Integumentary Integumentary StressorsStressors
Increased Risks Caused by Increased Risks Caused by Pediatric Differences in the SkinPediatric Differences in the Skin
Skin is thinner, more susceptible to Skin is thinner, more susceptible to irritants and infectionirritants and infection
Ratio of skin surface area to body volume Ratio of skin surface area to body volume is greater, allowing greater absorptionis greater, allowing greater absorption
More susceptible to bacterial invasionMore susceptible to bacterial invasion Less ability to regulate temperatureLess ability to regulate temperature
Common Pediatric Skin Common Pediatric Skin Diseases/DisordersDiseases/Disorders
ImpetigoImpetigo CellulitisCellulitis CandidiasisCandidiasis PediculosisPediculosis ScabiesScabies DermatitisDermatitis TineaTinea
ImpetigoImpetigo
Most common bacterial skin Most common bacterial skin infection of childhoodinfection of childhood
Highly contagious Highly contagious S. aureus S. aureus Incubation 7-10 daysIncubation 7-10 days Lesions resolve in 12-14 days Lesions resolve in 12-14 days
with treatment with treatment
Clinical ManifestationsClinical Manifestations
Lesions appear Lesions appear around mouth and around mouth and nosenose
Small vesicles initially Small vesicles initially filled with serous fluid filled with serous fluid then become pustularthen become pustular
Vesicles (bullae) Vesicles (bullae) rupture rapidlyrupture rapidly
Honey-colored fluid Honey-colored fluid from lesions becomes from lesions becomes crusted mildly pruriticcrusted mildly pruritic
Nursing Care for a Child Nursing Care for a Child with Impetigowith Impetigo
The child can spread impetigo merely by The child can spread impetigo merely by touching another part of the skin after touching another part of the skin after scratching infected areasscratching infected areas
Wash the child’s hands frequently with Wash the child’s hands frequently with antibacterial soapantibacterial soap
Maintain good hand washing Maintain good hand washing Distract child from touching lesionsDistract child from touching lesions
Nursing ManagementNursing Managementof Lesionsof Lesions
Gently wash lesions 3 times a day with Gently wash lesions 3 times a day with warm, soapy washcloth, crusts warm, soapy washcloth, crusts carefully removedcarefully removed
Apply topical antibiotic(Bactroban or Apply topical antibiotic(Bactroban or Bacitracin)Bacitracin)
Oral antibiotics effective against Oral antibiotics effective against staphylococcal and streptococcal staphylococcal and streptococcal organisms organisms
Severe infections treated with IV Severe infections treated with IV antibioticsantibiotics
Parental EducationParental Education Good hand washing to prevent spreadGood hand washing to prevent spread Cut child’s nails short, wash hands Cut child’s nails short, wash hands
often with anti-bacterial soap often with anti-bacterial soap Do not share towels, utensils with Do not share towels, utensils with
infected childinfected child Out of school or daycare for 24h once Out of school or daycare for 24h once
antibiotics startedantibiotics started Finish full course of antibioticsFinish full course of antibiotics
CandidiasisCandidiasis(thrush)(thrush)
Superficial fungal infection Superficial fungal infection (Candida albicans) of the oral (Candida albicans) of the oral mucous membranesmucous membranes
May also present in diaper May also present in diaper areaarea
EtiologyEtiology NeonateNeonate can be acquired during delivery if can be acquired during delivery if
mother has infection mother has infection Older infantOlder infant ImmunosupressionImmunosupression during antibiotic therapy,during antibiotic therapy, exposure to mother’s infected breastsexposure to mother’s infected breasts unclean bottles and pacifiersunclean bottles and pacifiers
Oral ThrushOral Thrush
White, curd-like White, curd-like plaques on plaques on tongue, gums, tongue, gums, buccal mucosa buccal mucosa (not easily (not easily removed)removed)
Diaper DermatitisDiaper Dermatitis
Diaper area Diaper area lesions are bright lesions are bright redred
Sharp BorderSharp Border Satellite lesionsSatellite lesions
