Chamberlain College of Nursing:NR 222 Nursing Care of Children with Integumentary Disorder #5,100% CORRECT

Chamberlain College of Nursing:NR 222 Nursing Care of Children with Integumentary Disorder #5 Skin 101 How to describe what you see (starred) Macule: a small (usally less than 1cm in diameter), flat blemish or discoloration that can be brown, tan, red, or white and has same texture as surrounding skin ex; Beauty makr Bulla: A raised, thin-walled blister greater than 0.5 cm in diameter, containing clear or serous fluid. EX: shingles or poison Ivy Vesicle: a small (less than 0.5 cm in diameter), thin walled, raised blister containing clear, serous, purulent, or bloody fluid. EX; Herpes Pustule: a circumscribed, pus or lymph filled, elevated lesion that varies in diameter and may be firm or soft and white or yellow. EX: pimples Wheal: a slightly raised, firm lesion of variable size and shape, surrounded by edema; skin may be red or pale. EX: Hives Nodule: a small, firm circumscribe elevated lesion 1 to 2 cm in diameter with possible skin discoloration. EX: lymphoma Papule: a small, solid, raised lesion less than 1 cm in diameter, with red to purple skin discoloration. EX: Hemangioma Tumor: A solid, raised mass usually larger than 2 cm in diameter with possible skin discoloration. Dobbler: upon admission you must explain skin lesion in details. Skin Infections (starred) • Bacterial: impetigo, folliculitis, cellulitis, staphylococcal scalded syndrome • Viral: herpes, varicella, molluscum contagiosum, warts • Fungal: tinea, candidiasis • RISK FACTORS: contact with infected person; immunocompromised • LAB: cultures Dobbler: to decipher what type an infection you need a culture it is better to get the pus or fluid sample. Sometime names are different depending where the infection is on the skin, for example candidiasis can present as yeast infection, thrush or a diaper rash. Tinea capitis on the scalp, tinea corpus is ringworm, tinea Curtis jock itch, Tinea pedis- Athlete foot. Nursing Education and Care (starred) • Watch for signs of infection • Prevent child from itching and touching • Hand hygiene • NO sharing of clothing, towels, brushes • Do not squeeze vesicles Dobbler: explain to the parents how to watch for signs of infection (bacterial, parasite etc). Not every anti-viral work usually management and washing. Advise not to itch or Don’t want to squeeze cause if live virus inside so if it pops and gets to another part of skin it will develop another rash Skin Infestations • Scabies • Pediculosis capitis (Lice) • Pinworm • Bed Bugs Parasitic & Helminthic Infections • Organisms larger than bacteria/ yeast • Live in/on host • Children are at increase risk due to poor hygiene - Poor hand washing - Put objects in mouth - Share toys Dobbler: Helminthic mean worm, most children don’t care about hygiene so they are at higher risk for these parasites Scabies Sign and symptom: itchy (especially at night), rash (in between fingers, trunk, head, neck, wrists and joints), pencil like marks on skin Treatment: 5% permethrin over entire body then repeat in 1-2 weeks, oral ivermectin Nursing Interventions: - Treat entire family - Wash all clothing/ towels in hot water - Calamine - Cool compress - Vacuum RISK OF: secondary infection Dobbler: pediatrician stick with topical oral meds are strong we typically treat the entire family clean compresses and rugs. They enjoy wet moist area. The main risk is secondary infection like staph infection. Common in densely populated areas Itchier at night Typically presents around fingers or around joints Usually a topical treatment for it HIGHLY contagious Scabies like moist warm areas, can live in rugs At risk for staff infection of skin if itching this and open lesions Oral ivermectin- strong, most people’s stomach can’t handle this Lice (Pediculosis capitis) (Starred) • Direct contact with hair of infested child • Less likely transmitted through belongings (but can live on them) • 6-10 days lay eggs (nits) to hatch, 2-3 weeks adult lice • Sign/symptoms: pruritus and visualization behind ears/nape neck: • Diagnose: by identification • Treatment: wash hair with permetherin with strict regimen; retreat 9 days after first treatment • Education: Disinfect clothing, towels etc. with hot water and hot cycle in dryer, soak combs in shampoo, dry-clean non