Transcript Growth and Development

Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Chapter 31
Caring for the Child with an
Integumentary Condition
Susan Ward
Shelton Hisley
A & P Review: The Skin
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Epidermis
Dermis
Subcutaneous fatty layer
Accessory structures
 Hair, sebaceous
glands
 Exocrine and apocrine
glands
Integumentary Changes as Children
Grow
 See Table 31-1
Skin Lesion
 Primary lesions
 Macules, papules, patches, nodules, tumors,
vesicles, pustules, bullae, and wheals
 Secondary lesions
 Result due to changes from the primary
lesions
 Crusts, scales, lichenifications, scars, keloids,
fissures, erosions, and ulcers
Wounds and Wound Healing
 Typical wounds
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Cuts
Scrapes
Burns
Secondary to surgical intervention
Wounds and Wound Healing
Three Phases of Skin Healing
 Inflammation
 Initial healing response (lasts 2–5 days)
 Preparatory stage for repair
 Proliferation
 Blood flow is reestablished to the site
 Natural debridement occurs (lasts 2–3 weeks)
 New cells cover the site
 Remodeling
 Scar formation (lasts 3 weeks to 2 years)
Skin Infections
Bacterial Infections
Acne Vulgaris
 Signs and symptoms
 Comedo—“whitehead”
 Inflammation
 Nursing care
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Assess the acne
Clean and moisturize with a water-soluble moisturizer
Treat acne with benzoyl peroxide
Administer topical antibiotics and then retinoids
Administer oral antibiotics (Accutane)
Impetigo
 Signs and symptoms
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Found on and around the mouth
Lesions begin as a vesicle or pustule
Honey-colored exudate
Pruritus
 Nursing care
 Prevent spread to others
 Discuss spontaneous resolution or use of topical antibiotic
 Administer oral antibiotics for widespread infection
Cellulitis
 Signs and symptoms
 Edema, erythema, hot to the touch
 Discomfort on palpation
 Malaise, fever, and chills
Nursing care
 Administer benzathine penicillin G
 Note that a severe case requires hospitalization and IV
antibiotics
 Administer steroids (decrease inflammation)
 Provide symptom control (children’s Advil)
Viral Infections
Human Papillomavirus: Warts
 Sign and symptoms
 Rough, raised, and flesh-colored
 Occur anywhere on the body
 Usually there is no pain or itching
 Nursing care
 Usually no intervention needed
 Discuss over-the-counter or prescription medications
that are available
Herpes Simplex (HSV-1 & HSV-2)
 HSV-1 (cold sore)
 HSV-2 (genital herpes)
 Signs and symptoms
 Painful, watery blisters on mucosal surfaces of the skin (lips, mouth, or
genital area)
 Lesions appear after a stimuli (febrile illness, stress, sexual contact,
ultraviolet light)
 Nursing care
 No cure
 Teach family that medications decrease the length of the outbreak
and/or increase the intervals between outbreaks (Acyclovir or Abreva)
Fungal Infections
Cutaneous Candidiasis
 Signs and symptoms
 Mouth—white or gray plaque
 Skin—fine red and slightly raised rash
 Nursing care
 Oral: nystatin (Mycostatin)—give orally after each feeding, two to
three times a day
 Skin: nystatin (Mycostatin), clotrimazole (Lotrimin), miconazole
(Monistat)— apply thin layer with a gloved finger to infected
area, two to three times a day
Ringworm
 Signs and symptoms
 Round, scaly lesions (red or inflamed)
 Bald areas
 Small black dots on scalp or itching
 Nursing care
 Give oral antifungal
 Discuss antifungal shampoo
 Discuss that everyone in the family needs treatment (no sharing
hair brushes or bath towels)
 Provide emotional support and suggest hairstyles
Dermatitis
Contact Dermatitis
 Signs and symptoms
 Skin irritated, inflamed, and pruritic
 Vesicles and bullae may be present
 Nursing care
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Use drying agent (Domeboro)
Provide cool baths
Administer low dose of over-the-counter hydrocortisone
Give oral steroids if more than 10% of body involved
Inform family that a topical anesthetic or a sedative may be needed
for sleeping
Atopic Dermatitis
 Signs and symptoms
 Red, raised rash that is pruritic and painful
 Rash in infants usually presents on head, face, arms, and legs
 Rash in older children usually presents in the folds of arms and legs,
occasionally on eyelids and neck
 Nursing care
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Prevent secondary infection
Provide good hygiene
Follow prescribed treatment protocols
Maintain skin hydration
 Conduct frequent monitoring and rash assessment
Seborrheic Dermatitis
 Signs and symptoms
 Red to pink patches with loose yellow greasy scaling
 Rash found on face, cheekbones, around nostrils,
