Transcript File - Gail McIlvain Simpson Teaching Portfolio

Lecture 11 – Unit 3.4
Nursing Care for Health Problems of
Toddlers and Preschool Children
Skin Alterations in Children
Wong
9th edition pp.423-432, 435-445, 1010-1035
8th edition pp 453-480, 1061-1089
Gail McIlvain-Simpson, MSN, PNP-BC
1
2
3
Learning Objectives
At the end of this discussion learners will be able to:
•
•
•
•
Discuss skin alterations & importance in addressing this issue
Discuss nursing assessment and management of skin lesions.
Compare and contrast primary skin lesions.
Discuss 3 common nursing management points regarding
atopic dermatitis.
• Name 2 reasons the incidence of childhood communicable diseases
have significantly declined.
• Discuss 2 teaching points for parents regarding communicable
diseases.
4
Learning Objectives
continued
• Discuss key points and nursing management of the following
diseases: fifth disease, roseola, and scarlet fever.
• Discuss diagnosis, symptoms, nursing management and
treatment of pinworms.
• Describe lead poisoning, its impact on children, nursing
management and treatment.
• Discuss childhood poisonings and nursing interventions for its
prevention.
• Describe diagnosis, treatment and anticipatory guidance for:
impetigo, tinea capitis, pediculosis capitis and Lyme disease
5
Skin Alterations in
Children
• What is key job of skin?
6
Skin Lesions
Etiologic Factors
• Contact with injurious agents, hereditary
factors, external factors; & systemic
diseases
• Highly individualized responses
• Child’s age is an important factor
7
Integument of Infants & Young
Children
•
•
•
•
Epidermis loosely bound to dermis
More susceptible to superficial bacterial infections
More likely to have associated systemic symptoms
Reacts to a primary irritant versus sensitizing antigen
8
Pathophysiology of
Dermatitis
• Accounts for more than half the skin problems in
children
• Inflammatory changes in skin
• Changes reversible
• More permanent issues with chronic problem
9
Integumentary - Nursing
History
–
–
–
–
–
–
–
–
–
Painful, itching, tingling
Restless or irritable
Favor or avoid a body part
New exposure
New food
New medications
Any allergies?
Playmates with similar lesions
Plants, insects, or chemicals
10
Diagnostic Evaluation
• What piece of the nursing process is key ?
11
Adolescent female
» www.vacineinformation.org/photos/variaap002.jpg
» Originally from AAP
12
Nursing Assessment
• Inspect - Describe color, shape, size,
distribution of lesions
• Palpate for temperature, moisture,
elasticity and edema
13
Descriptive Characteristics
•
•
•
•
•
•
•
Erythema
Ecchymosis
Petechiae
Primary lesions
Secondary lesions
Distribution pattern
Configuration and arrangement
14
15
• http://www.vaccineinformation.org/photos/rubecdc002a.jpg
16
Primary Skin Lesions
17
PRIMARY SKIN LESIONS
• Result of different stimuli either internal or external.
www.dermatologyinfo.net/english/chapters/chapter03.htm
• 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.
• Vesicle – elevated, circumscribed, superficial & filled with serous
fluid less than 1 cm in diameter (a small blister)
• Blister - a skin bleb filled with clear fluid
• Pustule – elevated & superficial, filled with purulent fluid (a skin
elevation filled with pus)
• Cyst – elevated, circumscribed papule filled with liquid or semi solid
material
18
Therapeutic Management
•
•
•
•
Prevent further damage
Eliminate cause
Prevent complications
Provide relief
19
Relief of symptoms
• Pruritus management
• Topical therapy
• Systemic Therapy
20
21
Contact Dermatitis
• Inflammatory reaction of the skin to chemical substances (natural or
synthetic)
• Causes a hypersensitivity response or direct irritation
• Initial 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
22
Treatment of Contact
Dermatitis
• Major goal – to prevent further exposure of the skin to
offending substance
• Based on severity
• If exposed cleanse as soon as possible
23
Atopic Dermatitis
Eczema
• Pruritic eczema
• Usually occurs during infancy & is associated with
allergic tendency (atopy)
• 3 Forms based on age & distribution of lesions:
Infantile eczema
Childhood
Pre adolescent & adolescent
24
Atopic Dermatitis
• Diagnosed via combination of history &
morphologic findings
• Cause unknown
• Majority of those affected have eczema, asthma,
food allergies or allergic rhinitis
25
Atopic Dermatitis
Management
• Major goals: hydrate skin, relieve pruritis, reduce
flare-ups, prevent & control secondary infection.
