The Child with Altered Skin Integrity
CPNP, CNS, MSN, RN
Key Function of Skin
Protection – shield from internal injury.
Immunity – contains cells that ingest bacteria and other
Thermoregulation – heat regulation through sweating,
shivering, and subcutaneous insulation
Communication / sensation / regeneration
Sweat glands function by the time the child is 3-years-
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
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
Atopic dermatitis or eczema
Assessment / Interventions
Identify causative agent
Cleanse with mild cleaner
Expose to air
Teach hazards of baby powder
Rash that occurs on the scalp.
It may cause scaling and redness of the scalp.
It may progress to other areas.
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 is an inflammatory skin condition
involving a cutaneous response occurring when skin is
exposed to certain external natural or systemic
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
Resolves over a few weeks when causative agent is
For itching and edema: Burrow’s solution, topical
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
Exudate and crusts
Common sites: cheeks, forehead, scalp, extensor surfaces
of arms and legs
Frequent re-hydration of the skin
To reduce the inflammation: topical corticosteroids
Control the itching: antihistamine such as Benadryl
Control infection: topical or oral antibiotics
A chronic, inflammatory process of the pilosebaceous
Occurrence; 85% of teenager aged 15 to 17 years.
More common in females than males.
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
Lesions are red and hyperpigmented
Prescription - Topical retinoid preparations
Prescription - Topical antibiotics may cause bacterial
Prescription – hormone therapy
Prescription - accutane
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
Transmission by direct contact with infected person,
clothing, grooming articles, bedding, or carpeting.
whitish colored eggs at
shaft of hair, redness at
site of itching.
Empty nit case Viable nit
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
• A contagious skin condition caused by the human skin
• Tiny, eight-legged creature burrows within the skin and
penetrate the epidermis and lays eggs
• Allergic reaction occurs
• Severe itching
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
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
• The most common skin infection in children.
• Causative agent is carried in the nasal area.
• Bacteria invade the superficial skin.
Group A beta-hemolytic streptococcal (GABHS)
Highly contagious skin infection.
Most common among children.
Spread through physical contact.
Clothes, bedding, towels and other objects.
•Good general hygiene – wash hands
•Wash lesions with soap and water
•Topical antibiotic therapy:
• Keflex PO – 2nd generation
•New antibacterial: Altabax (2007)
Impetigo / 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.
Culturing organism from lesion aspiration.
CT scan of head with peri-orbital cellulitis
Characteristic reddened or lilac-colored, swollen skin that
pits when pressed with finger.
Borders are indistinct.
Warm to touch.
Hospitalization if large area involved or facial cellulitis
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
Wear long pants when hiking or playing in wooded
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
Young children who have been severely burned have a
higher mortality rate than adults.
Shorter exposure to chemicals or temperature can injure
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
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
Delay in growth may follow extensive burns.
The most common cause of unconsciousness in the flame
burn patient is hypoxia due to smoke inhalation.
Look for ash and soot around nares.
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
Nasogastric tube to maintain gastric decompression
Foley catheter for urine specimen and monitor output
Evaluate burn area and determine the extent and depth
Percentage of Areas Affected
Depth of Burns
First Degree Burn
Involves only the epidermis and part of the underlying
Area is hot, red, and painful, but without swelling or
Sunburn is usually a first-degree burn.
Second Degree Burn
Involves the epidermis and part of the underlying skin
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.
Dead skin and debris are
Carefully trimmed. Gauze with ointment is applied
to burn wound.
Bowden, Dickey, Greenberg text
Children and Their Families
Healed donor site
Removal of split-thickness
Skin graft with dermatone.
Escharotomy / fasciotomy in a severely burned arm.
Burn Wound Covering
Therapy to Prevent Complications
Elasticized garment and Physical therapy to prevent contracture
“air-plane” splints. deformity.
Keep Kids Safe