and behind ears
 Nursing care
 Use antifungal therapy or topical corticosteroids
 Tell family about antiseborrheic shampoos
Cutaneous Skin Reactions
 Signs and Symptoms
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Four types—eruption, itching, swelling, or pustular
The allergic reaction can be mild or severe
Assess for facial swelling (especially lips and tongue)
Check throat with light (do not use a tongue blade)
Check nasal passages for swelling and redness
 Nursing care
 Educate about removing and avoiding allergen
 Give oral antihistamines and topical corticosteroids
 Teach about prevention
Stevens Johnson Syndrome
(Erythema Multiforme)
 Signs and symptoms
 Begins with nonspecific upper respiratory infection
 Bullae often appear in a target-like pattern
 Purulent conjunctivitis and skin lesions that rupture
 Fever, neutropenia, chills, malaise, weakness, and anemia
 Nursing care
 Eliminate the causative agent and treat skin lesions
 Use an air/fluid-filled bed, nutritional support, IV fluids, and pain
management
 Ensure a patent airway
Infestations
Lice (Pediculosis)
 Signs and symptoms
 Infest the body but primarily choose areas that have
longer hair: nape of neck and behind the ears
 Nursing care
 Visually inspect
 See Family Teaching Guidelines—Lice (Pediculosis)
Mite Infestation (Scabies)
 Signs and symptoms
 Rash is red streaked and appears linear from the burrowing
 Intense itching especially at night
 Papules (result of the inflammation)
 Nursing care
 Care is similar to that for pediculosis
 Use scabacide
 Give warm bath and apply cream or lotion (repeat in 1 week)
 Reinforce that all persons in close contact should also be treated
 Use dishwasher for cleaning toys and hair items
 Wash clothes, bedding, and towels in hot water and then place in dryer
Bites and Stings
Insects
 Signs and symptoms
 Mosquito—red papules and edema at site which produces itching, burning,
and minimal discomfort
 Spider—erythema, itching, and pain
 Tick—reddened area of the skin that can be raised and itchy; a general
sick feeling
 Bee, wasp/hornet—pain, erythema, and edema
 Nursing care
 Adhere to directives when out of doors
 Apply bug spray to clothing
 Reinforce that a child who has had a severe reaction should wear a
medical alert bracelet or necklace and carry an EpiPen or EpiPen Junior
Animal Bites
Dog Bites
 Signs and symptoms
 Consider location, redness, swelling, number of puncture wounds, abrasions, and
lacerations
 Assess for cellulitis
 Assess for nerve, muscle, and vascular damage
 Nursing care
 Obtain accurate history
 Clean with soap and water and thoroughly rinse
 Cover wound with topical antibiotic and clean dressing
 Administer tetanus booster if needed
 Assess for signs of infection
 Administer Human Rabies Immune Globulin (HRIG) or Human Diploid Cell Rabies
Vaccine (HDCV) if bite was from an unknown wild or domestic animal
 Contact local health department
Human Bites
 Signs and symptoms
 Redness, swelling, break in the skin, fever, and signs of infection
 Nursing care
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Obtain accurate history
Educate about testing for blood-borne pathogens
Irrigate wound
Apply topical antibiotic and clean dressing
Elevate extremity and monitor for infection
Notify health care provider if there is an infection
Evaluate immunization record
Diseases from Bites
Lyme Disease
 Signs and symptoms
 Ask family if there has been an occurrence of a tick
bite
 Bite found in groin, maxilla, or thigh
 Nursing care
 Remove tick(s)
 Clean area with soap and water (save tick[s])
 Administer oral antibiotics if infection is suspected
Rocky Mountain Spotted Fever
 Signs and symptoms
 Multisystem disease—mild, moderate, or severe
 Onset can be either gradual or sudden
 Sudden—nausea, vomiting, lack of appetite, abdominal pain, malaise, deep
muscle pain, and severe headache
 Red rash that blanches with pressure occurs 3–5 days after the onset of fever
(starts on extremities and moves to trunk)
 Petechial spotted rash occurs 6 or more days after initial symptoms
 Diarrhea and joint pain
 Splenomegaly, hepatomegaly, and jaundice
 Nursing care
 Give tetracycline or doxycycline (except in children younger than 8 years)
 Provide supportive therapy for other symptoms (antipyretics, anti-inflammatory
medications and IV fluids)
Cat Scratch Disease
 Signs and symptoms
 Tender lymphadenopathy
 General malaise and low-grade fever
 Nursing care
 Administer antibiotics
Burns
 Burns
 The third leading cause of death in children
 Boys between the ages of 1 and 4 are twice as likely as girls to be burned
 Average age of pediatric burn patient is 32 months