ManagementManagement
Nystatin oral suspension Nystatin oral suspension applied to mucous membranesapplied to mucous membranes
Diaper area treated with topical Diaper area treated with topical Nystatin creamNystatin cream
Parental EducationParental Education Good hand washingGood hand washing Thoroughly wash pacifier, bottlesThoroughly wash pacifier, bottles ApplyApply oral Nystatin after feeding to oral Nystatin after feeding to
promote increased absorptionpromote increased absorption Breasts should be treated with Breasts should be treated with
Nystatin cream if breast feedingNystatin cream if breast feeding Watch for spread to GI tract: fever, Watch for spread to GI tract: fever,
refusal to eatrefusal to eat
Pediculosis CapitisPediculosis CapitisHead liceHead lice
Lice can live on a human host for Lice can live on a human host for 48 hours48 hours
Nits (eggs) capable of hatching for Nits (eggs) capable of hatching for 10 days10 days
Transmitted by direct contact with Transmitted by direct contact with infected persons or indirect infected persons or indirect contact with contaminated objectscontact with contaminated objects
Clinical ManifestationsClinical Manifestations
Nits are visible on Nits are visible on hair shafts close hair shafts close to scalp usually to scalp usually behind ears and behind ears and at nape of neck, at nape of neck, difficult to difficult to remove remove
Intense pruritisIntense pruritis
Management involves three Management involves three goalsgoals
1.1. Kill the active lice Kill the active lice Kwell, Nix, RidKwell, Nix, Rid
Kwell is neurotoxicKwell is neurotoxic Use over the counter pyrethrins (RID) safe Use over the counter pyrethrins (RID) safe
and effectiveand effective Must treat hair again 1 to 2 weeks after Must treat hair again 1 to 2 weeks after
initial treatment initial treatment Over the counter pediculicide (NIX) kills Over the counter pediculicide (NIX) kills
head lice and eggs with 1 treatment, has head lice and eggs with 1 treatment, has residual activity for 10 daysresidual activity for 10 days
Management involves three Management involves three goalsgoals
2.2. Remove nitsRemove nits Inspect child’s hair with fine-toothed comb Inspect child’s hair with fine-toothed comb
Comb nits out when hair is wet (apply ½ vinegar Comb nits out when hair is wet (apply ½ vinegar ½ water mixture prior to combing)½ water mixture prior to combing)
3.3. Prevent spread or recurrencePrevent spread or recurrence Treat environmental objects Treat environmental objects Examine and treat family membersExamine and treat family members Vacuum carpets Vacuum carpets Check child for reinfestation 7 to 10 days after Check child for reinfestation 7 to 10 days after
treatmenttreatment Wash all bedding, hats in hot water and high dryer Wash all bedding, hats in hot water and high dryer
settingsetting Notify school if reoccursNotify school if reoccurs
Atopic Dermatitis (eczema)Atopic Dermatitis (eczema)
Chronic superficial inflammatory skin Chronic superficial inflammatory skin disorderdisorder
Affects children usually by age 5 yrsAffects children usually by age 5 yrs Children usually also have allergies Children usually also have allergies 75% will develop asthma75% will develop asthma
Atopic Dermatitis (eczema)Atopic Dermatitis (eczema)
Infant: Infant: erythematous areas erythematous areas of oozing and of oozing and crusting on cheeks, crusting on cheeks, forehead, scalp, forehead, scalp, flexor surfaces of flexor surfaces of arms and legsarms and legs
Papulovesicular Papulovesicular rash and scaly red rash and scaly red plaques become plaques become excoriatedexcoriated
Atopic Dermatitis (eczema)Atopic Dermatitis (eczema)
Childhood: skin Childhood: skin appears scaly with appears scaly with dry skindry skin
Can be exacerbated Can be exacerbated by sweating, contact by sweating, contact with irritating with irritating fabrics, emotional fabrics, emotional upsetupset
ManagementManagement Control pruritisControl pruritis Bathe with lukewarm water, mild, non-Bathe with lukewarm water, mild, non-
