Peds - ch 45

What are first, second, third, and fourth degree burns?

1st - superficial, epidermal injury and heal without scarring or sequelae within 4-5 days. Red, dry, painful, possible edema. 2nd - partial thickness (epidermis and dermis involved; heal within 2 weeks with minimal scarring); deep partial thickness (takes longer to heal, scars, and results in change in nail and hair appearance as well as sebaceous gland function; may require surgery). Painful, edema, wet appearance or blisters. 3rd and 4th - full thickness (significant tissue damage as it extends to hypodermis; extensive scarring; hair and sweat glands destroyed; require significant healing time; contractures and limited function; bone and tendon involvement classify as 4th degree; skin graft necessary). Painful, numb, red, edema, leathery, dry, waxy, peeling, charred.

The nurse is caring for a mother and newborn on a postpartum unit. The mother asks if it OK to use baby powder on newborns. Which response by the nurse would be most appropriate?

"Baby powder should not be used on newborns because of the risk of aspiration upon application."

How is cradle cap treated?

-Corticosteroid creams or lotions -Antidandruff shampoos with selenium sulfide, ketoconazole, tar

What is tinea cruris and treatment?

-Erythema, scaling, maceration in the inguinal creases and inner thighs -Treatment: topical antifungal for 4-6 weeks

How is fluid volume restored and maintained after a burn?

-Fluid calculation based on surface area -Use of crystalloid (Ringer's lactate) during the first 24 hours; in smaller kids, a small amt of dextrose may be added -Admin most of volume during first 8 hours -Reassess the child and adjust fluid rate accordingly; fluid requirements greatly decrease after 24 hours -Admin colloid fluid later in therapy once cap permeability is less concerning -Monitor the child's UO, expecting at least 1 ml/kg/hr -Daily weights same time each day -Monitor electrolyte levels

What does treatment of burns focus on?

-Fluid resuscitation -Wound care -Prevention of infection -Restoration of function -Sometimes surgery

What is treatment for acne vulgaris?

-Meds reducing Popionibacterium acnes, decreasing sebum production, normalizing skin shedding, eliminating inflammation -Benzoyl peroxide, salicylic acid, retinoids, topical or oral antibiotics -Isoretinoin -Oral contraceptives

Describe nonbullous impetigo.

-Papules progressing to vesicles, then painless pustules with a narrow red border -Honey colored exudate when the vesicles or pustules erupt which forms a crust on the ulcer-like base

How is contact dermatitis treated?

-Wash lesions daily with mild soap and water -Mildly debride crusted lesions -Tepid baths (colloidal oatmeal such as Aveeno) -Avoid hot baths or showers -Apply corticosteroids -Weeping lesions may be wrapped lightly -Burow or Domeboro solutions with a dressing applied twice daily for 20 min may help weepy -OTC preps such as calemine lotion or Ivy Rest may reduce itching and help dry lesions -Do not use topical antihistamines, benzocaine, neomycin

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

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

he parents of a child diagnosed with atopic dermatitis ask the nurse, "My child has a skin disorder. I don't understand why a complete blood count (CBC) was ordered?" What is the appropriate response by the nurse?

"Eosinophils are a type of white blood cell that are often elevated with atopic dermatitis. These are part of the CBC and helps in making the diagnosis."

The nurse is evaluating the parents' understanding of atopic dermatitis. Which statement shows their understanding?

"Flare-ups of lesions are not uncommon following therapy."

The parents of a child recently diagnosed with atopic dermatitis voice concern to the nurse that their child may develop asthma at some point. How should the nurse respond?

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

The school nurse has completed an educational program on first aid practices in the home. Which statement about burn care by a participant would indicate a need for further education?

"I guess my mom was right; she always put ice on our burns when we were kids." Steps for providing burn care at home to a first-degree (superficial) burn include running cool water, not ice, over the burn and covering it with a nonadherent bandage after cleaning with a fragrance-free mild soap. Other care includes not applying butter, ointments or creams; and administering acetaminophen or ibuprofen for pain.

A topical corticosteroid is prescribed for a child with contact dermatitis. Which statement by the mother would indicate the teaching was successful?

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

The nurse is caring for an infant with diaper dermatitis. Which statement by the child's parent would indicate a need for further education?

"I will use rubber pants over the cloth diapers in the future."

A child has an order for an erythrocyte sedimentation rate (ESR). The child's mother asks what the purpose of the test is. What is the best response by the nurse?

"This test will tell if your child has an infection or inflammation somewhere in their body."