• Avoid skin irritants & overheating
• Administer meds
• Shorten fingernails & toenails
• Enhance skin hydration – apply emollients while
skin is wet
26
Nursing Care Management
• Take history – Atopy in family
Previous involvement
• Controlling pruritus
• Dietary modifications
• Family Support
27
Poison Ivy, Oak, Sumac
28
Skin Disorders related to
Animal Contacts
29
30
Communicable Diseases
• Why has the incidence of childhood
communicable diseases significantly declined?
• Why have serious complications resulting from
such infections been further reduced?
• Why do nurses need to be familiar with infectious
agents?
31
Nursing Process for the Child with
Communicable Disease
•
•
•
•
•
Assessment- signs & symptoms
Diagnosis – ID of disease
Planning- expected patient outcome
Implementation- intervention strategies
Evaluation
32
What to assess if suspicion of
communicable disease?
•
•
•
•
Recent exposure to known case
Prodromal symptoms
Immunization history
History of having the disease
33
Components of
Prevention
Prevent disease
Prevent spread
Prevent complications
34
A child is admitted with an undiagnosed
exanthema – what should be done in this
case?
35
Communicable Disease
•
•
•
•
Know what it looks like
How it acts
What to do
What is the danger?
36
What to know about Infections
or Communicable Diseases?
• Occurs in humans of all ages
• Certain ones occur in specific age or developmental
groups
• Can be transmitted by direct or indirect route
• Can have total systemic involvement or sequelae
• May develop slowly after prolonged incubation period
37
Symptomatic and
Supportive Care
•
•
•
•
•
•
Isolation
Skin care
Antipyretics, analgesics, anti inflammatories
Rest
Hydration/Fluids
Comfort measures
38
Impetigo Contagiosa
(Bacterial)
•
•
•
•
Superficial bacterial infection of skin
Easily spread - very contagious
Staph or strep
Reddish macule,
becomes vesicular
39
Treatment of Impetigo
• Use of Burow solution
• Topical use of bactericidal ointment
• Systemic administration of oral or parenteral antibiotics in
severe or extensive cases
• Tends to heal without scarring
• Common in toddler, preschooler
• May superimpose on eczema
40
Viral Diseases of
Childhood
• Childhood communicable diseases
• Such as fifth disease
41
What is this?
– Healthy child
– www.vaccineinformation.org/photos/variaap015.jpg
– Originally from AAP
42
Fifth Disease
Erythema Infectiosum
• Agent - Human parvovirus B19 (HPV)
• Source- infected persons, mainly school age
• Transmission – Respiratory secretions, blood & blood
products
• Clinical Manifestations - rash in three stages:
• a) “Slapped- cheek” rash on the face
• b) 1 day after rash on face, maculopapular red spots
• c) Rash reappears if skin irritated or traumatized
43
Fifth Disease
(Erythema infectiosum)
•
Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998
Fifth Disease Management
• Complications -may result in fetal death (if mother is
infected during 2nd trimester of pregnancy.
• Aplastic crisis in children with hemolytic disease.
• Self-limited arthritis and arthralgia.
• Nursing care – symptomatic & supportive/isolation of
child not necessary, except hospitalized child
(immunosuppressed or with aplastic crises)
45
Roseola
Exanthema Subitum
• Agent - Human Herpes virus type 6 (HHV-6)
• Source - Possibly acquired from saliva of healthy adult
person, entry via nasal buccal or conjunctival mucosa
• Transmission –year round, no reported contact with
infected individual in most cases (usually limited to
children under 3 years of age but peak age is 6-15 months)
46
Roseola
(Exanthema Subitum)
• Clinical manifestations –
Persistent high fever for 3 to 4 days in a child who
appears well/quick drop in fever to normal with
appearance of rash.
Rose pink macules to maculopapules appearing first on
trunk, then spreading to neck, face & extremities.
Lymphadenopathy , inflamed pharynx, cough
Non pruritic rash fades on pressure so when you press
on the area the rash fades.
47
Roseola (Exanthema Subitum)
•
http://kidshealth.org/parent/infections/skin/roseola.html
48
Roseola - Management
• Treatment: nonspecific
• Nursing care – symptomatic, antipyretics to control fever (can have
febrile seizure) discuss precautions if they are prone to fever.