perfumed soapperfumed soap Applying moisturizer while skin is wetApplying moisturizer while skin is wet Anti-inflammatory corticosteroids creams for Anti-inflammatory corticosteroids creams for
inflamed areas inflamed areas Topical immunosuppresants may be used for Topical immunosuppresants may be used for
longer periods of time than topical steroidslonger periods of time than topical steroids Identification and avoidance of allergenic Identification and avoidance of allergenic
foodsfoods
Parental EducationParental Education Skin hydrationSkin hydration Support of uncomfortable, irritable child Support of uncomfortable, irritable child Mild detergents and soapMild detergents and soap Don’t bundle child Don’t bundle child Avoid sun exposureAvoid sun exposure Humidifier during winter monthsHumidifier during winter months Turn undergarments inside outTurn undergarments inside out Fingernails clean and shortFingernails clean and short
Common Types of Tinea Common Types of Tinea InfectionInfection
Tinea capitis (scalp)Tinea capitis (scalp) Tinea cruris (groin, buttocks, and scrotum)Tinea cruris (groin, buttocks, and scrotum) Tinea corporis (trunk, face, extremities)Tinea corporis (trunk, face, extremities) Tinea pedis (feet)Tinea pedis (feet)
Tinea CapitisTinea Capitis
Erythema papular Erythema papular rash of scalprash of scalp
Patches of alopeciaPatches of alopecia Treated with topical Treated with topical
and oral antifungalsand oral antifungals
Tinea CorporisTinea Corporis
Single circular 1” Single circular 1” scaly plaquesscaly plaques
Erythema to pale Erythema to pale pink/whitepink/white
Topical antifungals, Topical antifungals, continue to treat one continue to treat one week after rash goneweek after rash gone
Tinea CruisTinea Cruis
Warm moist Warm moist environment environment promotes fungal promotes fungal growthgrowth
Common in Common in adolescent male adolescent male
Topical antifungal Topical antifungal Loose clothingLoose clothing
Tinea PedisTinea Pedis
Sweaty feet promotes Sweaty feet promotes growthgrowth
Barefoot in common Barefoot in common wet areas wet areas (pools,lockeroom)(pools,lockeroom)
Topical antifungalTopical antifungal Fresh socks, toss old Fresh socks, toss old
shoesshoes
CellulitisCellulitis Bacterial infection of Bacterial infection of
skinskin Infected area will be Infected area will be
edetamous, edetamous, erythematous, very erythematous, very tender, warm-hottender, warm-hot
May have dischargeMay have discharge Usually associated Usually associated
with elevated WBCwith elevated WBC Can progress into Can progress into
bacterimabacterima Aggressive antibioticsAggressive antibiotics
ScabiesScabies
Mite infection-burrow under skinMite infection-burrow under skin Female mite burrows under skin and lays Female mite burrows under skin and lays
egg egg hatch in 3-5 days and cause severe hatch in 3-5 days and cause severe
intense itchingintense itching Secondary infections (impetigo, cellulitis) Secondary infections (impetigo, cellulitis)
commoncommon
Clinical ManifestationsClinical Manifestations
Intense, severe Intense, severe pruritis esp. at nightpruritis esp. at night
Papular-vesicluar Papular-vesicluar rash mainly in wrists, rash mainly in wrists, fingers, elbows, axilla fingers, elbows, axilla and groinand groin
May see a faint May see a faint burrow patternburrow pattern
ManagementManagement
ElimiteElimite Kwell can be used over 2 years of age but Kwell can be used over 2 years of age but
not preferrednot preferred Family members even if asymptomatic Family members even if asymptomatic
and day time contacts should be treatedand day time contacts should be treated Wash all bedding, clothing in hot water Wash all bedding, clothing in hot water
similar to that for pediculosissimilar to that for pediculosis
Case StudyCase Study
You are a school nurse. A 7-year-old boy You are a school nurse. A 7-year-old boy has what looks like impetigo on his right has what looks like impetigo on his right forearm. You call the mother at work at forearm. You call the mother at work at 10:00 am and ask her to come 10:00 am and ask her to come immediately to pick up her son and seek immediately to pick up her son and seek medical attention.medical attention.
