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The Child with Altered Skin Integrity Jan Bazner-Chandler CPNP, CNS, MSN, RN 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 Developmental Variances Sweat glands function by the time the child is 3-yearsold. The visco-elastic property of the dermis becomes completely functional at about 2 years. The neonate’s dermis is thin and very hydrated greater risk for fluid loss ineffective barrier against infection 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 Neonatal Dermatology Inflammatory Skin Disorders Diaper dermatitis Contact dermatitis Atopic dermatitis or eczema Diaper Dermatitis Assessment / Interventions Identify causative agent Cleanse with mild cleaner Apply barrier Zinc oxide / Desitine Expose to air Teach hazards of baby powder Cradle Cap Rash that occurs on the scalp. It may cause scaling and redness of the scalp. It may progress to other areas. Cradle Cap 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. 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. 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 Nickel Allergy 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 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. Dermatitis Assessment Pruritis Erythema Exudate and crusts Common sites: cheeks, forehead, scalp, extensor surfaces of arms and legs 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 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. 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 Acne Interventions Topical medications OTC preparations Prescription - Topical retinoid preparations Prescription - Topical antibiotics may cause bacterial resistance Prescription – hormone therapy Prescription – accutane 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. Assessment Symptoms: itching, whitish colored eggs at shaft of hair, redness at site of itching. Nits Empty nit case Viable nit 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 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 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 Scabies 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 Scabies Impetigo • • • The most common skin infection in children. Causative agent is carried in the nasal area. Bacteria invade the superficial skin. Causative agent Group A beta-hemolytic streptococcal (GABHS) Staph aureus Impetigo Spread Highly contagious Common in young children Spread through physical contact Interventions Wash hands Wash lesion with soap and water Topical antibiotics: Bactroban Altabax PO antibiotics: Keflex 1st generation cephalosporin Impetigo / cellulitis 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. Diagnostic Tests WBC count Blood culture Culturing organism from lesion aspiration. CT scan of head with peri-orbital cellulitis If cellulitis in the eye area may spread to brain Assessment Characteristic reddened or lilac-colored, swollen skin that pits when pressed with finger. Borders are indistinct. Warm to touch. Superficial blistering. Cellulitis Cellulitis – monitor spread 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 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. Poison Ivy 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 Systemic Response 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. 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 Percentage of Areas Affected Burns in Children Immature immune system can lead to increased risk of infection. Delay in growth may follow extensive burns. Alert The most common cause of unconsciousness in the flame burn patient is hypoxia due to smoke inhalation. Look for ash and soot around nares. Immediate Interventions Airway management Large bore needle for fluids (plasma or blood) Nasogastric tube to maintain gastric decompression Foley catheter for urine specimen and monitor output Evaluate burn area and determine the extent and depth of injury Accurate weigth Flame Burn Depth of Burns First Degree Burn Involves only the epidermis and part of the underlying skin layers. Area is hot, red, and painful, but without swelling or blistering. Sunburn is usually a first-degree burn. Second Degree Burn Involves the epidermis and part of the underlying skin layers. Pain is severe. Area is pink or red or mottled. Area is moist and seeping, swollen, with blisters. Third Degree or Full-thickness Involves injury to all layers of skin. Destroys the nerve and blood vessels No pain at first Area may be white, yellow, black or cherry red. Skin may appear dry and leathery. Electrical Burn Wound Management Dead skin and debris are Carefully trimmed. Gauze with ointment is applied to burn wound. Wound Management Bowden, Dickey, Greenberg text Children and Their Families Skin Grafts Removal of split-thickness Skin graft with dermatone. Healed donor site Compartment Syndrome Escharotomy / fasciotomy in a severely burned arm. Burn Wound Covering Therapy to Prevent Complications Elasticized garment and “air-plane” splints. Physical therapy to prevent contracture deformity. Keep Kids Safe
