The Child with Altered Skin Integrity

1. The Child with Altered Skin Integrity Jan Bazner-Chandler CPNP, CNS, MSN, RN

2. Key Function of Skin • Protection – shield from internal injury. • Immunity – contains cells that ingest bacteria and other substances. • Thermoregulation – heat regulation through sweating, shivering, and subcutaneous insulation • Communication / sensation / regeneration

3. Developmental Variances • Sweat glands function by the time the child is 3-years-old. • The visco-elastic property of the dermis becomes completely functional at about 2 years. • The neonate’s dermis is thin and very hydrated, thus is at greater risk for fluid loss and serves as an ineffective barrier.

4. Neonatal skin lesions • Vascular birth marks: hemangioma • Port wine stain • Abnormal pigmentation: Mongolian spots • Neonatal acne: small red papules and pustules appear on face trunk. • Milia: white or yellow, 1-2mm papules appearing on cheeks, nose, chin, and forehead

5. Inflammatory Skin Disorders • Diaper dermatitis • Contact dermatitis • Atopic dermatitis or eczema

6. Diaper Dermatitis

7. Assessment / Interventions • Identify causative agent • Cleanse with mild cleaner • Apply barrier • Expose to air • Teach hazards of baby powder

8. Cradle Cap • Rash that occurs on the scalp. • It may cause scaling and redness of the scalp. • It may progress to other areas.

9. Cradle Cap

10. Interventions • If confined to the scalp • Wash area with mild baby shampoo and brush with a soft brush to help remove the scales. • Do not apply baby oil or mineral oil to the area - this will only allow for more build up of the scales.

11. Contact Dermatitis • Contact dermatitis is an inflammatory skin condition involving a cutaneous response occurring when skin is exposed to certain external natural or systemic substances.

12. Assessment • Occurs in exposed areas of skin: • Face, neck, hands, forearms, legs and feet • Lesions may be well demarcated resembling the shape and size of the offending substance

13. Nickel Allergy

14. Interventions • Resolves over a few weeks when causative agent is removed • For itching and edema: Burrow’s solution, topical corticosteroids • In severe reactions: oral corticosteroids

15. Atopic dermatitis or Eczema • Chronic, relapsing inflammation of the dermis and epidermis characterized by itching, edema, papules, erythema, excoriation, serous discharge and crusting. • Patients have a heightened reaction to a variety of allergens.

16. Dermatitis

17. Assessment • Pruritis • Erythema • Exudate and crusts • Common sites: cheeks, forehead, scalp, extensor surfaces of arms and legs

18. Multidisciplinary Interventions • Frequent re-hydration of the skin • Elidel cream • To reduce the inflammation: topical corticosteroids • Control the itching: antihistamine such as Benadryl • Control infection: topical or oral antibiotics

19. Acne Vulgaris • A chronic, inflammatory process of the pilosebaceous follicles. • Occurrence; 85% of teenager aged 15 to 17 years. • More common in females than males.

20. Assessment • Over activity of oil glands at the base of hair follicles • Skin cell “plug” pores causing white heads and blackheads • Lesions usually occur on the face, back, chest and shoulders • Lesions are red and hyperpigmented

21. Acne

22. Interventions • Topical medications • OTC preparations • Prescription - Topical retinoid preparations • Prescription - Topical antibiotics may cause bacterial resistance • Prescription – hormone therapy • Prescription - accutane

23. Pediculosis • Head lice infestation ranges from 1% to 40% in children. • Most common in ages 5 to 12. • Less common in African American due to the shape of the hair shaft. • Transmission by direct contact with infected person, clothing, grooming articles, bedding, or carpeting.

24. Assessment Symptoms: itching, whitish colored eggs at shaft of hair, redness at site of itching.

25. Nits Empty nit case Viable nit

26. Interventions • Anti-lice shampoo • Removal of nits • Washing bedding, towels, anything child’s head may have come in contact with in hot soapy water. • Vacuum all floors and rugs • Do not need to fumigate the house • Child can return to school after 1 day of treatment

27. Scabies • A contagious skin condition caused by the human skin mite. • Tiny, eight-legged creature burrows within the skin and penetrate the epidermis and lays eggs • Allergic reaction occurs • Severe itching

28. Assessment • Pruritus especially profound at night or nap time. • Lesions may be generalized but tend to distribute on the palms, soles and axillae • In older children: finger webs, body creases, beltline and genitalia

29. Scabies

30. Interventions • Permethrin cream is drug of choice • Massage into all skin surfaces – neck to soles of feet - leave on for 8 to 14 hours. • Re-apply one week later

31. Scabies

32. Impetigo • The most common skin infection in children. • Causative agent is carried in the nasal area. • Bacteria invade the superficial skin.

33. Causative agent • Group A beta-hemolytic streptococcal (GABHS) • Staph aureus

34. Impetigo

35. Spread • Highly contagious skin infection. • Most common among children. • Spread through physical contact. • Clothes, bedding, towels and other objects.

36. Interventions • Good general hygiene – wash hands • Wash lesions with soap and water • Topical antibiotic therapy: (Bactroban) • Keflex PO – 2nd generation cephalosporin • New antibacterial: Altabax (2007)

37. Impetigo / cellulitis

38. Cellulitis • A full-thickness skin infection involving dermis and underlying connective tissue. • Any part of the body can be affected. • Cellulitis around the eyes is usually an extension of a sinus infection or otitis media.

39. Diagnostic Tests • WBC count • Blood culture • Culturing organism from lesion aspiration. • CT scan of head with peri-orbital cellulitis

40. Assessment • Characteristic reddened or lilac-colored, swollen skin that pits when pressed with finger. • Borders are indistinct. • Warm to touch. • Superficial blistering.

41. Cellulitis

42. Cellulitis

43. Interdisciplinary Interventions • Hospitalization if large area involved or facial cellulitis • IV antibiotics • Tylenol for pain management • Warm moist packs to area if ordered • Assess for spread • If peri-orbital test for ocular movement and vision acuity

44. Poison Oak, Ivy and Sumac • Three potent antigens that characteristically produce an intense dermatologic inflammatory reaction when contact is made between the skin and the allergens contained in the plant.

45. Poison Ivy

46. Interventions • Prevention: • Wear long pants when hiking or playing in wooded areas • Wash with soap and water to remove sticky sap • Cleanse under finger nails • Sap on fur, clothing or shoes can last up to 1 week if not cleansed properly • Topical cortisone to lesions • Oral prednisone if extensive

47. Systemic Response

48. Thermal Injuries • Young children who have been severely burned have a higher mortality rate than adults. • Shorter exposure to chemicals or temperature can injure child sooner. • Increased risk for for fluid and heat loss due to larger body surface area.

49. Burns in Children • Burns involving more that 10% of TBSA require fluid resuscitation • Infants and children are at increased risk for protein and calorie deficiency due to decreased muscle mass and poor eating habits • Scarring in more severe

50. Burns in Children • Immature immune system can lead to increased risk of infection. • Delay in growth may follow extensive burns.