washables, toys in air tight bag, Dobblers: lice very common in school age children they like to share things, lice live in hair Have to retreat 9 days after because that’s when eggs would hatch. Tiny comb are used to comb hair, lice checks are done in schools not sure of frequency. Education: Air tight bag- because you can literally suffocate the lice so when you take toys out you can just wash toys in hot water Looks like dandruff Dobblers: Easier to see in dark brown/black hair Lice are kind of sticky so won’t get pulled out of hair easily like dandruff (major way to tell difference when you see it at first because dandruff will come out easy) Pinworm (Enterobius vermicularis) • Sign/Symptoms: May be asymptomatic but commonly anal itching, • restless sleep, teeth grinding, weight loss, enuresis (bed-wetting) • Transmission: fecal oral route • Incubation:1-2 months • Diagnosis: adult worms visualized in perianal area, best when child sleeps; ova may be present in stool • Tape test under microscope: Put paper by child’s anus when sleeping so when they wake up you peel it off and there will be worms on it • Treatment/RN education: - Mebendazole single dose than repeat in 2 week - Treat all family members contagious - Frequent change cloths/bedding/shower in am - Keep nails short and avoid scratching perianal area Dobbler: transmitted fecal oral route it is high contagious. single dose of medication that is repeated later, all family is treated, have child shower in the morning as he has worms in his booty hole from the night before. Keep nail short to prevent re-infestation. Arthropod Bites and Stings • Flies • Fleas • Bees • Wasps • Ticks: biggest problem in our area • Spiders Lyme Disease (zoonotic) • Most common vector born in USA • Cause by Borrelia burgdorferi :bite of blacklegged deer tick • Mainly Northeast • Highest incidence: 5-9 years old • Tick must be attached 38-48 hours Dobbler: Lyme disease is vector born the tick bite the deer(reservoir) and bite you(host). Not every tick carry this disease it have to be a black legged deer tick must be attached 38 to 48 hours and you capture the thick for identification. Assessment • History of tick bite • Bulls-eye rash at site of tick bite (erythema migraines) don’t always occur Early Localized Stage 1: - Rash occurs 3-30 days after bite Bulls-eye at site Early Disseminated Stage 2 - Rash 3-10 weeks after bite fever, malaise, mild neck pain, Headache, fatigue, arthralgia and joint pain, cranial nerve palsy, conjunctivitis. Late Disease Stage 3: - Systemic involvement is advanced Recurrent arthritis large joint (knees) Dobbler: Don’t necessarily need bulls-eye rash to have it Notice at stage 2 normally and that’s when people go to dr Stages can occur so late Diagnostics and Treatment Two step test 1. EIA (sensitive enzyme immunoassay) or IFA (immunofluorescent assay) 2. If positive do Western Blot Medication Doxycycline 8 years old Amoxicillin 8 years old because Doxy discolors teeth Allergic to penicillin: cefuroxime axetil Length: 2-3 weeks Dobbler: If EIA or IFA first then if positive do western blot it indicates if the lyme disease is a recent infection or old. The longer you have this disease the more complications you will have. Doxy- standard medication for older than 8 years Amoxy- standard if younger than 8 years this treatment is long 2-3 weeks. Nursing Considerations for Lyme Disease Prevention: • Bug spray use; can cause toxicity if overused • Examine clothing, gear, and pets for ticks • Full body check after leaving high grass areas • Protective clothing Tick Removal: • Use tweezers • Grasp as close to skin as possible • Once removed clean with alcohol • Save tick for identification Dobbler: Treat pets for ticks and pre-treat them You want to get the head out, the part that’s biting the skin and clean with alcohol. Dermatitis Inflammatory reaction of the skin as a result of an irritant Common causes: feces, urine, soap, poison ivy, animals, metals, dyes, medications Types: - Contact dermatitis: inContact with poison Ivy - Diaper dermatitis - Cradle cap (seborrheic) - Poisonous Plant Exposure - Atopic Dermatitis (Eczema) Dobbler: extremely common irritation of the skin Contact Dermatitis S/S: - Itchy - Skin warm and tender - Presence of oozing, drainage, crusts - Skin becomes raw, scaly, or thickened - Red bumps