• Teach parents about antipyretic therapy.
49
Scarlet Fever
• Agent: Group A beta-hemolytic streptococci
• (called scarlatina in the past) diagnosed with a throat
culture/strep test
• Source: Usually from nasopharyngeal secretions of
infected persons and carriers.
• Transmission: direct contact, airborne droplets,
indirectly by contact with contaminated article or
ingestion of contaminated milk or food.
• Period of communicability: 10 days – during incubation
•
period & during clinical illness: during first 2 weeks
•
of carrier phase
50
Scarlet Fever
Abrupt high fever, increased pulse, vomiting, headache, chills, malaise,
halitosis, abdominal pain
Enanthema – tonsils enlarged, edematous & reddened
White strawberry tongue day 1
Red strawberry tongue day 4-5
Exanthema: rash appears within 12 hrs of prodromal signs
• Rash is tiny pinkish-red spots that cover whole body (absent on
face/flushed with circumoral pallor) scarlet spots or blotches,
giving a boiled lobster appearance. progresses to “sunburn with
goose pimples”
•
(feels like rough sandpaper)
•
Sloughing on palms & soles – complete by 2 weeks
51
Scarlet Fever
http://www.dermnetnz.org/dna.strept/scarle
t.html
52
Scarlet Fever –
Management
• Penicillin or oral cephalosporin
• Nursing Care:
Droplet precautions until 24 hours after treatment
initiated
Compliance with antibiotic therapy
Encourage rest and fluids
Measures to decrease discomfort of sore throat
53
54
Tinea Capitis (Fungal)
• Ringworm of scalp
• Scaly circumscribed patches and or patchy
scaling areas of alopecia
• Pruritic
• Person to person or animal to person
transmission
55
Tinea Capitis-Treatment
•
•
•
•
Oral griseofulvin - for weeks or months
Oral ketaconazole
Selenium sulfide shampoos
Topical antifungal agents(clortrimazole)
– inactivates organisms on hair
56
Tinea Capitis - Teaching
•
•
•
•
•
No exchange of anything that touches area
Use own towel
Protective cap at night
Examine pets
Watch public seats with headrests
57
Pinworms - Enterobiasis
• Agent: enterobius vermicularis the most
common helminthic (worms) infection in US
• Transmission: Pinworms are transferred via
fecal oral route. Can also be airborne
• Crowded conditions promote spread
58
Pinworm Life Cycle
•
•
•
•
Eggs ingested or inhaled and hatch in small intestine
Hatch in upper intestine
Mature & migrate through intestine
After mating adult females migrate out anus and lay eggs
• Eggs transferred to mouth by fingers from scratching or
from soiled night clothes, underclothes, bed linen or other
contaminated objects. Can also be inhaled because the
eggs float in air, that why it is so easily transmitted.
• Prone to reinfection
•
59
Pinworm - Symptoms
•
•
•
•
•
•
•
Intense itching of perianal area
General irritability
Restlessness
Poor sleep
Bedwetting
Distractibility
Short attention span
• Perivaginal itching
•
www.biosci.ohio~parasite/enterobius.html
60
Pinworms - Diagnosis
• Tape test
• Direct visualization
with flashlight
www.biosci.ohio~parasite/enterobius.html
61
Pinworms - Treatment
• Medications –
Anti helminthic
– **Mebendazole (Vermox)
– Pyrantel pamoate (Antiminth) Pinrid
– Albendazole
62
Pinworms – Nursing Care
Management
• Identify parasite, eradicate organism & prevent reinfection
• Environmental
– good hand washing
– daily showers
– wash bedding
– clean pajamas
– snug underwear
– fingernails short
63
Pediculosis Capitis
(Parasite)
• Head lice
• Pediculus humanus
capitis
• Common parasite in school
age children
64
65
Pediculosis Capitis
• Lay eggs at junction of a
hair shaft
• Nits hatch in 7-10 days
• Itching is usually the only
symptom
66
Pediculosis Capitis
67
Three Steps to Treatment
1.Application of pediculicidal product
– Permethrin (1%) crème rinse (NIX)
– Pyrethin Piperonyl butoxide Preparations –
RID
– Lindane shampoos - 1% Kwell, Scabene
– FDA warning neurotoxic)
– Malathion 0.5%Ovide
•
2.Manual removal of nit cases
3. Environmental
68
Removal of Nit Cases
– Extra fine-tooth comb
– “nit-picking”
– Examine head daily for 2
weeks
69
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
70
71
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
72
Ixodes Dammini Nymph
• From “Your Dog may be at Risk from Lyme
Disease”, Fort Dodge Laboratories, 1995.
