the child with altered skin integrity jan bazner-chandler cpnp, cns, msn, rn

The Child with Altered Skin Integrity

Jan Bazner-ChandlerCPNP, 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-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.

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

Inflammatory Skin Disorders Diaper dermatitis Contact dermatitis Atopic dermatitis or eczema

Diaper Dermatitis

Assessment / Interventions Identify causative agent Cleanse with mild cleaner Apply barrier 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 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)

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

Assessment Characteristic reddened or lilac-colored,

swollen skin that pits when pressed with finger.

Borders are indistinct. Warm to touch. Superficial blistering.

Cellulitis

Cellulitis

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

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.

Interventions Ascertain adequacy of airway, give oxygen,

prepare for intubation if indicated Large bore needle to deliver sufficient fluids at

a rapid rate – normal saline 20 mL / kg

Immediate Interventions 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

Percentage of Areas Affected

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 areCarefully trimmed.

Gauze with ointment is appliedto burn wound.

Wound Management

Bowden, Dickey, Greenberg textChildren and Their Families

Skin Grafts

Removal of split-thicknessSkin 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 contracturedeformity.

Keep Kids Safe