The Child with Altered Skin Integrity Jan Bazner-Chandler CPNP, CNS, MSN, RN
Dec 24, 2015
The Child with Altered Skin Integrity
Jan Bazner-ChandlerCPNP, CNS, MSN, RN
Key Function of Skin Protection – shield from internal injury. Immunity – contains cells that ingest bacteria
and other substances. 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-old. 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
Interventions 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 substances.
Assessment 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
Interventions Resolves over a few weeks when causative
agent is removed For itching and edema: Burrow’s solution,
topical corticosteroids 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 allergens.
Dermatitis
Assessment 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 follicles. Occurrence; 85% of teenager aged 15 to 17
years. More common in females than males.
Assessment 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 shoulders Lesions are red and hyperpigmented
Acne
Interventions Topical medications
OTC preparations Prescription - Topical retinoid preparations Prescription - Topical antibiotics may cause
bacterial resistance Prescription – hormone therapy Prescription - accutane
Pediculosis 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.
Assessment
Symptoms: itching, whitish colored eggs at shaft of hair, redness at site of itching.
Nits
Empty nit case Viable nit
Interventions
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
Scabies• A contagious skin condition caused by the
human skin mite. • Tiny, eight-legged creature burrows within the
skin and penetrate the epidermis and lays eggs
• Allergic reaction occurs• Severe itching
Assessment 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 genitalia
Scabies
Interventions 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
Scabies
Impetigo• 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
Impetigo
Spread Highly contagious skin infection. Most common among children. Spread through physical contact. Clothes, bedding, towels and other objects.
Interventions
•Good general hygiene – wash hands•Wash lesions with soap and water•Topical antibiotic therapy: (Bactroban)• Keflex PO – 2nd generation cephalosporin•New antibacterial: Altabax (2007)
Impetigo / cellulitis
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
Assessment Characteristic reddened or lilac-colored,
swollen skin that pits when pressed with finger.
Borders are indistinct. Warm to touch. Superficial blistering.
Cellulitis
Cellulitis
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
Interventions Prevention: Wear long pants when hiking or playing in
wooded areas 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 resuscitation 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 infection. Delay in growth may follow extensive burns.
Alert The most common cause of unconsciousness
in the flame burn patient is hypoxia due to smoke inhalation.
Look for ash and soot around nares.
Interventions 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 blistering. Sunburn is usually a first-degree burn.
Second Degree Burn Involves the epidermis and part of the
underlying skin layers. 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 areCarefully trimmed.
Gauze with ointment is appliedto burn wound.
Wound Management
Bowden, Dickey, Greenberg textChildren and Their Families
Skin Grafts
Removal of split-thicknessSkin graft with dermatone.
Healed donor site
Compartment Syndrome
Escharotomy / fasciotomy in a severely burned arm.
Burn Wound Covering
Therapy to Prevent Complications
Elasticized garment and“air-plane” splints.
Physical therapy to prevent contracturedeformity.
Keep Kids Safe