that can form weeping area Dobbler: Doesn’t clear up that quickly Diaper Dermatitis S/S: - Small red patches that can blend together - Itchy - Bright, red rash that extends gradually - Can be excoriated Fungal diaper dermatitis (not as common) S/S: - Fiery red (beefy) and scaly - Edge very defined and raised - Can have pimples, ulcers, or pus filled Dobbler: If you start to treat things like this and nothing works, try an antifungal that you can buy OTC. One thing that is Common with moms- try to use breast milk for any kind of skin issues and though good for some, do NOT use for diaper area because it will feed fungus so use creams that area out there Seborrheic Dermatitis (Cradle cap) S/S: Scaly white to yellow scales Poisonous Plant Exposure (poison ivy) Similar to other types but more commonly will form into vesicles Dobbler: Some people are immune and some are very sensitive to it Nursing Care (starred) Contact: - Clean area - Remove irritant Diaper: Clean Area: - Change frequently - Clean with water (avoid alcohol wipes) - Leave area open to air - Apply skin barrier - Prevention is key Remove Irritant: - Skin barrier like zinc oxide - Treat if fungal Cradle Cap Clean Area: - Gently scrub crusted area - Use fine-tooth comb - Shampoo daily with shampoo Remove Irritant: - Antiseborrheic shampoo or mineral oil Poison plant: Clean Area: - Clean affected area with soap and cold water - Wash clothing - Add calamine Remove Irritant: - Topical corticosteroid Oral if needed Dobbler: Leave open to air Atopic Dermatitis/eczama - Skin dry and rough - Erythematous - Intense puritis - Hypopigmentation - Clusters Common areas: Face, trunk, scalp, Hands, feet, and Extensor surfaces Dobbler: AKA eczema Commonly comes with allergies and asthma Atopic Dermatitis Nursing Care: - Keep skin hydrated - Tepid baths/ 2-3x a week - Cotton clothing; avoid synthetic - Avoid excessive heat - Avoid irritants - Keep nails trimmed - Watch for infection - Oatmeal bath Medications: - Benadryl - Claritin - Topical corticosteroids - Topical immunomodulators (nonsteroidal) Medication Name: Antihistamines: Hydroxyzine or diphenhydramine (Benadryl) Use: Antipruritic Client Education: • Educate on safe administration and schedule • Sedating effect • Monitor for safety when medicated Medication Name: Antibiotics Use: Treat secondary infections Client Education: • Educate on appropriate administration and importance of completing course Medication Name: Antifungal Clotrimazole Use: Treat Candida infections Client Education: • Educate on appropriate administration and importance of medication Acne • Most common in adolescence • Pilosebaceous follicles of face, neck, chest, upper back • Genetic link • Both males and females; hormonal flare up more in girls • Cosmetic products increase outbreaks Findings during exacerbations and remissions • Open comedones (blackhead): usually filled with dead tissue and dirt • Closed comedones (white head): typically filled with pus Nursing Care Education: Gently wash face; avoid scrubbing Adherence to plan of care Eat balanced meal Tretinoin: apply pea size amount and avoid sun Benzoyl: can bleach linens and clothing Isotretinoin: teratogenic; females need BCP; monitor behavioral changes (suicide) & lipid panel; drying affect Treatment: Tretinoin: interrupts normal keratinization Benzoyl Peroxide: antibacterial Antibiotics: topical and oral Isotretinoin: strong medication that stops growth of acne; for severe and used as last resort. (determine if sexually active) Dobbler: Education is important diet plays a role but uncertain on how much (greasy food and chocolate) cause break out. Benzoyl- common in OTC washes and creams but it does bleach linens of bed. Isotretinoin- Accutane, teratogenic, risk of fetus deformities. Before given to teenage girls, must do pregnancy tests because this will cause severe deformities in babies. Monitor behavior changes(suicidal) Accutane usually very last option dermatologists use Females to be put on birth control if on isotretinoin Pediatric Burns • Prevention is key • Risk factors are abuse , neglect, lack of supervision • Grading according to TBSA total body surface area Dobbler: Common because children don’t know things are hot Burin Depth: Epidermal (1st degree) Skin involvement: Epidermis Signs: blanch to touch and are erythematous, no