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The Child With Altered Skin Integrity by jennyyingdi


									The Child with Altered Skin Integrity

                          Jan Bazner-Chandler
                          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
Developmental Variances
   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
    ineffective barrier.
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
   Diaper dermatitis
   Contact dermatitis
   Atopic dermatitis or eczema
Diaper Dermatitis
Assessment / Interventions
   Identify causative agent
   Cleanse with mild cleaner
   Apply barrier
   Expose to air
   Teach hazards of baby powder
Cradle Cap
   Rash that occurs on the scalp.
   It may cause scaling and redness of the scalp.
   It may progress to other areas.
Cradle Cap
   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
   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
Nickel Allergy
   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
   Pruritis
   Erythema
   Exudate and crusts
   Common sites: cheeks, forehead, scalp, extensor surfaces
    of arms and legs
Multidisciplinary Interventions
    Frequent re-hydration of the skin
        Elidel cream
    To reduce the inflammation: topical corticosteroids
    Control the itching: antihistamine such as Benadryl
    Control infection: topical or oral antibiotics
Acne Vulgaris
   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
   Topical medications
       OTC preparations
       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
    hair shaft.
   Transmission by direct contact with infected person,
    clothing, grooming articles, bedding, or carpeting.
   Symptoms: itching,
    whitish colored eggs at
    shaft of hair, redness at
    site of itching.

       Empty nit case   Viable nit

    Anti-lice shampoo
    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.
Causative agent
   Group A beta-hemolytic streptococcal (GABHS)
   Staph aureus
   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.
Diagnostic Tests
   WBC count
   Blood culture
   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.
   Superficial blistering.
Interdisciplinary Interventions
   Hospitalization if large area involved or facial cellulitis
   IV antibiotics
   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
    the plant.
Poison Ivy
   Prevention:
   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
Systemic Response
Thermal Injuries
   Young children who have been severely burned have a
    higher mortality rate than adults.
   Shorter exposure to chemicals or temperature can injure
    child sooner.
   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
Immediate Interventions
   Admission weight
   Nasogastric tube to maintain gastric decompression
   Foley catheter for urine specimen and monitor output
   Evaluate burn area and determine the extent and depth
    of injury
Flame Burn
Percentage of Areas Affected
Depth of Burns
First Degree Burn
   Involves only the epidermis and part of the underlying
    skin layers.
   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.
Electrical Burn
 Wound Management

Dead skin and debris are
Carefully trimmed.         Gauze with ointment is applied
                           to burn wound.
Wound Management

                   Bowden, Dickey, Greenberg text
                   Children and Their Families
Skin Grafts

                             Healed donor site
Removal of split-thickness
Skin graft with dermatone.
Compartment Syndrome

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

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