Lecture 11 – Unit 3.4

Lecture 11 – Unit 3.4

Nursing Care for Health Problems of Toddlers and Preschool

Children Skin Alterations in Children

Gail McIlvain-Simpson, MSN, PNP-BC

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Topic Areas• Communicable diseases in

children, pathology, diagnosis, nursing assessment, and treatment.

• Screening and treatment for lead poisoning, and poison prevention

• Skin alterations in children • Lyme Disease •

• .

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Communicable Diseases

• Handouts on Blackboard– Communicable Diseases In Early

Childhood– Integumentary Disorders

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Communicable Diseases

• Why has the incidence of childhood communicable diseases significantly declined?

• Why have serious complications resulting from such infections been further reduced?

• As nurses what are two key reasons nurses must be familiar with infectious agents?

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Nursing Process for the Child with Communicable

Disease• Assessment• Diagnosis – Problem ID• Planning• Implementation• Evaluation

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What to assess if suspicion of communicable disease?

• Recent exposure to known case• Prodromal symptoms• Immunization history• History of having the disease

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Components of Prevention

Prevention of disease & control of spread to others.

• Primary prevention• Prevent complications

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A child is admitted with an undiagnosed exanthema – what

should be done in this case?

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Chicken Pox Varicella

• Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998

Chicken Pox - Varicella

Adolescent female» www.vacineinformation.org/photos/variaap002.

jpg» Originally from AAP

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Chicken Pox - Varicella

4 year old, day 5» www.vacinneinformation.org/photos/varicdc006a.jpg» Originally from CDC

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Shingles or Herpes Zoster

– Healthy child– www.vaccineinformation.org/photos/variaap015.jpg– Originally from AAP

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DiptheriaCorynebacterium

diphtheriae

• http://www.vaccineinformation.org/photos/diphiac001.jpg

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Fifth Disease (Erythema infectiosum)

• Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998

Roseola (Exanthema Subitum)

• http://kidshealth.org/parent/infections/skin/roseola.html

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Rubeola (Measles)

Koplik Spots

• http://lebonheur.adam.com/pages/ency/articleImage.asp?file=2558.jpg&lang=en

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Rubeola (Measles)

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Mumps

• http://www.vaccineinformation.org/photos/mumpcdc001a.jpg

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Mumps

• http://www.immunize.org/catg.d/iped1861/img0016.htm

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Pertussis

– http://www.vaccineinformation.org/photos/pertaap002.jpg

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Pertussis (Whooping Cough)

• http://www.vaccineinformation.org/photos/pertiac001.jpg

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Pertussis Deaths

• “Whooping cough deaths on rise in infants”

• Each year there are an increase of 5000-7000 cases of whooping cough each year and has been steadily rising each year.

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German Measles cdn-write.demandstudios.com/.../70/7/238

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Rubella

• http://www.vaccineinformation.org/photos/rubecdc002a.jpg 24

Congenital rubella syndrome

• http://www.vaccineinformation.org/photos/rubeiac003.jpg

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Scarlet Fever

• http://www.dermnetnz.org/dna.strept/scarlet.html

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White and Red Strawberry Tongue

• http://www.dental.mu.edu/oralpath/grad/mucutaneous/sld075.htm

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Enterobiasus (Pinworms)

• http://ww.dpd.cdc.gov/dpdx/HTML/Enterobiasis.htm

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Pinworm Life Cycle

Eggs IngestedHatch in small IntestineAttaches to colon wallMatures in 2-3 weeksLives in rectum or colonLays eggs on perianal skinScratch perianal area

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Pinworm - Symptoms

• Intense itching of perianal area• No systemic reaction• Unexplained irritability• Restlessness• Poor sleep• Short attention span• Perivaginal itching

• www.biosci.ohio~parasite/enterobius.html

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Pinworms - Diagnosis

• Tape test• Direct visualization with flashlight

www.biosci.ohio~parasite/enterobius.html

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Pinworms - Treatment

• Medications - Anthelmintic– Mebendazole (Vermox)– Pyrantel pamoate (Antiminth)

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Pinworms - Treatment

• Environmental– good hand washing– daily showers– wash bedding– clean pajamas– snug underwear– fingernails short

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Lead Poisoning

• Is a major preventable environmental health problem (CDC – 1997)

• Brain & nervous system damage• Irreversible health effects• Reduced intelligence• Learning disabilities

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Pathophysiology• Lead can affect any part of body• Most concerning – effect on young child’s developing

brain & nervous system• Lead disrupts biochemical processes & may have direct

effect on release of neurotransmitters, causing alterations in blood brain barrier & may interfere with regulation of synaptic activity

• Mild to moderate levels of lead – can affect cognition & behavior in children

• Can cause longterm neurocognitive signs

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Lead PoisoningDiagnostic Evaluation

