Integumentary

Integumentary

Lecture 11 Unit 3.4 Nursing Care for Health Problems of Toddlers and Preschool Children Skin Alterations in Children Gail McIlvain-Simpson, MSN, PNPBC 1

Topic Areas Communicable diseases in children, pathology, diagnosis, nursing assessment, and treatment. Screening and treatment for lead poisoning, and poison prevention Skin alterations in children Lyme Disease

2 Communicable Diseases Handouts on Blackboard Communicable Diseases In Early Childhood Integumentary Disorders

3 Communicable Diseases Why has the incidence of childhood communicable diseases significantly declined? Why have serious complications resulting from such infections been

further reduced? As nurses what are two key reasons nurses must be familiar with infectious agents? 4 Nursing Process for the Child with Communicable Disease

Assessment Diagnosis Problem ID Planning Implementation Evaluation

5 What to assess if suspicion of communicable disease?

Recent exposure to known case Prodromal symptoms Immunization history History of having the disease 6 Components of Prevention Prevention of disease & control of

spread to others. Primary prevention Prevent complications 7 A child is admitted with an undiagnosed exanthema what should be done in this case?

8 Chicken Pox Varicella Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998

Chicken Pox - Varicella Adolescent female www.vacineinformation.org/photos/variaap002. jpg Originally from AAP 10 Chicken Pox - Varicella

4 year old, day 5 www.vacinneinformation.org/photos/varicdc006a.jpg Originally from CDC 11 Shingles or Herpes Zoster

Healthy child www.vaccineinformation.org/photos/variaap015.jpg Originally from AAP 12 Diptheria Corynebacterium diphtheriae

http://www.vaccineinformation.org/photos/diphiac001.jpg 13 Fifth Disease (Erythema infectiosum) Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998

Roseola (Exanthema Subitum) http://kidshealth.org/parent/infections/skin/ roseola.html 15

Rubeola (Measles) Koplik Spots http://lebonheur.adam.com/pages/ency/articleImage.asp?file=2558.jpg&lang=en 16 Rubeola (Measles)

17 Mumps http://www.vaccineinformation.org/photos/mumpcdc001a.jpg 18 Mumps

http://www.immunize.org/catg.d/iped1861/img0016.ht m 19 Pertussis http://www.vaccineinformation.org/photos/pertaap002.jpg

20 Pertussis (Whooping Cough) http://www.vaccineinformation.org/photos/pertiac001.jpg 21

Pertussis Deaths Whooping cough deaths on rise in infants Each year there are an increase of 5000-7000 cases of whooping cough each year and has been steadily rising each year. 22

German Measles cdn-write.demandstudios.com/.../70/7/238 23 Rubella http://www.vaccineinformation.org/photos/ rubecdc002a.jpg

24 Congenital rubella syndrome http://www.vaccineinformation.org/photos/rubeiac003.jpg 25

26 Scarlet Fever http://www.dermnetnz.org/dna.strept/scarlet.html 27

White and Red Strawberry Tongue http://www.dental.mu.edu/oralpath/grad/mucutaneous/sld075.htm 28 Enterobiasus (Pinworms)

http://ww.dpd.cdc.gov/dpdx/HTML/Enterobiasis.htm 29 Pinworm Life Cycle Eggs Ingested Hatch in small Intestine Attaches to colon wall Matures in 2-3 weeks

Lives in rectum or colon Lays eggs on perianal skin Scratch perianal area 30 Pinworm Symptoms

Intense itching of perianal area No systemic reaction Unexplained irritability Restlessness

Poor sleep Short attention span Perivaginal itching www.biosci.ohio~parasite/enterobius.html 31 Pinworms Diagnosis Tape test Direct visualization

with flashlight www.biosci.ohio~parasite/enterobius.html 32 Pinworms Treatment Medications - Anthelmintic Mebendazole (Vermox) Pyrantel pamoate (Antiminth)

33 Pinworms - Treatment Environmental good hand washing daily showers wash bedding clean pajamas snug underwear fingernails short

34 Lead Poisoning Is a major preventable environmental health problem (CDC 1997) Brain & nervous system damage Irreversible health effects Reduced intelligence

Learning disabilities 35 Pathophysiology Lead can affect any part of body Most concerning effect on young childs developing brain & nervous system Lead disrupts biochemical processes & may have direct effect on release of neurotransmitters, causing

alterations in blood brain barrier & may interfere with regulation of synaptic activity Mild to moderate levels of lead can affect cognition & behavior in children Can cause longterm neurocognitive signs 36 Lead Poisoning Diagnostic Evaluation

