The Child with Altered Skin Integrity

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The Child with Altered Skin Integrity

• Jan Bazner-Chandler
• CPNP, CNS, MSN, RN

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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

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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 neonates dermis is thin and very hydrated,
  thus is at greater risk for fluid loss and serves
  as an ineffective barrier.

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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

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Inflammatory Skin Disorders

• Diaper dermatitis
• Contact dermatitis
• Atopic dermatitis or eczema

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Diaper Dermatitis
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Assessment / Interventions

• Identify causative agent
• Cleanse with mild cleaner
• Apply barrier
• Expose to air
• Teach hazards of baby powder

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Cradle Cap

• Rash that occurs on the scalp.
• It may cause scaling and redness of the scalp.
• It may progress to other areas.

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Cradle Cap
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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.

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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.

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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

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Nickel Allergy
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Interventions

• Resolves over a few weeks when causative agent is
  removed
• For itching and edema Burrows solution, topical
  corticosteroids
• In severe reactions oral corticosteroids

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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.

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Dermatitis
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Assessment

• Pruritis
• Erythema
• Exudate and crusts
• Common sites cheeks, forehead, scalp, extensor
  surfaces of arms and legs

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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

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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.

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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

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Acne

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Interventions

• Topical medications
• OTC preparations
• Prescription - Topical retinoid preparations
• Prescription - Topical antibiotics may cause
  bacterial resistance
• Prescription hormone therapy
• Prescription - accutane

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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.

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Assessment

• Symptoms itching, whitish colored eggs at shaft
  of hair, redness at site of itching.

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Nits
Empty nit case
Viable nit
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Interventions

• Anti-lice shampoo
• Removal of nits
• Washing bedding, towels, anything childs 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

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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

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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

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Scabies
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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

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Scabies
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Impetigo

• The most common skin infection in children.
• Causative agent is carried in the nasal area.
• Bacteria invade the superficial skin.

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Causative agent

• Group A beta-hemolytic streptococcal (GABHS)
• Staph aureus

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Impetigo

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Spread

• Highly contagious skin infection.
• Most common among children.
• Spread through physical contact.
• Clothes, bedding, towels and other objects.

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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)

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Impetigo / cellulitis
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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.

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Diagnostic Tests

• WBC count
• Blood culture
• Culturing organism from lesion aspiration.
• CT scan of head with peri-orbital cellulitis

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Assessment

• Characteristic reddened or lilac-colored, swollen
  skin that pits when pressed with finger.
• Borders are indistinct.
• Warm to touch.
• Superficial blistering.

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Cellulitis
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Cellulitis
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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

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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.

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Poison Ivy
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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

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Systemic Response
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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.

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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

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Burns in Children

• Immature immune system can lead to increased risk
  of infection.
• Delay in growth may follow extensive burns.

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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.

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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

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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

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Flame Burn
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Percentage of Areas Affected
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Depth of Burns
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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.

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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.

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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.

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Electrical Burn
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Wound Management
Dead skin and debris are Carefully trimmed.
Gauze with ointment is applied to burn wound.
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Wound Management
Bowden, Dickey, Greenberg text Children and Their
Families
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Skin Grafts
Healed donor site
Removal of split-thickness Skin graft with
dermatone.
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Compartment Syndrome
Escharotomy / fasciotomy in a severely burned arm.
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Burn Wound Covering
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Therapy to Prevent Complications
Elasticized garment and air-plane splints.
Physical therapy to prevent contracture deformity.
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Keep Kids Safe