 Children are at high risk for burns due to environment, behavior, and age
 Types of burns
 Thermal
 Chemical
 Electrical
 Radiation
Burn Categories—Depth
 First degree—superficial
 Erythematous and painful
 Second degree—superficial partial thickness or deep
partial thickness
 Red and painful with blister formation
 Third degree—full thickness
 White, waxy, does not bleed or blanch; skin may be black in color
(eschar)
 Less painful because nerve fibers were destroyed
Classifying Burns
 Surface area
 Calculate total
body surface area
(TBSA)
 Calculations rule of
9’s
Classification of Burn Severity
 Severity
 Mild
 Moderate
 Severe
Nursing Care
 Minor burns—The six “C’s”
 Clothing—remove any clothing
 Cooling—burns need to be cooled immediately
 Cleaning—wash the wound with mild soap and rinse well with
water
 Chemoprophylaxis—apply topical ointment; a tetanus booster is
also given
 Covering—cover the burn with gauze
 Comfort—give pain medication
Nursing Care
 Moderate and major burns
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Assess frequently
Provide fluid resuscitation
Maintain general nutrition
Manage pain
Give meticulous wound care
Provide burn recovery
Assessment
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Burn history
ABCs
Transport to emergency room
Remove clothing
Decontaminate wound
Assess wound for depth, surface area, and severity
Photograph or use video charting
Fluid Resuscitation
 IV fluids—lactated Ringer’s solution
 Monitor urine output
Nutrition
 Caloric requirement for a patient with a burn
covering >30% of the body is 2000 to 2200
calories/day
 Enteral feeding is initiated within 6 hours
Pain Management
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Give pain medications (morphine sulfate)
Give anxiety medications (midazolam)
Provide psychological support
Do not undermedicate adolescents
Use nonpharmacological interventions
(distraction)
Wound Care
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Initially decontaminate wound
Debride wound (tub or enzyme collagenase)
Clean wound
Perform escharotomy
If no eschar or devitalized tissue is present, the wound
can be treated with antibiotic cream and re-dressed
 Apply transparent occlusive dressings so the wound can
be easily assessed for infection
 Use impregnated dressings
Skin Replacement
 Temporary skin replacement
 Biobrane™, Transcyte™
 Permanent skin replacement
 Xenograft, cadaver skin (allograft)
 Integra™, Apligraf™
 Cultured epithelial autograft (CEA),
autografting
Burn Recovery
 Burns are managed by phases of recuperation as well as
the type and severity of burns
 Acute phase—time of initial assault until wound closure
 Second phase—from time of wound closure until scar maturation
 Care involves the family and health care team
 Scar revision may be necessary (re-hospitalization)
 Promote optimal functioning and minimal negative
psychological impact
Hypothermia
 Signs and symptoms
 Based on classifications—mild, moderate, and severe
 Nursing care
 Initiate emergency medical care
 Complete assessment of airway, breathing, and circulation
 Initiate CPR
 Obtain rectal temperature
 Remove all wet and cold clothing, wrap child in warm blankets
 Administer warmed oxygen and IV fluids
 Monitor VS and urine output
 Perform electrocardiogram
 Raise body temperature using forced-air warming systems
Frostbite
 Signs and symptoms
 Red, blue, or waxy skin
 Prickling or painful sensation
 Nursing care
 Care similar to hypothermia
 Place child in warm area, remove wet/cold clothing and replace with warm
clothing
 Re-warm using tap water for ½ hour (do not run warm water directly from the
tap)
 Do not massage area or apply dry heat
 After re-warming, wrap extremity in soft cloth
 Encourage child to rest
 Instruct parents to call health care provider if problems arise
Pressure Ulcers
 Signs and symptoms
 Earliest sign is a reddened area on the skin that does
not disappear within 30 minutes of removing the
cause
 Skin can appear to have an abrasion and look raw or
rubbed
 Stages of pressure ulcer
Nursing Care
 See the Braden Scale (bradenscale.com)
 Carefully inspect skin at least 3 times a day
 Note color of affected area, signs of infection, character of the skin lesion,
wound edges, drainage
 Measure the diameter and determine the depth of the pressure ulcer
 Address anemia (diet high in iron)
 Keep bed clothing straight and wrinkle free
 Use air, water, or gel mattresses and pads to decrease pressure
 Keep skin clean and dry
 Keep child off the affected area
 Apply topical treatments or collodial dressings
 Use preventive measures (move routinely and shift weight)