• Children rarely have symptoms • Venous blood specimen • Lead levels greater than 10mcg/dl (has

dropped from 80mcg/dl in 1950’s)• CDC –recommends targeted screening on

basis of each state’s determination of need• Universal screening done at ages 1-2 years

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Lead Poisoning• Historical perspective• Lead does not decompose• Cultural perspective• Risk factors

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Lead Exposure

• Lead based paint is the most common source

• Ingestion or Inhalation• See Box 14-6 Wong 8th edition

page 476

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Other sources of Lead

• Lead crystal decanters and glasses • Pre-1978 tableware and some imported

tableware• Jewelry in vending machines from Jan 2002 to

August 2004• Toys• Chewing on household objects that contain

lead: Brass keys, jewelry, fishing sinkers, pre-1970 furniture, pre-1996 mini-blinds

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Federal Disclosure Regulations

• Must disclose Known Lead-Based Paint & LBP Hazards when sell or lease house

• Many pre-1978 homes have lead based paint

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Lead Poison Treatment• Chelation therapy

– Medications• Succimer• Ca Na2EDT

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Nursing Care Management

• As nurses what is your primary goal?

• ???????• ???????

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Anticipatory Guidance• Hazards of lead based paints in older

homes• Ways to control led hazard safety• Hazards accompanying repainteing &

renovations of home to houses built before 1978

• Additional exposures (ie dinnerware from other countries)

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Ingestion of Injurious Agents

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American Association of Poison Control Center

• Poison Exposure?Call Your Poison Centerat 1-800-222-1222.

•  Free, professional, 24/7/365Don’t guess, be sure…

• http://www.1-800-222-1222.info/jingles/engver1.asp

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Poison Prevention

• Post Poison Control Number

(CDC web site)

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Poisonings• Significant health concern• Majority occur in children younger than

6 years of age• Can occur with medications & many

other substances• Children poisoned by ingestion due to

their developmental characteristics

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Most Common Poisonings

• Cleaning substances• Pain relievers• Cosmetics• Personal care products• Plants• Cough and cold preparations• Improper use causing

poisoning49

Diffenbachia (Dumb Cane)

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Philodendron

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Poison Prevention

• Store poisons out of children’s reach• Keep products in the original containers• Never call medicine “candy”• Place safety latches on all drawers and

cabinets containing poisonous products• Read labels before using a cleanser or

other chemical product• Post poison Control Center number near• the telephone.

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Poison Control Literature

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Poisonings

• First Priority is the Child• Terminate Exposure to toxic

substance• Determine poison• Call Poison Control Center before

intervention

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Gastric Decontamination

• Remove ingested poison: Absorbing toxin with activated charcoal Gastric Lavage Increase bowel motility (catharsis)

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Activated Charcoal• Most commonly used method of gastric

decompression• odorless, tasteless, fine black powder• give within 1 hour of poison• mix with water, saline or flavoring to make

slurry• give through straw or NG tube• Potential complications – aspiration,

constipation, intestinal obstruction

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Gastric Lavage• When child admitted to ER• Performed to empty stomach of toxic

contents. • Procedure associated with serious

complications: gastrointestinal perforation, hypoxia, aspiration_

• No longer recommended in cases of ingestion

• To use in cases who present within 1 hr of ingestion, decreased GI motility, sustained release medication ingestion, or massive amounts of life threatening poison 57

Cathartics

• Enhances excretion of charcoal-poison complex

• If charcoal mixed with sorbital - not necessary• 20%Magnesium sulfate 250 mg/kg/dose• Repeat q 1-2 h until stooling begin• Use is controversial particularly in pediatrics

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Antidotes• Minority of poisons have specific antidotes to

counteract the poison• Highly effective & should be available in all

Emergency facilities• Examples – N-acetlcysteine for

acetaminophen poisoning, oxygen for carbon monoxide inhalation, naloxoned for opioid overdose, romazicon for benzodiazipines (valium) overdose , antivenom for certain poisonous bites

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Selected Poisonings in Children -

• Corrosives• Hydrocarbons• Plants• Acetaminophen

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Web sites for Additional Information on Plant

Poisonings

• Guide to Poisonous and Toxic Plants - http://chppm-www.apgea.army.mil/ento/plant.htm

• Most Commonly Ingested Plants -

http://www.kidsource.com/kidsource/content/ingested.html

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Stages of Acetaminophen

Poisoning• Initial Period (2 to 4 hours after ingestion)

– Nausea, vomiting, sweating, pallor

• Latent period (24 to 36 hours)– patient improves

• Hepatic involvement (may last up to 7 days)– pain in right upper quadrant– jaundice, confusion, stupor– coagulation abnormalities

• Recovery– patients who do not die in hepatic stage gradually– recover

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Prevention• Prevent recurrence• Discuss difficulties of constantly

watching & safeguarding children• How to identify risk?

