Download Key Function of Skin

Skin – Immune Disorders
Jan Bazner-Chandler
CPNP, CNS, MSN, RN
Key Function of Skin
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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
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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.
Diagnostic Tests
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Cultures
Scraping
Skin biopsy
Skin testing
Woods lamp
Woods Lamp
Neonatal skin lesions
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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
Inflammatory Skin Disorders
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Diaper dermatitis
Contact dermatitis
Atopic dermatitis or eczema
Diaper Dermatitis
Diaper Dermatitis
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Identify causative agent
Cleanse with mild cleaner
Apply barrier
Expose to air
Teach hazards of baby powder
Cradle Cap
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Rash that occurs on the scalp.
It may cause scaling and redness of
the scalp.
It may progress to other areas.
Treatment
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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.
Cradle Cap
Baby Care
Atopic dermatitis or Eczema
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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
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History of asthma, allergic rhinitis
Lesions generally occur in creases.
Management:
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Control the itching: OTC Benadryl
Reduce inflammation: topical
corticosteroids
Hydrate the skin
Elidel Cream
Preventing infection
Acne Vulgaris
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A chronic, inflammatory process of the
pilosebaceous follicles.
Occurrence; 85% of teenager aged 15
to 17 years.
More common in females than males.
Acne
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Over activity of oil glands at the base
of hair follicles
Hormone activity
Skin cell “plug” pores causing white
heads and blackheads.
No “cure”
Acne
Management of Acne
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Topical medications
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OTC preparations
Prescription - Topical retinoid preparations
Prescription - Topical antibiotics
Systemic medication
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Antibiotics
Hormonal therapy – birth control pills
Accutane * use with extreme caution when all
else fails
Pediculosis
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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.
Pediculosis
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Head lice
Pubic lice
Body lice
Signs and Symptoms
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Symptoms: itching,
whitish colored eggs
at shaft of hair,
redness at site of
itching.
Nits
Empty nit case
Viable nit
Interventions
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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
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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
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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
Management
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Permethrin cream is drug of choice
Massage into all skin surfaces – neck
to soles of feet - leave on for 8 to 14
hours.
Clothing bedding and other contact
items need to be washed in hot soapy
water.
Vacuum upholstered furniture - rugs
Scabies
Scabies
Impetigo
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The most common skin infection in
children.
Causative agent is carried in the nasal
area.
Bacteria invade the superficial skin.
Causative agent
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Group A beta-hemolytic streptococcal
(GABHS)
Staph aureus
Impetigo
Spread
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Highly contagious skin infection.
Most common among children.
Spread through physical contact.
Clothes, bedding, towels and other
objects.
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)
Outcomes
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Self-limiting
No scarring or pox marks post
infection.
Super-infection especially in the
neonate.
Impetigo / cellulitis
Cellulitis
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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.
Assessment
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History and physical exam
WBC count
Blood culture
Culturing organism from lesion
aspiration.
CT scan with peri-orbital cellulitis
Clinical Manifestations
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Characteristic reddened or lilaccolored, swollen skin that pits when
pressed with finger.
Borders are indistinct.
Warm to touch.
Superficial blistering.
Cellulitis
Cellulitis
Interventions
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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
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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
Poison Oak
Interventions
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Prevention:
Wear long pants when hiking or playing in
the brush.
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.
Systemic Response
Burns in Children
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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
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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.
Burns in Children
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Immature immune system can lead to
increased risk of infection.
Delay in growth may follow extensive
burns.
Management of Burns
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Ascertain adequacy of airway, oxygen,
intubation
Large bore needle to deliver sufficient
fluids at a rapid rate.
Remove clothing and jewelry and
examine.
Alert
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The most common cause of
unconsciousness in the flame burn
patient is hypoxia due to smoke
inhalation.
Look for ash and soot around nares.
Management of Burns
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Admission weight.
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.
Flame Burn
Management
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NG tube in place.
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Catheter for fluid replacement.
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Ambulation to prevent problems
associated with immobilization
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Percentage of Areas Affected
Depth of Burns
First Degree Burn
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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
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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
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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.
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
Wound Management
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Hydrotherapy is used to cleanse the
wound. Gauze pads are used
To debride the wound by removing
exudates and previous applied
Medication.
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.
Burns
Ball & Bender
Flash burn from gasoline.
Electrical burn caused by biting
of electrical cord.
