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Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families Chapter 31 Caring for the Child with an Integumentary Condition Susan Ward Shelton Hisley A & P Review: The Skin Epidermis Dermis Subcutaneous fatty layer Accessory structures Hair, sebaceous glands Exocrine and apocrine glands Integumentary Changes as Children Grow See Table 31-1 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 Wounds and Wound Healing Typical wounds Cuts Scrapes Burns Secondary to surgical intervention Wounds and Wound Healing Three Phases of Skin Healing Inflammation Initial healing response (lasts 2–5 days) Preparatory stage for repair Proliferation Blood flow is reestablished to the site Natural debridement occurs (lasts 2–3 weeks) New cells cover the site Remodeling Scar formation (lasts 3 weeks to 2 years) Skin Infections Bacterial Infections Acne Vulgaris Signs and symptoms Comedo—“whitehead” 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) 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 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 (children’s Advil) Viral Infections 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 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) Fungal Infections Cutaneous Candidiasis Signs and symptoms Mouth—white or gray plaque Skin—fine 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 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 Dermatitis 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 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 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 Cutaneous Skin Reactions Signs and Symptoms Four types—eruption, 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 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 Infestations 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 Guidelines—Lice (Pediculosis) 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 Bites and Stings Insects Signs and symptoms Mosquito—red papules and edema at site which produces itching, burning, and minimal discomfort Spider—erythema, itching, and pain Tick—reddened area of the skin that can be raised and itchy; a general sick feeling Bee, wasp/hornet—pain, 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 Animal Bites 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 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 Diseases from Bites 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 tick[s]) Administer oral antibiotics if infection is suspected Rocky Mountain Spotted Fever Signs and symptoms Multisystem disease—mild, moderate, or severe Onset can be either gradual or sudden Sudden—nausea, vomiting, lack of appetite, abdominal pain, malaise, deep muscle pain, and severe headache Red rash that blanches with pressure occurs 3–5 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) Cat Scratch Disease Signs and symptoms Tender lymphadenopathy General malaise and low-grade fever Nursing care Administer antibiotics 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 Burn Categories—Depth First degree—superficial Erythematous and painful Second degree—superficial partial thickness or deep partial thickness Red and painful with blister formation Third degree—full thickness White, waxy, does not bleed or blanch; skin may be black in color (eschar) Less painful because nerve fibers were destroyed Classifying Burns Surface area Calculate total body surface area (TBSA) Calculations rule of 9’s Classification of Burn Severity Severity Mild Moderate Severe Nursing Care Minor burns—The six “C’s” Clothing—remove any clothing Cooling—burns need to be cooled immediately Cleaning—wash the wound with mild soap and rinse well with water Chemoprophylaxis—apply topical ointment; a tetanus booster is also given Covering—cover the burn with gauze Comfort—give pain medication Nursing Care Moderate and major burns Assess frequently Provide fluid resuscitation Maintain general nutrition Manage pain Give meticulous wound care Provide burn recovery 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 Fluid Resuscitation IV fluids—lactated Ringer’s solution Monitor urine output Nutrition Caloric requirement for a patient with a burn covering >30% of the body is 2000 to 2200 calories/day Enteral feeding is initiated within 6 hours Pain Management Give pain medications (morphine sulfate) Give anxiety medications (midazolam) Provide psychological support Do not undermedicate adolescents Use nonpharmacological interventions (distraction) 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 Skin Replacement Temporary skin replacement Biobrane™, Transcyte™ Permanent skin replacement Xenograft, cadaver skin (allograft) Integra™, Apligraf™ Cultured epithelial autograft (CEA), autografting Burn Recovery Burns are managed by phases of recuperation as well as the type and severity of burns Acute phase—time of initial assault until wound closure Second phase—from 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 Hypothermia Signs and symptoms Based on classifications—mild, 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 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 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 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)