blisters Sensation: may be painful Healing capacity: will heal spontaneously Healing time: within 7 days Scar formation: no scarring Burin Depth: Superficial partial thickness (2nd degree) Skin involvement: Epidermis and superficial dermis Signs: blanch to touch and tend to blisters Sensation: extremely painful Healing capacity: will heal spontaneously Healing time: within 14 days Scar formation: low to moderate risk of hypertrophic scarring Burin Depth: Deep partial thickness (2nd degree) Skin involvement: Epidermis and deep reticular dermis Signs: Do not blanch to touch, appear pale with large blisters. Sensation: maybe painful or reduced/ absent sensation Healing capacity: will not heal spontaneously, will need surgery Healing time: over 21 days Scar formation: moderate to high risk of hypertrophic scarring Burin Depth: Full thickness (3rd degree) Skin involvement: Epidermis and entire dermis Signs: can appear white, black or cherry red, no blisters. Sensation: absent sensation Healing capacity: no healing capacity, will need surgery Healing time: will not heal spontaneously Scar formation: will scar Burin Depth: 4th degree Skin involvement: involving underlying structures (subcutaneous fat, muscle and bones) Signs: charred, skeletonized. Sensation: absent of sensation Healing capacity: no healing capacity Healing time: will not heal spontaneously Scar formation: usually requires ampultaion Total Body Surface Area Graded as: • Minor • Moderate • Major According to the American Burn Association Body section & Surface Area - Head and Neck = 18 percent - Anterior trunk (chest & abdomen) = 18 percent - Posterior trunk (back and buttocks) = 18 percent - Upper extremities = 18 percent (each arm= 9 percent) - Lower extremities = 27.5 percent (each leg = 13.5 percent) - Genitalia and perineum = 1 percent Nursing Care of Minor Burns • Initial treatment of burns: Clean area; avoid friction and cover • Apply antimicrobial like silver sulfadiazine (2nd & 3rd degree) • Provide pain meds • Avoid butter/greasy lotion • Check immunization status: administer tetanus if more than 5 years Dobbler: Butter/greasy lotion- makes it worse Picture is 3rd and 2nd degree burn, partial thickness IS blanchable, blotchy and red 3rd degree- past all epithelium, NON blanchable, sensation lacks *review textbook and ATI on how to care for burns* Apply antimicrobial because of altered skin integrity so concerned about secondary infections 1. The nurse is taking care of a 7-year-old child with a skin rash called a papule. Which clinical finding should the nurse expect to assess with this type of skin rash? * A. A lesion that is elevated, palpable, firm and circumscribed; less than 1 cm in diameter 2. The nurse is teaching nursing students about childhood skin lesions. Which is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid? * D. Vesicle 3. The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion? * C. Flat, brown mole less than 1 cm in diameter 4. A school-age child falls on the playground and has a small laceration on the forearm. The school nurse should do which to cleanse the wound? * D. Wash wound gently with mild soap and water for several minutes. 6. Which nursing consideration is important when caring for a child with impetigo contagiosa? * C. Carefully wash hands and maintain cleanliness when caring for an infected child. 7. The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse what will happen to their child’s skin after the infection has subsided and healed. Which answer should the nurse give? * A. There will be no scarring. 8. Cellulitis is often caused by: * D. Streptococcus or Staphylococcus organisms. 9. The nurse is conducting a staff in-service on appearance of childhood skin conditions. Lymphangitis (“streaking”) is frequently seen in which condition? * A. Cellulitis 10. The nurse should expect to assess which causative agent in a child with warts? * D. Virus 11. The nurse should implement which prescribed treatment for a child with warts? * B. Local destruction 12. Herpes zoster is caused by the varicella virus and has an affinity for: * C. posterior root ganglia and posterior horn of the spinal cord. 14. Tinea capitis (ringworm), frequently found in schoolchildren, is caused by a(n): * B. fungus. 