Keep Kids Safe
Infants Immune System
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No active immune response at birth
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Passive immunity from mother
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Potential for immune response is
present / active response is lacking
Immune Response
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IgG is received from mother transplacental and in breast milk
6 to 9 months infants start to produce
IgG
Immune system starts to assume
defensive role
Active immunity begins after exposure
to antigens
Neonatal Sepsis
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Can be caused by bacterial, fugal,
parasitic or viral pathogens.
Etiology: complex interaction of
maternal-fetal colonization,
transplacental immunity and physical
and cellular defenses of the fetus and
mother.
Sepsis
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Laboratory confirmed blood stream
infection
Neonatal sepsis
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Mortality rate 50%
1 to 8 cases per 1000 live births
Meningitis occurs in 1/3
Major Risk Factors
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Maternal prolonged rupture of
membranes > 24 hours
Intra-partum maternal fever > 38C
Prematurity
Sustained fetal tachycardia > 160
Minor Risk Factors
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Twin gestation
Premature infant
Low APGAR
Maternal Group B Streptococcus
Foul lochia
Etiology
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Group B beta-hemolytic Streptococcus
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Escherichia coli
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Haemophilus Influenza
Diagnostic Tests
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C-Reactive Protein * earliest indicator of
infectious / inflammatory process
CBC with differential
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WBC
Blood Culture – rule out blood borne
bacteria – sepsis (take 3 days for final
culture results)
Lumbar Puncture – rule out meningitis
Urine Culture – rule out UTI
Clinical Manifestations
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Respiratory distress
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Temperature instability
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> 99.6 (37 C) or < 97 (36 C)
Gastrointestinal symptoms
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Tachypnea / apnea / hypoxia
Vomiting, diarrhea, poor feeding
Decreased activity: lethargic / not
eating
Blood Test
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C-Reactive Protein
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Protein appears within 6 hours or
exposure
Blood culture to identify causative agent
Medical Management
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Ampicillin
Gentamicin
Cefotaxime
Acyclovir: herpes
Nursing Interventions
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Administer IV antibiotics
Monitor therapeutic levels
Monitor VS, temperature, O2
saturation
Activity level
Sucking
Infant parent bonding
Outcomes
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Newborn will achieve normalization of
body function
Parents will participate in care
Newborn will demonstrate no signs of
CV, neurological or respiratory
compromise
Newborn will experience no hearing
loss as a result of antibiotic therapy
SCIDS
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Severe Combined Immunodeficiency
Disease
Hereditary disease
Absence of both humoral and cell
mediated immunity
Clinical Manifestations
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Susceptibility to infection
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Frequent infection
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Failure of infection to respond to
antibiotic treatment
Treatment
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Manage infection
Bone marrow
transplant
Acquired Immunodeficiency Syndrome
/ AIDS
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Human immunodeficiency virus type 1
is a retro virus that attacks the immune
system by destroying T lymphocytes.
AIDS
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T lymphocytes are critical to fighting
infection and developing immunity.
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HIV renders the immune system
useless and the child is unable to fight
infection.
Killer T-cells
Blood Testing in Infants
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Babies born to HIV-positive mothers
initially test positive for HIV antibodies.
Only 13 to 39% of these infants are
actually infected.
Infants who are not infected with HIV
may remain positive until they are
about 18- months-old.
Treating Infants in Utero
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Routinely offer HIV testing to all
pregnant women.
Administration of zidovudine (AZT)
can decrease the likelihood of
perinatal transmission from 25% to
8%.
Modes of Transmission
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Three chief modes of transmission:
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Sexual contact (both homosexual and
heterosexual).
Exposure to needles or other sharp
instruments contaminated with blood or
bloody body fluids.
Mother-to-infant transmission before or
around the time of birth.
Symptoms in Children
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An infant who is HIV positive will generally
exhibit symptoms between 9 months to 3
years.
Failure to thrive
Pneumonia, chronic diarrhea, opportunistic
infections
Encephalopathy: leading to developmental
delay, or loss of previously obtained
milestones.
Interdisciplinary Interventions
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Maternal treatment during pregnancy.
Newborn receives zidovudine for 6
weeks after birth.
Prophylaxis with Septra or Bactrim
when CD4 level starts to drop.
Interventions
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Age-appropriate immunizations except
those containing live attenuated
viruses. Can be given when T-Cell
count is adequate
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Chicken pox - Varicella
MMR – measles, mumps, rubella
Community Interventions
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Education and prevention are the best
ways to manage AIDS.
Safe sexual practices
Monogamous relationship
Avoidance of substances such as
alcohol and drugs that can cloud
judgment.
Changes in HIV
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Number of infected newborns has
dropped due to treatment of HIV
infected mothers.
HIV has become a chronic disease in
children
Team approach
Emphasis on community teaching