Children rarely have symptoms Venous blood specimen Lead levels greater than 10mcg/dl (has dropped from 80mcg/dl in 1950s) CDC recommends targeted screening on basis of each states determination of need Universal screening done at ages 1-2 years 37

Lead Poisoning Historical perspective Lead does not decompose Cultural perspective Risk factors

38 Lead Exposure Lead based paint is the most common source Ingestion or Inhalation See Box 14-6 Wong 8th edition page 476

39 Other sources of Lead Lead crystal decanters and glasses Pre-1978 tableware and some imported tableware Jewelry in vending machines from Jan 2002 to August 2004 Toys

Chewing on household objects that contain lead: Brass keys, jewelry, fishing sinkers, pre1970 furniture, pre-1996 mini-blinds 40 Federal Disclosure Regulations Must disclose Known Lead-Based Paint & LBP Hazards when sell or lease house

Many pre-1978 homes have lead based paint 41 Lead Poison Treatment Chelation therapy Medications Succimer Ca Na2EDT

42 Nursing Care Management As nurses what is your primary goal? ??????? ???????

43 Anticipatory Guidance Hazards of lead based paints in older homes Ways to control led hazard safety Hazards accompanying repainteing & renovations of home to houses built before 1978 Additional exposures (ie dinnerware

from other countries) 44 Ingestion of Injurious Agents 45 American Association of Poison Control Center

Poison Exposure? Call Your Poison Center at 1-800-222-1222. Free, professional, 24/7/365 Dont guess, be sure http://www.1-800-222-1222.info/jin gles/engver1.asp 46 Poison Prevention

Post Poison Control Number (CDC web site) 47 Poisonings Significant health concern Majority occur in children younger than 6 years of age

Can occur with medications & many other substances Children poisoned by ingestion due to their developmental characteristics 48 Most Common Poisonings

Cleaning substances Pain relievers Cosmetics

Personal care products Plants Cough and cold preparations Improper use causing poisoning 49 Diffenbachia (Dumb Cane)

50 Philodendron 51 Poison Prevention Store poisons out of childrens reach Keep products in the original containers Never call medicine candy

Place safety latches on all drawers and cabinets containing poisonous products Read labels before using a cleanser or other chemical product Post poison Control Center number near the telephone.

52 Poison Control Literature 53 Poisonings

First Priority is the Child Terminate Exposure to toxic substance Determine poison Call Poison Control Center before intervention 54 Gastric

Decontamination Remove ingested poison: Absorbing toxin with activated charcoal Gastric Lavage Increase bowel motility (catharsis) 55 Activated Charcoal

Most commonly used method of gastric decompression odorless, tasteless, fine black powder give within 1 hour of poison mix with water, saline or flavoring to make slurry give through straw or NG tube Potential complications aspiration, constipation, intestinal obstruction

56 Gastric Lavage When child admitted to ER Performed to empty stomach of toxic contents. Procedure associated with serious complications: gastrointestinal perforation, hypoxia, aspiration_ No longer recommended in cases of

ingestion To use in cases who present within 1 hr of ingestion, decreased GI motility, sustained release medication ingestion, or massive amounts of life threatening poison 57 Cathartics Enhances excretion of charcoal-poison

complex If charcoal mixed with sorbital - not necessary 20%Magnesium sulfate 250 mg/kg/dose Repeat q 1-2 h until stooling begin Use is controversial particularly in pediatrics 58 Antidotes Minority of poisons have specific antidotes to

counteract the poison Highly effective & should be available in all Emergency facilities Examples N-acetlcysteine for acetaminophen poisoning, oxygen for carbon monoxide inhalation, naloxoned for opioid overdose, romazicon for benzodiazipines (valium) overdose , antivenom for certain poisonous bites 59

Selected Poisonings in Children Corrosives Hydrocarbons Plants

Acetaminophen 60 Web sites for Additional Information on Plant Poisonings Guide to Poisonous and Toxic Plants -

http://chppm-www.apgea.army.mil/ento/plant.htm Most Commonly Ingested Plants http://www.kidsource.com/kidsource/content/ingeste d.html 61 Stages of Acetaminophen