15. The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. The nurse should expect that therapeutic management for this child includes: * A. administering oral griseofulvin. 16. Parents tell the nurse that their child keeps scratching the areas where he has poison ivy. The nurse’s response should be based on which knowledge? * D. Scratching the lesions may cause them to become secondarily infected. 17. The nurse is taking care of a child with scabies. Which primary clinical manifestation should the nurse expect to assess with this disease? * C. Pruritus 18. Which is usually the only symptom of pediculosis capitis (head lice)? * A. Itching 19. The nurse is talking to the parents of a child with pediculosis capitis. Which should the nurse include when explaining how to manage pediculosis capitis? * D. “You will need to remove nits with an extra-fine tooth comb or tweezers.” 20. The management of a child who has just been stung by a bee or wasp should include the application of: * A. cool compresses. 21. A father calls the clinic nurse because his 2-year-old child was bitten by a black widow spider. The nurse should advise which to the father? * C. Take child to emergency department. 22. A mother calls the emergency department nurse because her child was stung by a scorpion. The nurse should recommend: * C. keeping the child quiet and coming to the emergency department. 24. The school nurse is conducting a class for school-age children on Lyme disease. Which is characteristic of Lyme disease? * C. Caused by a spirochete that enters the skin through a tick bite 25. The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. This is most likely caused by: * B. Candida albicans. 26. The nurse is teaching a class on preventing diaper rash in newborns to a group of new parents. Which statement made by a parent indicates a correct understanding of the teaching? * B. “If my infant’s buttocks become slightly red, I will expose the skin to air.” 28. Atopic dermatitis (eczema) in the infant is: * D. associated with allergy with a hereditary tendency. 29. Nursing care of the infant with atopic dermatitis focuses on: * C. preventing infection. 30. . Tretinoin (Retin-A) is a topical agent commonly used to treat acne. Nursing considerations with this drug should include: * C. explaining that medication should not be applied until at least 20 to 30 minutes after washing. 31. When is isotretinoin (Accutane) indicated for the treatment of acne during adolescence? * A. The acne has not responded to other treatments. 32. A child experiences frostbite of the fingers after prolonged exposure to the cold. Which intervention should the nurse implement first? * A. Rapid rewarming of the fingers by placing in warm water 33. Which best describes a full-thickness (third-degree) burn? * C. Destruction of all layers of skin evident with extension into subcutaneous tissue 34. A child is admitted with extensive burns. The nurse notes that there are burns on the child’s lips and singed nasal hairs. The nurse should suspect that the child has a(n): * B. inhalation injury. 35. Which explains physiologically the edema formation that occurs with burns? * C. Increased capillary permeability 36. The most immediate threat to life in children with thermal injuries is: * A. shock. 37. After the acute stage and during the healing process, the primary complication from burn injury is: * D. infection. 38. An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. Which is important in her immediate care? * D. Remove her burned clothing and jewelry. 39. A young child has sustained a minor burn to the foot. Which is recommended for treatment of a minor burn? * D. Cleanse the wound with a mild soap and tepid water. 40. A toddler sustains a minor burn on the hand from hot coffee. Which is the first action the nurse should recommend in treating this burn? * B. Hold burned area under cool running water. 41. A parent of a child with major burns asks the nurse why a high-calorie and high-protein diet is prescribed. Which response should the nurse make? * D. The diet will avoid protein breakdown. 47. Which is one of the first signs of overwhelming sepsis in a child with burn injuries? * C. Disorientation 51. A nurse is teaching a parent of an infant about treatment of seborrhea dermatitis (cradle cap). Which should the nurse include in the instructions? * C. Shampoo every day with an antiseborrheic shampoo.