A newborn has a generalized rash on the skin, which the nurse identifies as erythema toxicum neonatorum. Which information would the nurse include when explaining the condition to the newborn's parent?

"What you see on your newborn's skin is erythema toxicum neonatorum. It is a common newborn skin condition that typically resolves on its own in about 1 week. There is nothing special you will need to do for this."

What is treatment for psoriasis?

-Anti-inflammatory cream -Tar shampoo -Mineral oil and warm towels to remove plaques -Sunlight

A nurse is caring for a child with a wasp sting. Which nursing intervention is a priority?

Administer diphenhydramine per protocol. The nurse should administer diphenhydramine as soon as possible after the sting in an attempt to minimize a reaction.

A nurse is caring for a child with second- and third-degree (partial- and full-thickness) burns over 15% of the body. The child reports severe itching in and around the burn sites. Which action would be most appropriate for the nurse to perform?

Administer diphenhydramine.

What are bullae?

Bullae are large blisters on the skin that are filled with clear fluid. Many different skin conditions can cause bullae to form. They can be caused by infection or inflammation of the skin. This is a typical early appearance of a poison ivy rash, located on the knee.

A 2-year-old child is brought to the urgent care center for treatment of burns on both hands. The parent reports that the child pulled the coffee pot over and the hot liquid splashed on to the child's hands. The nurse examines the child and notes that the backs of the hands are reddened with a well-defined line of demarcation at the wrists. Several medium to large blisters are also present. What initial action should the nurse take?

Make arrangements to transfer the child to the hospital. Burns on the hands or feet of a child are criteria for admission to a burn center. In addition, the nurse should suspect child abuse (child mistreatment) because of the defined lines of demarcation on the burns (glove pattern) which indicates that the child's hands were placed in scalding liquid versus a splash pattern if the pot had been knocked over. Although the nurse may suspect child abuse (child mistreatment), the initial action should be to get the child to the hospital.

What types of wounds can be referred to a 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

What is the best technique to perform an assessment of the skin?

Skin assessment involves inspection and palpation in a room with natural daylight.

Why does an infant lose more heat and is more prone to bacterial infections than an adult?

The epidermis is thinner and blood vessels lie closer to the surface because there is less subcutaneous fat.

The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing action is priority?

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

The nurse is caring for a child brought to a pediatric clinic for swelling in the lower extremities. The skin is reddened with undefined borders and pits slightly when pressed. Based on the assessment findings, which of the following would the nurse suspect?

cellulitis Cellulitis is characterized by reddened or lilac-colored, swollen skin that pits when pressed by the fingertips.

The nurse is conducting a physical examination of a boy with erythema multiforme. Which assessment finding should the nurse expect?

lesions over the hands and feet, and extensor surfaces of the extremities with spread to the trunk

The nurse is examining a child for indications of frostbite and notes blistering with erythema and edema. The nurse notes which degree of frostbite?

second-degree frostbite

The client is scheduled to have potassium hydroxide testing performed. What will be needed to complete this test?

skin scrapings Potassium hydroxide (KOH) testing is done to assess for the presence of a fungal infection. Skin scrapings are placed on a microscope slide and a drop of KOH 20% drop is added.

The nurse admits a child who has sustained a severe burn. The child's immunizations are up to date. Which immunization would the child most likely be given at this time?

tetanus toxoid vaccine

What is tinea pedis and treatment?

-Athlete's foot -Red, scaling rash on soles and between the toes -Treatment: topical antifungal cream, powder or spray

How is a cold injury treated?

-Remove wet or tight clothing -Avoid vigorous massage to decrease damage -Immerse affected part in 104F water for 15-30 min -Administer analgesics -Keep thawed part loosely covered, warm, and dry -Splinting may be used to decreased edema -Consult wound care specialist

What is acne neonatorum?

-Response to maternal androgens or to transient androgen production in the newborn often occurring 2-4 weeks of age -Usually no treatment necessary

What is staphylococcal scalded skin syndrome?

-Results from S. aureus that produces a toxin causing exfoliation -Abrupt onset and results in diffuse erythema and skin tenderness; most common <5 year old -Flattish bullae that rupture within hours -Red, weeping surface is left, most commonly on face, groin, neck, and axillary region, fever

What are kids who are burned have higher risk of?

Infection and hypothermia

An adolescent is to receive topical retinoid therapy for his moderately severe acne. The nurse would instruct the adolescent about which adverse effects? Select all that apply.

-burning -photosensitivity -dryness

A 6-year-old child is diagnosed with tinea capitis and treatment is initiated. The nurse instructs the parents to have the child return to school within which time frame?

