alteration in skin integrity

Alteration in skin integrity:skin conditions in childrenShawna Mudd, DNP, CPNP-AC, CRNP-BC

Newborn skin

• Largest organ of the body▫ 4% of body weight in a newborn

Structure of skin as it grows

Assessment of skin in a child

• Proper setting▫ Well lit room▫ Clothes off

• Proper documentation of the lesion▫ Distribution (location of the rash), pattern

(organization and configuration), lesion color

Dermatitis

• Broad description of changes that occur in the skin in response to various stimuli

• 4 most common types:▫ Atopic ▫ Contact ▫ Allergic ▫ Seborrheic

Contact dermatitis

• Localized inflammatory reaction▫ Common irritants include soaps, detergents,

lotions, etc• Nursing education

▫ Mild soap, wash clothes before first wearing▫ Recognizing signs and symptoms of infection

Diaper dermatitis (contact)▫ One of the most common skin

disorders of infancy▫ Sparing of the inguinal folds▫ Treatment –gentle, thorough

cleansing and application of lubricants

▫ May be complicated by candida albicans

Dermatlas.org

Also contact dermatitis…

Allergic dermatitis• Delayed hypersensitivity

reaction (repeated exposures needed)

• Common allergens include:▫ Nickel, poison ivy, neomycin,

bacitracin, latex

Atopic dermatitis (Eczema)“The itch that rashes”

• Affects 17% of infants, children and adolescents• 65% develop symptoms the first year of life

▫ 90% by age 5

Factors affecting atopic dermatitis

• External▫ Dry skin, soaps, fabrics, foods, environmental

antigens, etc• agents act together to produce-

PRURITIS!

Acute atopic dermatitis• Intense itching • Characteristic rash in locations

typical of the disease ▫ Infants- face, trunk,

extremities▫ Childhood- flexural creases,

wrists and ankles▫ Adolescents- flexural creases,

hands, face and neck• Chronic or repeatedly

occurring symptoms • Personal or family history of

atopic disorders (eczema, allergies, asthma)

Dermatlas.org

Chronic atopic dermatitis

Dermatlas.org

Nursing education for atopic dermatitis• Skin care

▫ Daily bathing with unscented soap▫ Topical steroids if prescribed, then▫ Lubrication, lubrication, lubrication

Common bacterial pediatric skin infectionsImpetigo• Highly contagious• Most common bacterial skin

condition in children• Staphylococci or

streptococcus, or both• Vesicles that easily rupture

forming honey crusted lesions

Pediatric abscessesMethycillin resistant staphylococcus aureus (MRSA)

• Resistant strain of staph infection

• Historically seen only in hospitalized patients▫ MRSA now most common

cause of abscesses in all patients

▫ CA-MRSA• Most commonly present as

skin abscesses

CA-MRSACauses• Crowded living conditions• Sharing of personal items (towels, razors, sports

equipment, etc)• Frequent skin to skin activities• Frequent antibiotic use

Treatment and nursing education

• Incision and drainage• Antibiotics

• Keep wounds covered• Wash hands• Bath regularly• Avoid sharing of hygiene products

Viral skin infections in children

• Can range from benign and self limited conditions to life threatening

• For a number of viral illness in children▫ The rash gives the clue to the diagnosis

Fifth disease“slapped cheek”

Herpes simplex virus

dermatlas.com

Fungal infections • Tinea corporis

▫ Superficial fungal infection▫ Annular plaques▫ “worm-like” border

AKA ringworm▫ Respond readily to topical

antifungals

Fungal infections• Tinea capitis

▫ Broken off hair▫ Erythema and scaling of

underlying scalp▫ Needs treatment with oral

antifungals

Skin injuries in childrenBurns• A leading cause of injury related deaths in

children <9 year of age• Causes

▫ Inadequate adult supervision▫ Child inquisitiveness▫ Inability to get away from burning agent▫ Intentional abuse▫ Experimentation/risk taking activities (teens,

young adults)

Burn types

• Thermal▫ Flames, scalds, contact▫ 80% of all thermal burns in toddlers are from hot

liquids or greaseScalds The most common type of inflicted burn,

particularly between the ages of 1-3

Other burn types

• Chemical• Electrical• Radioactive

Exposure time

• Temperature and time to cause a full thickness burn:

150°F (66°C) 2 seconds140°F (60°C) 6 seconds125°F (52°C) 2 minutes120°F (49°C) 10 minutes

** coffee and other hot beverages are often served at temps of 160-180 º

Emergency management

• 1- Circulation, Airway, Breathing• Followed by:

▫ Injury hx and mechanism▫ Secondary survey for additional injuries

Remove all clothing Apply cool, saline soaked gauze - NO ICE- or large

blanket to prevent hypothermia Labs-CBC, CMP, urinalysis (for presence of

myoglobin), CO levels for fire related burns and CXR

Treatment of major burns

• Focus on▫ Decreasing burn fluid loss▫ Preventing infection▫ Controlling pain▫ Promoting nutrition▫ Salvaging viable tissue

Pain management• Opioids. Morphine or Dilaudid, Sometimes

Methadone preferred for action on peripheral nerve pain. PCA preferred for dressing changes.

• Prevent pain, especially for first debridement or dressing change.

• Round the clock medication in addition to pre-medication for dressing changes.

• What pain assessment instrument would you use for patients in each age group, and for child with neurocognitive impairment?

Burn center referral• Burn Center Referral Criteria • * any patient with partial-thickness burns involving more than 10% TBSA• * any patient with burns to the face, hands, feet, genitalia, perineum, or

major joints• * any patient with third-degree burns, regardless of age• * any patient with chemical and/or electrical burns, including injury by

lightning• * any patient with inhalation injury• * any patient with concomitant medical problems that could exacerbate

management, recovery, or mortality• * any patient with burns and concomitant trauma in that the burn injury

presents the greatest risk• * burned children in hospitals without qualified staff or equipment to care

for children• * any patient who will need specialized social, emotional, or long-term

rehabilitation as a result of burn injuries

American Burn Association, 2007

Prevention• Hot water heater temperatures should be set at a

maximum of 120 degrees F• Smoke detectorsBUT…….90% of unintentional scald burns are not tap water

scalds opening microwaves, older children cooking,

NOODLE SOUP

Psychosocial issues

• Coping skills, support, pain management

• Referrals: Nurse, child life specialist, social work, psychiatry, pain team, physical therapy

• Association of body image changes with traumatic event, possible loss of family and home.

Home care/dressing changes

• Dressing changes▫ Pre-medication to prevent pain.▫ Give realistic choices.▫ Distraction techniques.▫ Clean hands. Prevent infection. Monitor for

infection.▫ Do something calming and happy for child

when done.▫ Support family, provide resources