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Skin Alterations in Children

• Review A & P of skin• Know primary skin lesions

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Primary Skin Lesions

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www.dermatologyinfo.net/english/chapters/chapter03.htm

• PRIMARY SKIN LESIONS• The primary skin lesions are the original lesions that appear as a

result of different stimuli either internal or external. The different primary skin lesions seen on examination are:

• Macule - a circumscribed flat area of different color from the surrounding skin. Macules may become raised due to edema, where it is then called maculopapules

• Papule - a raised circumscribed elevation of skin.• Nodule or tubercle - a solid elevation of the skin, larger than a papule.• Plaque - a raised thick portion of the skin, which has well defined

edges with a flat or rough surface.• Erythema (redness of the skin surface) -This is the commonest

primary skin lesions, which appears in most skin diseases. Erythema is due to dilatation of dermal blood vessels and edema.

• Blister - a skin bleb filled with clear fluid• Vesicle - a small blister.• Bulla - a large vesicle• Pustule - a skin elevation filled with pus• Cyst - a cavity filled with fluid.• Nevus - hereditary skin disorders due to deficiency or excess of the

normal constituents of the skin and usually defined as nevi.•   66

Skin LesionsEtiologic Factors

• Contact with injurious agents• Highly individualized responses• Child’s age is an important factor

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Integument of Infants & Young Children

• Epidermis loosely bound to dermis• More susceptible to superficial bacterial

infections• More likely to have associated systemic

symptoms• React to a primary irritant versus sensitizing

antigen

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Pathophysiology of Dermatitis

• More than half the problems in children – dermatitis

• Inflammatory changes in skin – grossly & microscopically similar but different in course &causation

• Changes reversible • More permanent issues with chronic

problem

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Integumentary - Nursing History

– Painful, itching, tingling– Restless or irritable– Favor or avoid a body part– Access to chemicals, been in the

woods, around a woodpile– Eaten a new food– Taking any medications– Have any allergies– Playmates with similar lesions

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Nursing Assessment

• Describe color, shape, size, distribution of lesions

• Palpate for temperature, moisture, elasticity and edema

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Therapeutic Management

• Eliminate cause• Prevent further damage• Prevent complications• Provide relief

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Pruritis

• Mittens• Fingernails short, well-trimmed• Antipruritic medications -

Benadryl, Atarax

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Topical Management

• Glucocorticoids– anti-inflammatory effects

• Topical therapy– cool compresses– Burrow’s solution– Oatmeal baths (Aveeno)

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Impetigo contagiosa

• Superficial infection of skin• Easily spread - very contagious• Staph or strep• Reddish macule, becomes

vesicular

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Impetigo

• Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998

Treatment of Impetigo

• Topical antibiotics• Oral or parenteral antibiotics in

severe or extensive cases• Tends to heal without scarring• Common in toddler, preschooler• May superimpose on eczema

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Scalded Skin Syndrome

• Staph aureus infection• Macular erythema with sandpaper

texture of involved skin• Large bullae• Systemic antibiotics• Burow solution

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Scalded Skin Syndrome

• Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998

Tinea Capitis (Fungal)

• Ringworm of scalp• Fungal infection• Scaly circumscribed patches and or

patchy scaling areas of alopecia• Pruritic• Person to person or animal to person

transmission

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Tinea Capitis

• http://dermatlas.med.jhmi.edu/derm/result.cfm?Diagnosis=108

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Tinea Capitis

• Lissauer, Tom and Clayden, Graham, Illustrated Textbook of Paediatrics, Mosby, Philadelphia, 1997, p. 263

Tinea Capitis

• Oral griseofulvin - for weeks or months

• Selenium sulfide shampoos• Topical antifungal agents

– inactivates organisms on hair

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Teaching

• No exchange of anything that touches area

• Use own towel • Protective cap at night• Examine pets• Watch public seats with headrests

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Pediculosis Capitis

• Head lice • Pediculus humanus capitisCommon parasite in school age children

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Pediculosis Capitis

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Pediculosis Capitis

• Lay eggs at junction of a hair shaft• Nits hatch in 7-10 days• Itching is usually the only

symptom

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Nit Case under Microscope

• Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998

Empty & Live Nit Case

CDC Fact sheet – Head Lice

Infestation

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Pediculosis capitis• Symptoms

– Pruritic• Diagnosis

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Three Steps to Treatment

• Application of pediculicidal product– Permethrin (1%) crème rinse– Pyrethin Preparations – RID– Lindane shampoos - 1% Kwell,