1 week Once treatment is initiated for tinea capitis, the child can return to school or day care after 1 week.

An adolescent with atopic dermatitis reports interest in using herbal preparations to help manage the condition. What response(s) is appropriate? Select all that apply.

-"Some people find the use of chamomile beneficial in managing this condition." -"Some people find the use of chamomile beneficial in managing this condition."

What is erythema multiforme?

-Acute, self-limiting hypersensitivity reaction usually in response to virus, bacteria, drug, or food -Stevens-Johnson syndrome and toxic epidermal necrolysis are the most severe forms that occur due to meds or Mycoplasma infections

Describe folliculutis.

-Red, raised hair follicles

What is tinea versicolor and treatment?

-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 -Treatment: apply selenium sulfide shampoo overnight; imidazole

What is acne vulgaris?

-Typical acne -Due to sebaceous glands producing sebum and connected to a duct to the follicular canal that opens on the skin's surface -Increased production of sebum in adolescence and abnormal shedding of outermost layer of skin causes keratin plug that fills the follicle and allows bacterial overgrowth, inflammation

What are common bacterial skin infections?

-bullous and nonbullous impetigo -folliculutis -cellulitis -staphylococcal scalded skin syndrome --all often caused by S. aureus and group A beta-hemolytic strep

What are ways to describe lesions: 1. in a line 2. round, oval 3. rosy, maculopapular rash 4. Bull's eye-like

1. Linear 2. Annular 3. Morbilliform 4. Target lesion

An adolescent with tinea versicolor is admitted for treatment of the disorder. Which nursing diagnosis will the nurse identify as having the highest priority for this client?

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

The nurse is caring for a child with a second-degree (partial-thickness) burn. What assessment findings would the nurse expect to observe?

Edema with wet blistering skin

What accurately depicts the hemodynamic changes that occur in the body within the first 24 to 48 hours after a burn?

Hematocrit and white blood cell (WBC) counts increase.

The nurse is discussing dietary intake with the parents of a 4-year-old child who has been diagnosed with atopic dermatitis. Later, the nurse notes the menu selection made by the parents for the child. Which selection indicates the need for further instruction?

peanut butter and jelly sandwich Atopic dermatitis is commonly associated with allergies to food. Common culprits may include peanuts, eggs, orange juice, and wheat-containing products.

What is tinea corporis and treatment?

-Ringworm -Annular lesion with raised peripheral scaling and central clearing -Treatment: topical antifungal for 4 weeks

What are the gland statuses in infants?

-Sebaceous glands function immaturely at birth - sebum lubricates hair, skin -Eccrine sweat glands are somewhat functional and will produce sweat as a response to emotional stimuli and heat and become fully functional into middle childhood -Apocrine sweat glands are nonfunctional in infants and mature during puberty

What should be avoided and done for eczema?

-Avoided: hot water, perfumes, dyes, fragrance, synthetic fibers, wool, tight clothing, heat, scratching -Do: mild soaps to clean only dirty areas, unscented Dove, Tone, Caress, Oil of Olay, Cetaphil, Aquanil, Eucerin, Aquaphor, Vaseline, Crisco; trim nails short, 100% cotton, divert child from scratching

What is contact dermatitis?

-Cell-mediated response to an antigenic substance exposure -Allergic response within 24-48 hrs after exposure -Usually due to exposure to nickel, cobalt chemicals, cosmetics, plants like poison icy, Eastern and Western poison oak, poison sumac. -Extremely pruritic rash that may last 2-4 weeks with lesions that may be vesicular and crusty -Use topical steroids

A 1-year-old child was brought to the clinic for evaluation of dry, itchy red patches of skin on the arms and legs. A diagnosis of atopic dermatitis (eczema) is made. Which would be an essential element to include in the plan of care for this child?

Frequently rehydrating the skin. To maintain healthy skin in the child with atopic dermatitis, hydration practices should be implemented to replace moisture in the stratum corneum and prevent transdermal water losses. Scratching itchy skin is a reflex that is very difficult to stop; preventing the itch is more effective. Topical antibiotics and oral corticosteroids are not treatments for atopic dermatitis.

How can diaper dermatitis be prevented?

-Change diapers frequently -Avoid rubber pants -Gently wash the diaper area with a soft cloth, avoiding harsh soaps -Use baby wipes but avoid ones with fragrance or preservatives -Once rash has occurred, allow the infant to go diaperless for a period of time each day and blow ry the area on the warm setting for 3-5 min

What is seborrhea?