Poisoning Initial Period (2 to 4 hours after ingestion) Nausea, vomiting, sweating, pallor Latent period (24 to 36 hours) patient improves Hepatic involvement (may last up to 7 days) pain in right upper quadrant jaundice, confusion, stupor

coagulation abnormalities Recovery patients who do not die in hepatic stage gradually recover 62 Prevention Prevent recurrence Discuss difficulties of constantly

watching & safeguarding children How to identify risk? 63 Skin Alterations in Children Review A & P of skin Know primary skin lesions

64 Primary Skin Lesions 65

PRIMARY SKIN LESIONS The primary skin lesions are the original lesions that appear as a result of different stimuli either internal or external. The different primary skin lesions seen on examination are: Macule - a circumscribed flat area of different color from the surrounding skin. Macules may become raised due to edema, where it

is then called maculopapules Papule - a raised circumscribed elevation of skin. Nodule or tubercle - a solid elevation of the skin, larger than a papule. Plaque - a raised thick portion of the skin, which has well defined edges with a flat or rough surface. Erythema (redness of the skin surface) -This is the commonest primary skin lesions, which appears in most skin diseases. Erythema is due to dilatation of dermal blood vessels and edema. Blister - a skin bleb filled with clear fluid Vesicle - a small blister.

Bulla - a large vesicle Pustule - a skin elevation filled with pus Cyst - a cavity filled with fluid. Nevus - hereditary skin disorders due to deficiency or excess of the normal constituents of the skin and usually defined as nevi. 66 Skin Lesions Etiologic Factors

Contact with injurious agents Highly individualized responses Childs age is an important factor 67 Integument of Infants & Young Children Epidermis loosely bound to dermis More susceptible to superficial bacterial

infections More likely to have associated systemic symptoms React to a primary irritant versus sensitizing antigen 68 Pathophysiology of Dermatitis

More than half the problems in children dermatitis Inflammatory changes in skin grossly & microscopically similar but different in course &causation Changes reversible More permanent issues with chronic problem 69

Integumentary Nursing History Painful, itching, tingling Restless or irritable Favor or avoid a body part Access to chemicals, been in the woods, around a woodpile Eaten a new food Taking any medications Have any allergies Playmates with similar lesions

70 Nursing Assessment Describe color, shape, size, distribution of lesions Palpate for temperature, moisture, elasticity and edema 72

Therapeutic Management Eliminate cause Prevent further damage Prevent complications

Provide relief 73 Pruritis Mittens Fingernails short, well-trimmed Antipruritic medications Benadryl, Atarax 74

Topical Management Glucocorticoids anti-inflammatory effects Topical therapy cool compresses Burrows solution Oatmeal baths (Aveeno)

75 Impetigo contagiosa Superficial infection of skin Easily spread - very contagious

Staph or strep Reddish macule, becomes vesicular 76 Impetigo

Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998 Treatment of Impetigo Topical antibiotics Oral or parenteral antibiotics in severe or extensive cases Tends to heal without scarring Common in toddler, preschooler May superimpose on eczema

78 Scalded Skin Syndrome Staph aureus infection Macular erythema with sandpaper texture of involved skin Large bullae Systemic antibiotics

Burow solution 79 Scalded Skin Syndrome Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill,

New York, 1998 Tinea Capitis (Fungal) Ringworm of scalp Fungal infection Scaly circumscribed patches and or patchy scaling areas of alopecia Pruritic Person to person or animal to person

transmission 81 Tinea Capitis http://dermatlas.med.jhmi.edu/derm/result.cfm?Diagnosis=108

82 Tinea Capitis Lissauer, Tom and Clayden, Graham, Illustrated Textbook of Paediatrics, Mosby, Philadelphia, 1997, p. 263 Tinea Capitis

Oral griseofulvin - for weeks or months Selenium sulfide shampoos Topical antifungal agents inactivates organisms on hair 84 Teaching No exchange of anything that

touches area Use own towel Protective cap at night Examine pets Watch public seats with headrests 85 Pediculosis Capitis Head lice

Pediculus humanus capitis Common parasite in school age children 86 87 Pediculosis Capitis

88 Pediculosis Capitis Lay eggs at junction of a hair shaft Nits hatch in 7-10 days Itching is usually the only symptom 89

Nit Case under Microscope Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998 Empty & Live Nit Case

CDC Fact sheet Head Lice Infestation 92 93 Pediculosis capitis Symptoms

Pruritic Diagnosis 94 Three Steps to Treatment Application of pediculicidal product Permethrin (1%) crme rinse

Pyrethin Preparations RID Lindane shampoos - 1% Kwell, Scabene Malathion 0.5%Ovide Manual removal of nit cases Environmental 95 Application of

