Caring for the Child with an Integumentary Condition

1
Chapter 31

• Caring for the Child with an Integumentary
  Condition

2
A P Review The Skin

• Epidermis
• Dermis
• Subcutaneous fatty layer
• Accessory structures
• Hair, sebaceous glands
• Exocrine and apocrine glands

3
Integumentary Changes as Children Grow

• See Table 31-1

4
Skin Lesion

• Primary lesions
• Macules, papules, patches, nodules, tumors,
  vesicles, pustules, bullae, and wheals
• Secondary lesions
• Result due to changes from the primary lesions
• Crusts, scales, lichenifications, scars, keloids,
  fissures, erosions, and ulcers

5
Wounds and Wound Healing

• Typical wounds
• Cuts
• Scrapes
• Burns
• Secondary to surgical intervention

6
Wounds and Wound Healing

• Three Phases of Skin Healing
• Inflammation
• Initial healing response (lasts 25 days)
• Preparatory stage for repair
• Proliferation
• Blood flow is reestablished to the site
• Natural debridement occurs (lasts 23 weeks)
• New cells cover the site
• Remodeling
• Scar formation (lasts 3 weeks to 2 years)

7
Skin Infections
8
Bacterial Infections
9
Acne Vulgaris

• Signs and symptoms
• Comedowhitehead
• Inflammation
• Nursing care
• Assess the acne
• Clean and moisturize with a water-soluble
  moisturizer
• Treat acne with benzoyl peroxide
• Administer topical antibiotics and then retinoids
• Administer oral antibiotics (Accutane)

10
Impetigo

• Signs and symptoms
• Found on and around the mouth
• Lesions begin as a vesicle or pustule
• Honey-colored exudate
• Pruritus
• Nursing care
• Prevent spread to others
• Discuss spontaneous resolution or use of topical
  antibiotic
• Administer oral antibiotics for widespread
  infection

11
Cellulitis

• Signs and symptoms
• Edema, erythema, hot to the touch
• Discomfort on palpation
• Malaise, fever, and chills
• Nursing care
• Administer benzathine penicillin G
• Note that a severe case requires hospitalization
  and IV antibiotics
• Administer steroids (decrease inflammation)
• Provide symptom control (childrens Advil)

12
Viral Infections
13
Human Papillomavirus Warts

• Sign and symptoms
• Rough, raised, and flesh-colored
• Occur anywhere on the body
• Usually there is no pain or itching
• Nursing care
• Usually no intervention needed
• Discuss over-the-counter or prescription
  medications that are available

14
Herpes Simplex (HSV-1 HSV-2)

• HSV-1 (cold sore)
• HSV-2 (genital herpes)
• Signs and symptoms
• Painful, watery blisters on mucosal surfaces of
  the skin (lips, mouth, or genital area)
• Lesions appear after a stimuli (febrile illness,
  stress, sexual contact, ultraviolet light)
• Nursing care
• No cure
• Teach family that medications decrease the length
  of the outbreak and/or increase the intervals
  between outbreaks (Acyclovir or Abreva)

15
Fungal Infections
16
Cutaneous Candidiasis

• Signs and symptoms
• Mouthwhite or gray plaque
• Skinfine red and slightly raised rash
• Nursing care
• Oral nystatin (Mycostatin)give orally after
  each feeding, two to three times a day
• Skin nystatin (Mycostatin), clotrimazole
  (Lotrimin), miconazole (Monistat) apply thin
  layer with a gloved finger to infected area, two
  to three times a day

17
Ringworm

• Signs and symptoms
• Round, scaly lesions (red or inflamed)
• Bald areas
• Small black dots on scalp or itching
• Nursing care
• Give oral antifungal
• Discuss antifungal shampoo
• Discuss that everyone in the family needs
  treatment (no sharing hair brushes or bath
  towels)
• Provide emotional support and suggest hairstyles

18
Dermatitis
19
Contact Dermatitis

• Signs and symptoms
• Skin irritated, inflamed, and pruritic
• Vesicles and bullae may be present
• Nursing care
• Use drying agent (Domeboro)
• Provide cool baths
• Administer low dose of over-the-counter
  hydrocortisone
• Give oral steroids if more than 10 of body
  involved
• Inform family that a topical anesthetic or a
  sedative may be needed for sleeping

20
Atopic Dermatitis

• Signs and symptoms
• Red, raised rash that is pruritic and painful
• Rash in infants usually presents on head, face,
  arms, and legs
• Rash in older children usually presents in the
  folds of arms and legs, occasionally on eyelids
  and neck
• Nursing care
• Prevent secondary infection
• Provide good hygiene
• Follow prescribed treatment protocols
• Maintain skin hydration
• Conduct frequent monitoring and rash assessment