What did you see that made you suspect What did you see that made you suspect impetigo?impetigo?
Why should the child not be sent home on Why should the child not be sent home on the bus with a note for the mother?the bus with a note for the mother?
How will the mother be expected to care for How will the mother be expected to care for her son at home?her son at home?
What are the primary goals in treating What are the primary goals in treating impetigo?impetigo?
When do you expect the child to return to When do you expect the child to return to school?school?
The MD has recommended frequent baths for The MD has recommended frequent baths for hydration for a child with eczema. Following hydration for a child with eczema. Following each bath, the nurse should:each bath, the nurse should:
a.a. Apply a light coating of emollient to the child’s Apply a light coating of emollient to the child’s skin while still wetskin while still wet
b.b. Dry the skin thoroughly and apply baby Dry the skin thoroughly and apply baby powderpowder
c.c. Dry the skin thoroughly and leave it exposed Dry the skin thoroughly and leave it exposed to airto air
d.d. Apply a dilute solution of 1 part hydrogen Apply a dilute solution of 1 part hydrogen peroxide mixed with 9 parts normal salineperoxide mixed with 9 parts normal saline
Which procedure, performed by patients of an Which procedure, performed by patients of an infant with eczema would lead the nurse to infant with eczema would lead the nurse to realize that additional health teaching is realize that additional health teaching is necessary?necessary?
a.a. Frequent colloid bathsFrequent colloid baths
b.b. Topical steroid to affected areasTopical steroid to affected areas
c.c. Avoidance of wool clothingAvoidance of wool clothing
d.d. Application of alcohol to crusted areaApplication of alcohol to crusted area
A preschooler has head lice and must have her A preschooler has head lice and must have her head shampooed with a pediculicide that must head shampooed with a pediculicide that must remain on the scalp and hair for several remain on the scalp and hair for several minutes. How could the nurse best gain this minutes. How could the nurse best gain this child’s cooperation during the necessary child’s cooperation during the necessary treatment?treatment?
a.a. Offer the child a reward for good behaviorOffer the child a reward for good behaviorb.b. Inform the child that her parents will be notified Inform the child that her parents will be notified
if she fails to cooperateif she fails to cooperatec.c. Allow the child to apply the shampoosAllow the child to apply the shampoosd.d. Make a game of the treatment “Beauty Parlor”Make a game of the treatment “Beauty Parlor”
The nurse is providing home care instructions for The nurse is providing home care instructions for a family with a toddler diagnosed with lice, the a family with a toddler diagnosed with lice, the nurse includes which of the following nurse includes which of the following instructions in the teaching plan? (select all instructions in the teaching plan? (select all that apply)that apply)
a.a. Immerse combs and brushes in boiling water for 30-Immerse combs and brushes in boiling water for 30-minutesminutes
b.b. Vacuum floor and furnitureVacuum floor and furniturec.c. Have mother use a bright light and magnifying glass to Have mother use a bright light and magnifying glass to
examine the child’s headexamine the child’s headd.d. Launder the child’s bedding and clothing in hot water Launder the child’s bedding and clothing in hot water
with detergent and dry in a hot dryer for 20 minuteswith detergent and dry in a hot dryer for 20 minutese.e. Teach children to not share combs, brushes and hatsTeach children to not share combs, brushes and hats
Permethrin 5% (Elimite) is prescribed for a 10-Permethrin 5% (Elimite) is prescribed for a 10-year-old child diagnosed with scabies. What year-old child diagnosed with scabies. What instructions should the nurse provide for the instructions should the nurse provide for the mother?mother?
a.a. Apply the lotion liberally from neck to toeApply the lotion liberally from neck to toe
b.b. Wrap the child in a clean sheet after treatmentWrap the child in a clean sheet after treatment
c.c. Leave the lotion on for 10 minutes then rinseLeave the lotion on for 10 minutes then rinse
d.d. Apply the lotion only to the child’s scalpApply the lotion only to the child’s scalp
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