74
Univ. of Chicago – 2006 article
from Infectious Disease Society
of America
• http://www.journals.uchicago.edu/CID/jour
nal/issues/v43n9/40897/40897.html
75
Lyme Disease - Stages
• Stage 1
– Tick bite
– Erythematous papule
– Bull’s eye rash
76
• Erythema Migrans • Bull’s eye rash
Lyme Disease Stages
• Stage 2
– Systemic involvement of neurologic, cardiac
and musculoskeletal systems
• Stage 3
– Musculoskeletal pain
– Arthritis
78
Lyme Disease
• Diagnosis
– Symptoms
– Lab: Elisa, Western Blot, PCR
• Management
– Doxycycline or Amoxicillin
79
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 light colored clothing
• Wear a hat
• Tuck pant legs into socks
• Wear shoes that leave no part of the foot exposed
• No DEET for infants & smaller children
80
Lead Poisoning
• Major preventable environmental health problem (CDC –
1997)
• Irreversible health effects
Brain & nervous system damage
Reduced intelligence
Learning disabilities
81
Lead Poisoning
•
•
•
•
Historical perspective
Lead does not decompose
Cultural perspective
Risk factors
82
Pathophysiology of Lead
Poisoning
• Lead can affect any part of body
• Most concerning – effect on young child’s 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 long term neurocognitive signs
83
Lead Poisoning
Diagnostic Evaluation
• Children rarely have symptoms
• Venous blood specimen
• Lead levels greater than 10mcg/dl (has dropped from
80mcg/dl in 1950’s)
• CDC –recommends targeted screening on basis of each
state’s determination of need
• Universal screening done at ages 1-2 years
84
85
Anticipatory Guidance
• Hazards of lead based paint in older
housing
• Ways to control lead hazards safety
• How to choose safe toys
• Hazards accompanying repainting and
renovation in homes built before 1978
• Other exposure sources
86
Screening
• Universal screening- ages 1 & 2
• Targeting screening- is acceptable when an
area has been determined by existing data
to have less risk
87
Lead Poison Treatment
• Chelation therapy
– Medications
• Succimer
• Ca Na2EDTA
88
Nursing Care Management
• As nurses what is your primary goal?
89
Ingestion of Injurious
Agents
• Significant health
concern
• Majority occur in
children younger than
6 years of age
• Can occur with
medications & many
other substances
90
Most Common
Poisonings
•
•
•
•
•
Cleaning substances
Cosmetics & Personal care products
Plants
Foreign bodies
Pharmaceuticals
91
Poisonings
•
•
•
•
First Priority – Assess the child
Terminate exposure
Identify poison
Prevent poison absorption
92
Principles of Emergency
Treatment
• Advise parents to Call Poison Control Center before
initiating any intervention
• PCC begin treatment at home or take to emergency room
• Treat the child first, not the poison (vital signs, respiratory
or circulatory support)
• Terminate exposure
• Identify the poison
93
Gastric Decontamination
• Remove ingested poison:
Absorbing toxin with activated charcoal
Gastric Lavage
Increase bowel motility (catharsis)
94
Activated Charcoal
• Most commonly used method of gastric
decontamination
• 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
95
Gastric Lavage
• Performed to empty stomach of toxic contents.
• Procedure associated with serious complications:
gastrointestinal perforation, hypoxia, aspiration
• No longer recommended in all 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
96
Antidotes
• Minority of poisons have specific antidotes
• Used to counteract the poison
• Highly effective & should be available in all Emergency
facilities
• Examples – N-acetlcysteine for acetaminophen poisoning,
oxygen for carbon monoxide inhalation, naloxone for
opioid overdose
97
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
98
Poison Prevention
• Ultimate objective – to prevent poisonings
from occurring or
recurring
• Think developmentally
99
Prevention
• Prevent recurrence
• Discuss difficulties of constantly watching
& safeguarding children
• How to identify risk?
100
Poison Prevention
•
•
•
•
•
•
•
•
Store poisons out of children’s 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 1-800-222-1222
Educate children
101
Questions
102