21
Seborrheic Dermatitis

• Signs and symptoms
• Red to pink patches with loose yellow greasy
  scaling
• Rash found on face, cheekbones, around nostrils,
  and behind ears
• Nursing care
• Use antifungal therapy or topical corticosteroids
  
• Tell family about antiseborrheic shampoos

22
Cutaneous Skin Reactions

• Signs and Symptoms
• Four typeseruption, itching, swelling, or
  pustular
• The allergic reaction can be mild or severe
• Assess for facial swelling (especially lips and
  tongue)
• Check throat with light (do not use a tongue
  blade)
• Check nasal passages for swelling and redness
• Nursing care
• Educate about removing and avoiding allergen
• Give oral antihistamines and topical
  corticosteroids
• Teach about prevention

23
Stevens Johnson Syndrome (Erythema Multiforme)

• Signs and symptoms
• Begins with nonspecific upper respiratory
  infection
• Bullae often appear in a target-like pattern
• Purulent conjunctivitis and skin lesions that
  rupture
• Fever, neutropenia, chills, malaise, weakness,
  and anemia
• Nursing care
• Eliminate the causative agent and treat skin
  lesions
• Use an air/fluid-filled bed, nutritional support,
  IV fluids, and pain management
• Ensure a patent airway

24
Infestations
25
Lice (Pediculosis)

• Signs and symptoms
• Infest the body but primarily choose areas that
  have longer hair nape of neck and behind the
  ears
• Nursing care
• Visually inspect
• See Family Teaching GuidelinesLice (Pediculosis)

26
Mite Infestation (Scabies)

• Signs and symptoms
• Rash is red streaked and appears linear from the
  burrowing
• Intense itching especially at night
• Papules (result of the inflammation)
• Nursing care
• Care is similar to that for pediculosis
• Use scabacide
• Give warm bath and apply cream or lotion (repeat
  in 1 week)
• Reinforce that all persons in close contact
  should also be treated
• Use dishwasher for cleaning toys and hair items
• Wash clothes, bedding, and towels in hot water
  and then place in dryer

27
Bites and Stings
28
Insects

• Signs and symptoms
• Mosquitored papules and edema at site which
  produces itching, burning, and minimal discomfort
• Spidererythema, itching, and pain
• Tickreddened area of the skin that can be raised
  and itchy a general sick feeling
• Bee, wasp/hornetpain, erythema, and edema
• Nursing care
• Adhere to directives when out of doors
• Apply bug spray to clothing
• Reinforce that a child who has had a severe
  reaction should wear a medical alert bracelet or
  necklace and carry an EpiPen or EpiPen Junior

29
Animal Bites
30
Dog Bites

• Signs and symptoms
• Consider location, redness, swelling, number of
  puncture wounds, abrasions, and lacerations
• Assess for cellulitis
• Assess for nerve, muscle, and vascular damage
• Nursing care
• Obtain accurate history
• Clean with soap and water and thoroughly rinse
• Cover wound with topical antibiotic and clean
  dressing
• Administer tetanus booster if needed
• Assess for signs of infection
• Administer Human Rabies Immune Globulin (HRIG) or
  Human Diploid Cell Rabies Vaccine (HDCV) if bite
  was from an unknown wild or domestic animal
• Contact local health department

31
Human Bites

• Signs and symptoms
• Redness, swelling, break in the skin, fever, and
  signs of infection
• Nursing care
• Obtain accurate history
• Educate about testing for blood-borne pathogens
• Irrigate wound
• Apply topical antibiotic and clean dressing
• Elevate extremity and monitor for infection
• Notify health care provider if there is an
  infection
• Evaluate immunization record

32
Diseases from Bites
33
Lyme Disease

• Signs and symptoms
• Ask family if there has been an occurrence of a
  tick bite
• Bite found in groin, maxilla, or thigh
• Nursing care
• Remove tick(s)
• Clean area with soap and water (save ticks)
• Administer oral antibiotics if infection is
  suspected

34
Rocky Mountain Spotted Fever

• Signs and symptoms
• Multisystem diseasemild, moderate, or severe
• Onset can be either gradual or sudden
• Suddennausea, vomiting, lack of appetite,
  abdominal pain, malaise, deep muscle pain, and
  severe headache
• Red rash that blanches with pressure occurs 35
  days after the onset of fever (starts on
  extremities and moves to trunk)
• Petechial spotted rash occurs 6 or more days
  after initial symptoms
• Diarrhea and joint pain
• Splenomegaly, hepatomegaly, and jaundice
• Nursing care
• Give tetracycline or doxycycline (except in
  children younger than 8 years)
• Provide supportive therapy for other symptoms
  (antipyretics, anti-inflammatory medications and
  IV fluids)

35
Cat Scratch Disease

• Signs and symptoms
• Tender lymphadenopathy
• General malaise and low-grade fever
• Nursing care
• Administer antibiotics