Pediculocidal Product Do not administer after warm bath or shower Must remain on scalp and hair for several minutes Keep off rest of body 96 Removal of Nit Cases

Soak hair in vinegar solution Extra fine-tooth comb nit-picking Examine head daily for 2 weeks 97 Lice combs 98

Environmental Teaching Anyone can get them Can be transmitted on personal items Wash clothing and linens in hot water Dry clothing in hot dryer Seal non-washable items in plastic bags for 14 days Soak combs in lice-killing products for 1 hour or in boiling water for 10 minutes

Vacuum car seats, furniture, stuffed animals 99

100 Lyme Disease Recognized in 1975

Most common tick borne disease in US Spirochete - Borrelia burgdorferi Deer tick - Ixodes Dammini in northeast Host - white tailed deer and white footed mice 101 Distribution of Lyme Disease

102 103 Ixodes dammini nymph From Your Dog may be at Risk from Lyme Disease, Fort Dodge Laboratories, 1995.

105 Lyme Disease Carrier ID Fort Dodge Laboratories, 1995 106 Univ. of Chicago 2006

article from Infectious Disease Society of America http://www.journals.uchicago.edu/ CID/journal/issues/ v43n9/40897/40897.html 107 Lyme Disease Stages Stage 1

Yick bite Erythematous papule Bulls eye rash 108 Erythema Migrans Bulls eye rash Erythema migrans

www.acponline.org/shell/patient/diagnosis.htm cgi/printhappy.pl/lyme 110 Lyme Disease Stages

Stage 2 systemic involvement of neurologic, cardiac and musculoskeletal systems Stage 3 Musculoskeletal pain Arthritis 111

Lyme arthritis Lyme Disease Diagnosis By symptoms Elisa, Western Blot, PCR Management Doxycycline or Amoxicillin

113 Teaching Prevention & Education avoid areas where deer are frequently seen walk in the center of trails wear long pants and long-sleeved shirts that fit tightly at the ankles

and wrists wear a hat tuck pant legs into socks wear shoes that leave no part of the foot exposed 114 Lyme Disease Prevention

Wear light colored clothing Carefully examine for ticks No DEET - insect repellent - for infants and small children www.cdc.gov/ncidod/ticktips2005 115 Steven-Johnson Syndrome

Erythema multiforme exudativum lesions of skin and mucous membranes Hypersensitivity reaction to certain drugs Erythematous papular rash on any cutaneous surface 116 Nursing

Protective isolation Monitor IV Maintain fluid and electrolyte balance Liquid diet Viscous lidocaine Meticulous mouth care Administer Antibiotics

Artificial tears 117 Scabies Sarcoptes Scabiei - Parasitic mite 118 Scabies

Lissauer, Tom and Clayden, Graham, Illustrated Textbook of Paediatrics, Mosby, Philadelphia, 1997, p. 264 Scabies

Burrows Intense pruritis - esp. at night Maculopapular lesions Intertriginous areas 120 Management

5% Permethrin (Elimite) 1% Gamma benzene hexaxhloride (Lindane) Soothing ointments or lotions 121 Contact Dermatitis Inflammatory reaction of the skin to chemical substances (natural or synthetic)

Causes a hypersensitivity response or direct irritationInitial reaction in exposed area Sharp delineation between inflamed & normal skin (faint erythema to massive bullae) Itching is constant primary irritant or sensitizing agent Infants contact dermatitis occurs on convex surface of diaper area Other agents plants (poison ivy), animal irritants (fur), metal etc

122 Treatment of Contact Dermatitis Major goal to prevent further exposure of the skin to offending substance Otherwise based on severity Following exposure cleanse as soon as possible Prevention avoiding contact

123 Atopic Dermatitis Eczema Descriptive category of Dermatologic diseases Pruritic eczema Usually occurs during infancy & is associated with allergic tendancy 3 Forms based on age & distribution of

lesions: Infantile eczema Childhood Preadolewscent & adolescent, 124 Atopic Dermatitis Diagnosed via combination of history & morphologic findings

Cause unknown Majority of those affected have eczema, asthma, food allergies or allergic rhinitis 125 Atopic Dermatitis Management Major goals: hydrate the skin, relieve pruritis,

reduce flare-ups, prevent & control secondary infection. Avoid skin irritants & overheating Administer medications 126 Nursing Care Management Take history atopy in family History of previous involvement

Fingernails & toenails shortened 127 The END 128

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