-Chronic inflammatory dermatitis that may occur on the skin or scalp (cradle cap) -Inflammation reaction to fungus Pityrosporum ovale and is worsened by sebaceous involvement related to maternal hormones and androgens in the adolescent

What is psoriasis?

-Chronic inflammatory skin disease with periods of remission and exacerbation -Hyperproliferation of epidermis with rash developing at sites of mechanical, thermal, physical trauma -Erythematous papules that coalesce to form plaques with silvery or yellow-white scale and sharply demarcated borders -Layers of scale may be present which result in pinpoint bleeding (Auspitz sign) when removed

What is the patho of burned tissue?

-Coagulation after the injury -Blood vessels have increased permeability, allowing water, electrolytes, and protein to leak and cause edema -Edema forms rapidly in the first 18 hours and peaks at 48 hours with capillaries returning to normal by 72 hours and the lymphatics can reabsorb the edema fluid -Fluid loss is 5-10x greater than what is lost in undamaged skin and fluid loss continues until the damaged surface is healed or grafted -Hypermetabolic state where cardiac output increases, insulin resistance occurs, and increased protein catabolism happens, also increased risk for respiratory injury and aspiration

What are s/s of erythema multiforme?

-Fever -Malaise -Achiness (myalgia) -Rash, pruritus, burning -Lesions on hands, feet, trunk -Erythematous macules (flat reddended areas) to papules, plaqus, vesicles, and target lesions over a period of days (multiforme)

What is diaper candidiasis and treatment?

-Fiery red lesions, scaling in the skin folds, and satellite lesions -Treatment: nystatin topical with diaper changes for several days

How is urticaria treated?

-Identify and remove trigger -Administer antihistamines, corticosteroids, topical antipruritics

What is atopic dermatitis?

-Eczema, chronic disorder characterized by extreme itching and inflamed, reddened and swollen skin with relapses and remissions; in response to allergen -Associated with asthma, allergic rhinitis, food allergies -Rash is red, dry, scaly; may have vesicles

What is urticaria?

-Hives -Type I hypersensitivity reaction caused by immunologically mediated Ag-Ab response to histamine release from mast cells -Erythema, wheals; begins rapidly and disappears within a few days to 6 weeks -Most common causes are food, drugs animal stings, infections, environmental stimuli

What is diaper dermatitis?

-Inflammatory reaction of the skin in the area covered by the diaper -Nonimmunologic response to a skin irritant, such as urine, feces

What tests are used to determine fungal infection?

-KOH prep will show branching hyphae -Wood lamp will fluoresce yellow-green if caused by Microsporum (tinea capitis) -Fungal culture of plucked hair for tinea capitis

Describe cellulitis

-Localized infection and inflammation of the skin and subcut tissue and is usually preceded by skin trauma -Periorbital cellulitis is a bacterial infection of the eyelids and tissue surrounding the eye -Erythema, pain, edema, warmth at site of skin disruption, fever

How should you cleanse a burn?

-Remove clothing -Wash and rinse the burn thoroughly with mild soap and cool water from the tap. Never ice. -If tar, remove with cool water and mineral oil -Do not remove blisters unless debridement is recommended

What can be used to prevent contact dermatitis?

-Wear long clothes out in woods -Identify and remove offending plants -Vinyl gloves -Wash anything that comes in contact with plant's oil residue -Wash vigorously with soap and water within 10 minutes of exposure -Zanfel and Tecnu Oak-N-Icy Outdoor Skin Cleanser may prevent rash if used to wash the skin soon after exposure -Ivy Block can be used before possible exposure

A 10-year-old has been bitten on the lower posterior arm by a dog, requiring several stitches. The child was just admitted to the hospital for 3 days of antibiotic therapy. When developing the care plan, the nurse identifies which nursing diagnoses as being the top 2 priorities?

-Impaired skin integrity -Risk for infection

What is tinea capitis and treatment?

-Patches of scaling in the scalp with central hair loss -Risk of kerion development (inflamed, boggy mass that is filled with pustules) -Treatment: oral griseofulvin, selenium sulfide shampoo; no school or daycare for 1 week after treatment started

Describe bullous impetgio

-Red macules and bullous eruptions on an erythematous base -Size may be from a few millimeters to several centimeters

What might an intentional vs. unintentional burn look like?

-Unintentional: spatter-type, nonuniform, asymmetric distribution -Intentional: uniform stocking or glove distribution when the child's extremity is held under very hot water as punishment

The nurse is discussing acne vulgaris with a group of adolescents. The teenagers make the following statements regarding the topic. Which statement is the most accurate regarding acne vulgaris?

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