory skin disease with periods of remission and exacerbation; control is possible with conscientious therapy. It is an immune-mediated disorder occurring in persons with a genetic predisposition. While psoriasis only affects about 2% of the adult population, between 30% and 45% of all psoriasis cases are diagnosed in childhood. Hyperproliferation of the epidermis occurs, with a rash developing at sites of mechanical, thermal, or physical trauma. Therapeutic management includes skin hydration with emollient creams, use of tar preparations, topical steroids, and ultraviolet light, among others.

Nursing management for insect sting and spider bites:

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.

Nurisng management for cold injury:

Remove wet or tight clothing. Avoid vigorous massage to decrease the chance of damaging the skin further. Immerse the affected part in 104°F water for 15 to 30 minutes. 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 the wound care specialist or plastic surgeon for further management.

Sebaceous ans sweat gland in childrne:

Sebaceous glands function immaturely at birth. The 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. They become fully functional in the middle childhood years. Until that time, temperature regulation is less effective compared to older children and adults.

Saborrhea:

Seborrhea is a 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 may also manifest seborrhea on the nose or eyebrows, behind the ears, or in the diaper area. It usually resolves over a period of weeks to months. Adolescents manifest seborrhea on the scalp (dandruff) and on the eyebrows and eyelashes, behind the ears, and between the shoulder blades. t is thought that seborrhea is an inflammatory reaction to the fungus Pityrosporum ovale and is worsened by sebaceous involvement related to maternal hormones in the infant and androgens in the adolescent. Therapeutic management includes treating the skin lesions with corticosteroid creams or lotions. Antidandruff shampoos containing selenium sulfide, ketoconazole, or tar are used to treat the scalp.

Atopic dermatitis: laboratory and diagnostic tests

Serum immunoglobulin E (IgE) levels may be elevated in the child with atopic dermatitis. Skin prick allergy testing may determine the food or environmental allergen to which the child is sensitive.

Restoring and maintaining fluid volume:

Several formulas are available for the calculation of resuscitative fluids in children. Most experts recommend that pediatric burn therapy include: Fluid calculation based on the body surface area burned (Fig. 45.22) Use of a crystalloid (Ringer's lactate) during the first 24 hours; in smaller children, a small amount of dextrose may be added Administration of most of the volume during the first 8 hours (amounts and timing of fluid volume resuscitation will vary from child to child) Reassessment of the child and adjustment of the fluid rate accordingly; fluid requirements greatly decrease after 24 hours and should be adjusted to reflect this. Administration of a colloid fluid later in therapy once capillary permeability is less of a concern Monitoring of the child's urine output as part of ongoing assessment of response to therapy, expecting at least 1 mL/kg/hr Daily weights obtained at the same time each day (the best indicator of fluid volume status) Monitoring of electrolyte levels (particularly sodium and potassium) for their return to normal levels

Pressure ulcers:

Skin breakdown involves changes in intact skin, which may range from blanchable erythema to deep pressure ulcers. The term pressure ulcer refers to damage to the skin resulting in skin loss and development of a crater that may range from mild to deep. Pressure ulcers 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.

Variations in pediatric anatomy and physiology?

Skin is the largest organ of the body and serves to protect the underlying tissues from trauma and invasion by microorganisms. The skin's health reflects the internal well-being of the body.

Sunburn:

Sunburn occurs as a result of overexposure to the ultraviolet (UV) rays of the sun. The erythema and eventual blisters occur as a result of the skin's blood flow changes 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. Sunburn is usually treated with cool compresses, cooling lotions, and oral nonsteroidal antiinflammatory agents.

Providing burn care at home:

Teach parents about proper burn care in the home. Seek medical attention for burns when: the child has a second- or third-degree burn. burns result from a fire, an electrical wire or socket, or chemicals. the child has a burn on the face, scalp, hands, feet, or genitals or over the joints. the burn appears to be infected. the burn is causing prolonged and significant pain. concern exists that the burn was a result of abuse.

Differences in the skin between children and adutls:

The infant's epidermis is thinner than the adult's, and the blood vessels lie closer to the surface because there is a decreased amount of subcutaneous fat. Thus, the infant loses heat more readily through the skin's surface than the older child or adult does. The thinness of the infant's 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. This means that friction may easily cause separation of the layers, resulting in blistering or skin breakdown. The infant's skin is also less pigmented than that of the adult (in all races), placing the infant at increased risk of skin damage from ultraviolet radiation.

Common medical treatments:

The nurse caring for the child with an integumentary disorder should be familiar with the procedures and medications, how they work, and common nursing implications related to their use. Nursing management of the child with an alteration in tissue integrity/integumentary disorder requires astute assessment skills, accurate nursing analyses and development of expected outcomes, implementation of appropriate interventions, and evaluation of the entire process. Many skin rashes may be associated with other, often serious illnesses, so the nurse must use comprehensive and excellent assessment skills when evaluating rashes in children.

Treating infected burns:

The potential for burn infection increases if the child has a large, open burn wound and if there are other sources of infection, such as multiple intravenous lines. In addition, children who are immunocompromised have an increased risk of burn infection. In burn wound cellulitis, the area around the burn becomes increasingly red, swollen, and painful early in the course of burn management. With invasive burn cellulitis, the burn develops a dark brown, black, or purplish color, with a discharge and foul odor. Burn impetigo is characterized by multifocal small superficial abscesses. Burn impetigo causes marked destruction of skin-grafted areas. Extensive infected burns may also become infected with a fungus.