Scabene– Malathion 0.5%Ovide

• Manual removal of nit cases• Environmental

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Application of Pediculocidal Product– Do not administer after warm bath or

shower– Must remain on scalp and hair for

several minutes– Keep off rest of body

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Removal of Nit Cases

– Soak hair in vinegar solution– Extra fine-tooth comb– “nit-picking”– Examine head daily for 2 weeks

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Lice combs

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Environmental - Teaching

– Anyone can get them– Can be transmitted on personal items– Wash clothing and linens in hot water– Dry clothing in hot dryer– Seal non-washable items in plastic bags for

14 days– Soak combs in lice-killing products for 1

hour or in boiling water for 10 minutes– Vacuum car seats, furniture, stuffed

animals

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Lyme Disease

• Recognized in 1975• Most common tick borne disease in US• Spirochete - Borrelia burgdorferi• Deer tick - Ixodes Dammini in northeast• Host - white tailed deer and white

footed mice

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Distribution of Lyme Disease

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Ixodes dammini nymph

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• From “Your Dog may be at Risk from Lyme Disease”, Fort Dodge Laboratories, 1995.

Lyme Disease Carrier IDFort Dodge Laboratories,

1995

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Univ. of Chicago – 2006 article from Infectious

Disease Society of America• http://

www.journals.uchicago.edu/CID/journal/issues/v43n9/40897/40897.html

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Lyme Disease - Stages

• Stage 1– Yick bite– Erythematous papule– Bull’s eye rash

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• Erythema Migrans -• Bull’s eye rash

Erythema migrans

• www.acponline.org/shell- cgi/printhappy.pl/lyme/patient/diagnosis.htm

• 110

Lyme Disease Stages

• Stage 2– systemic involvement of neurologic,

cardiac and musculoskeletal systems• Stage 3

– Musculoskeletal pain– Arthritis

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Lyme arthritis

Lyme Disease

• Diagnosis– By symptoms– Elisa, Western Blot, PCR

• Management– Doxycycline or Amoxicillin

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Teaching - Prevention &

Education• avoid areas where deer are

frequently seen• walk in the center of trails• wear long pants and long-sleeved

shirts that fit tightly at the ankles and wrists

• wear a hat• tuck pant legs into socks• wear shoes that leave no part of

the foot exposed 114

Lyme Disease Prevention

• Wear light colored clothing• Carefully examine for ticks• No DEET - insect repellent - for

infants and small children

• www.cdc.gov/ncidod/ticktips2005

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Steven-Johnson Syndrome

• Erythema multiforme exudativum• lesions of skin and mucous membranes• Hypersensitivity reaction to certain

drugs• Erythematous papular rash on any

cutaneous surface

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Nursing

• Protective isolation• Monitor IV• Maintain fluid and electrolyte

balance• Liquid diet• Viscous lidocaine• Meticulous mouth care• Administer Antibiotics• Artificial tears

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Scabies

• Sarcoptes Scabiei - Parasitic mite

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Scabies

• Lissauer, Tom and Clayden, Graham, Illustrated Textbook of Paediatrics, Mosby, Philadelphia, 1997, p. 264

Scabies

• Burrows• Intense pruritis - esp. at night• Maculopapular lesions• Intertriginous areas

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Management

• 5% Permethrin (Elimite)• 1% Gamma benzene hexaxhloride

(Lindane)• Soothing ointments or lotions

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Contact Dermatitis• Inflammatory reaction of the skin to chemical

substances (natural or synthetic)• Causes a hypersensitivity response or direct

irritationInitial reaction in exposed area• Sharp delineation between inflamed & normal skin

(faint erythema to massive bullae)• Itching is constant primary irritant or sensitizing agent• Infants – contact dermatitis occurs on convex surface of

diaper area• Other agents – plants (poison ivy), animal irritants (fur),

metal etc

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Treatment of Contact Dermatitis

• Major goal – to prevent further exposure of the skin to offending substance

• Otherwise based on severity• Following exposure cleanse as soon as

possible• Prevention – avoiding contact

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Atopic DermatitisEczema

• Descriptive category of Dermatologic diseases• Pruritic eczema• Usually occurs during infancy & is associated

with allergic tendancy• 3 Forms based on age & distribution of

lesions:• Infantile eczema• Childhood• Preadolewscent & adolescent,

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Atopic Dermatitis• Diagnosed via combination of

history & morphologic findings• Cause unknown• Majority of those affected have

eczema, asthma, food allergies or allergic rhinitis

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Atopic Dermatitis Management

• Major goals: hydrate the skin, relieve pruritis, reduce flare-ups, prevent & control secondary

infection.• Avoid skin irritants & overheating• Administer medications

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Nursing Care Management• Take history – atopy in family• History of previous involvement• Fingernails & toenails shortened

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The END

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