36
Burns

• Burns
• The third leading cause of death in children
• Boys between the ages of 1 and 4 are twice as
  likely as girls to be burned
• Average age of pediatric burn patient is 32
  months
• Children are at high risk for burns due to
  environment, behavior, and age
• Types of burns
• Thermal
• Chemical
• Electrical
• Radiation

37
Burn CategoriesDepth

• First degreesuperficial
• Erythematous and painful
• Second degreesuperficial partial thickness or
  deep partial thickness
• Red and painful with blister formation
• Third degreefull thickness
• White, waxy, does not bleed or blanch skin may
  be black in color (eschar)
• Less painful because nerve fibers were destroyed

38
Classifying Burns

• Surface area
• Calculate total body surface area (TBSA)
• Calculations rule of 9s

39
Classification of Burn Severity

• Severity
• Mild
• Moderate
• Severe

40
Nursing Care

• Minor burnsThe six Cs
• Clothingremove any clothing
• Coolingburns need to be cooled immediately
• Cleaningwash the wound with mild soap and rinse
  well with water
• Chemoprophylaxisapply topical ointment a
  tetanus booster is also given
• Coveringcover the burn with gauze
• Comfortgive pain medication

41
Nursing Care

• Moderate and major burns
• Assess frequently
• Provide fluid resuscitation
• Maintain general nutrition
• Manage pain
• Give meticulous wound care
• Provide burn recovery

42
Assessment

• Burn history
• ABCs
• Transport to emergency room
• Remove clothing
• Decontaminate wound
• Assess wound for depth, surface area, and
  severity
• Photograph or use video charting

43
Fluid Resuscitation

• IV fluidslactated Ringers solution
• Monitor urine output

44
Nutrition

• Caloric requirement for a patient with a burn
  covering gt30 of the body is 2000 to 2200
  calories/day
• Enteral feeding is initiated within 6 hours

45
Pain Management

• Give pain medications (morphine sulfate)
• Give anxiety medications (midazolam)
• Provide psychological support
• Do not undermedicate adolescents
• Use nonpharmacological interventions (distraction)

46
Wound Care

• Initially decontaminate wound
• Debride wound (tub or enzyme collagenase)
• Clean wound
• Perform escharotomy
• If no eschar or devitalized tissue is present,
  the wound can be treated with antibiotic cream
  and re-dressed
• Apply transparent occlusive dressings so the
  wound can be easily assessed for infection
• Use impregnated dressings

47
Skin Replacement

• Temporary skin replacement
• Biobrane, Transcyte
• Permanent skin replacement
• Xenograft, cadaver skin (allograft)
• Integra, Apligraf
• Cultured epithelial autograft (CEA), autografting
  

48
Burn Recovery

• Burns are managed by phases of recuperation as
  well as the type and severity of burns
• Acute phasetime of initial assault until wound
  closure
• Second phasefrom time of wound closure until
  scar maturation
• Care involves the family and health care team
• Scar revision may be necessary (re-hospitalization
  )
• Promote optimal functioning and minimal negative
  psychological impact

49
Hypothermia

• Signs and symptoms
• Based on classificationsmild, moderate, and
  severe
• Nursing care
• Initiate emergency medical care
• Complete assessment of airway, breathing, and
  circulation
• Initiate CPR
• Obtain rectal temperature
• Remove all wet and cold clothing, wrap child in
  warm blankets
• Administer warmed oxygen and IV fluids
• Monitor VS and urine output
• Perform electrocardiogram
• Raise body temperature using forced-air warming
  systems

50
Frostbite

• Signs and symptoms
• Red, blue, or waxy skin
• Prickling or painful sensation
• Nursing care
• Care similar to hypothermia
• Place child in warm area, remove wet/cold
  clothing and replace with warm clothing
• Re-warm using tap water for ½ hour (do not run
  warm water directly from the tap)
• Do not massage area or apply dry heat
• After re-warming, wrap extremity in soft cloth
• Encourage child to rest
• Instruct parents to call health care provider if
  problems arise

51
Pressure Ulcers

• Signs and symptoms
• Earliest sign is a reddened area on the skin that
  does not disappear within 30 minutes of removing
  the cause
• Skin can appear to have an abrasion and look raw
  or rubbed
• Stages of pressure ulcer

52
Nursing Care

• See the Braden Scale (bradenscale.com)
• Carefully inspect skin at least 3 times a day
• Note color of affected area, signs of infection,
  character of the skin lesion, wound edges,
  drainage
• Measure the diameter and determine the depth of
  the pressure ulcer
• Address anemia (diet high in iron)
• Keep bed clothing straight and wrinkle free
• Use air, water, or gel mattresses and pads to
  decrease pressure
• Keep skin clean and dry
• Keep child off the affected area
• Apply topical treatments or collodial dressings
• Use preventive measures (move routinely and shift
  weight)