What is the pathophysiology of acne vulgaris:

The sebaceous gland produces sebum and is connected by a duct to the follicular canal that opens on the skin's surface. Androgens stimulate sebaceous gland proliferation and production of sebum. These hormones exhibit increased activity during the pubertal years. Abnormal shedding of the outermost layer of the skin (the stratum corneum) occurs at the level of the follicular opening, resulting in a keratin plug that fills the follicle.

Cold Injury:

The term "frostbite" implies freezing of the tissues. It is described on a continuum from first to fourth degree. When a child is exposed to an extremely cold environment, changes in cutaneous circulation help to maintain the core body temperature. Because circulation is shunted to the core, the most peripheral body parts are those at highest risk for frostbite.

Laboratory and diagnositic testing:

The tests can assist the physician or nurse practitioner in diagnosing the disorder or can be used as guidelines in determining ongoing treatment. Some of the tests are obtained by laboratory or nonnursing personnel, while others might be obtained by the nurse. In either instance the nurse should be familiar with how the tests are obtained, what they are used for, and normal versus abnormal results. This knowledge will also be necessary when providing child and family education related to the testing.

Therapeutic management for acne vulgaris:

Therapeutic management focuses on reducing P. acnes, decreasing sebum production, normalizing skin shedding, and eliminating inflammation. Teach the adolescent to cleanse the skin gently twice a day. Medication therapy may include a combination of benzoyl peroxide, salicylic acid, retinoids, and topical or oral antibiotics.

Therapetic management of wouds:

Therapeutic management of burns focuses on fluid resuscitation, wound care, prevention of infection, and restoration of function. Burn infections are treated with antibiotics specific to the causative organism. If invasive burn damage occurs, surgery may be necessary.

Nursing management for fungal infection:

Tinea corporis is contagious, but the child may return to day care or school once treatment has begun. Identify and treat family members or other contacts. Counsel the child with tinea capitis and parents that hair will usually regrow in 3 to 12 months. Wash sheets and clothes in hot water to decrease the risk of the infection spreading to other family members. Instruct the child with tinea pedis to keep the feet clean and dry. Rinse feet with water or a water/vinegar mixture and dry them well, especially between the toes. Encourage the child to wear cotton socks and shoes that allow the feet to breathe. Counsel the child or adolescent with tinea cruris to wear cotton underwear and loose clothing. It is important to maintain good hygiene, particularly after sports practice or a sporting event.

What is the integumentary diorders in children?

Tissue integrity refers to the ability of body tissues to maintain normal physiologic processes. Nurses may encounter children with alterations in tissue integrity should be familiar with various integumentary disorders that children experience. Alterations in tissue integrity or integumentary disorders occur often in children and are caused by exposure to infectious microorganisms, hypersensitivity reactions, hormonal influences, and injuries. Some integumentary disorders are as mild and self-limited as a minor abrasion. Others, such as atopic dermatitis, are chronic and must be managed consistently. Finally, some tissue integrity alterations can be severe and even life-threatening, such as full-thickness burns.

Nursing assessment for burns:

Upon arrival, evaluate the child with burns to determine if he or she will require intensive management. Remove any smoldering clothing. Obtain a brief history of the burn circumstances while you are assessing the child and providing care.

Urticaria:

Urticaria, commonly called hives, is a type I hypersensitivity reaction caused by an immunologically mediated antigen-antibody response of histamine release from mast cells. Vasodilation and increased vascular permeability result, and erythema and wheals then occur. Urticaria usually begins rapidly and may disappear in a few days or may take up to 6 weeks to resolve.

Nursing management for uticardia:

Wash or shampoo the affected areas with a mild soap. Apply antiinflammatory 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 to 15 minutes later, using a brush to gently lift the crusts; do not forcibly remove the crusts.

Human and animals bites:

Yearly, significant emergency room visits occur as a result of bites from mammals. Dog bites account for the majority of injuries, but in children human and cats bites account for the most infected bites. The hand and face are common locations for animal bites. A dog is most often provoked to bite a child when the child is playing with the dog or when the child hits, kicks, hugs, grabs, or chases the dog. Therapeutic management involves cleansing and irrigating the wound, wound suturing or stapling if necessary, and 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.

Management:

portant to culture the infected area for MRSA. Therapeutic management of most bacterial skin infections includes topical or systemic antibiotics and appropriate hygiene. Treatment of periorbital cellulitis focuses on intravenous antibiotic administration during the acute phase followed by completion of the course with oral antibiotics. Complications of periorbital cellulitis include bacteremia and progression to orbital cellulitis, which is a more extensive infection involving the orbit of the eye.

Common medical treatments:

wet dressing: Dressing moistened with lukewarm water (sterile water may be required in certain cases) Sunscreen: Lotion, gel, or cream with a sun-protective factor (SPF). Bathing: Use of lukewarm water (with or without soap) to bathe.

Special burn care and skin grafting:

• To prevent infection and promote healing: • Biosynthetic skin coverings such as Biobrane (silicone film bonded to flexible nylon fabric and purified collagen peptides) and Mepilex Ag (soft silicone soaked with silver) • Kaltostat (calcium alginate dressing) is a brown seaweed extract that is spun into a fiber that is highly absorbent. It reacts with exudate on the wound to form a protective gel. • Autograft allows for permanent coverage of a deep partial-thickness or full-thickness burn. • Consists of child's own skin • Split thickness consists of epidermis and superficial layers of dermis. The donor site heals completely. • Full thickness consists of full dermal thickness. Cover the donor site with fine-mesh gauze or synthetic wound coverings to allow the site to heal.