alteration in skin integrity
TRANSCRIPT
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Alteration in skin integrity:skin conditions in childrenShawna Mudd, DNP, CPNP-AC, CRNP-BC
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Newborn skin
• Largest organ of the body▫ 4% of body weight in a newborn
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Structure of skin as it grows
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Assessment of skin in a child
• Proper setting▫ Well lit room▫ Clothes off
• Proper documentation of the lesion▫ Distribution (location of the rash), pattern
(organization and configuration), lesion color
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Dermatitis
• Broad description of changes that occur in the skin in response to various stimuli
• 4 most common types:▫ Atopic ▫ Contact ▫ Allergic ▫ Seborrheic
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Contact dermatitis
• Localized inflammatory reaction▫ Common irritants include soaps, detergents,
lotions, etc• Nursing education
▫ Mild soap, wash clothes before first wearing▫ Recognizing signs and symptoms of infection
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Diaper dermatitis (contact)▫ One of the most common skin
disorders of infancy▫ Sparing of the inguinal folds▫ Treatment –gentle, thorough
cleansing and application of lubricants
▫ May be complicated by candida albicans
Dermatlas.org
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Also contact dermatitis…
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Allergic dermatitis• Delayed hypersensitivity
reaction (repeated exposures needed)
• Common allergens include:▫ Nickel, poison ivy, neomycin,
bacitracin, latex
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Atopic dermatitis (Eczema)“The itch that rashes”
• Affects 17% of infants, children and adolescents• 65% develop symptoms the first year of life
▫ 90% by age 5
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Factors affecting atopic dermatitis
• External▫ Dry skin, soaps, fabrics, foods, environmental
antigens, etc• agents act together to produce-
PRURITIS!
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Acute atopic dermatitis• Intense itching • Characteristic rash in locations
typical of the disease ▫ Infants- face, trunk,
extremities▫ Childhood- flexural creases,
wrists and ankles▫ Adolescents- flexural creases,
hands, face and neck• Chronic or repeatedly
occurring symptoms • Personal or family history of
atopic disorders (eczema, allergies, asthma)
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Dermatlas.org
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Chronic atopic dermatitis
Dermatlas.org
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Nursing education for atopic dermatitis• Skin care
▫ Daily bathing with unscented soap▫ Topical steroids if prescribed, then▫ Lubrication, lubrication, lubrication
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Common bacterial pediatric skin infectionsImpetigo• Highly contagious• Most common bacterial skin
condition in children• Staphylococci or
streptococcus, or both• Vesicles that easily rupture
forming honey crusted lesions
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Pediatric abscessesMethycillin resistant staphylococcus aureus (MRSA)
• Resistant strain of staph infection
• Historically seen only in hospitalized patients▫ MRSA now most common
cause of abscesses in all patients
▫ CA-MRSA• Most commonly present as
skin abscesses
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CA-MRSACauses• Crowded living conditions• Sharing of personal items (towels, razors, sports
equipment, etc)• Frequent skin to skin activities• Frequent antibiotic use
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Treatment and nursing education
• Incision and drainage• Antibiotics
• Keep wounds covered• Wash hands• Bath regularly• Avoid sharing of hygiene products
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Viral skin infections in children
• Can range from benign and self limited conditions to life threatening
• For a number of viral illness in children▫ The rash gives the clue to the diagnosis
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Fifth disease“slapped cheek”
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Herpes simplex virus
dermatlas.com
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Fungal infections • Tinea corporis
▫ Superficial fungal infection▫ Annular plaques▫ “worm-like” border
AKA ringworm▫ Respond readily to topical
antifungals
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Fungal infections• Tinea capitis
▫ Broken off hair▫ Erythema and scaling of
underlying scalp▫ Needs treatment with oral
antifungals
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Skin injuries in childrenBurns• A leading cause of injury related deaths in
children <9 year of age• Causes
▫ Inadequate adult supervision▫ Child inquisitiveness▫ Inability to get away from burning agent▫ Intentional abuse▫ Experimentation/risk taking activities (teens,
young adults)
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Burn types
• Thermal▫ Flames, scalds, contact▫ 80% of all thermal burns in toddlers are from hot
liquids or greaseScalds The most common type of inflicted burn,
particularly between the ages of 1-3
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Other burn types
• Chemical• Electrical• Radioactive
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Exposure time
• Temperature and time to cause a full thickness burn:
150°F (66°C) 2 seconds140°F (60°C) 6 seconds125°F (52°C) 2 minutes120°F (49°C) 10 minutes
** coffee and other hot beverages are often served at temps of 160-180 º
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Emergency management
• 1- Circulation, Airway, Breathing• Followed by:
▫ Injury hx and mechanism▫ Secondary survey for additional injuries
Remove all clothing Apply cool, saline soaked gauze - NO ICE- or large
blanket to prevent hypothermia Labs-CBC, CMP, urinalysis (for presence of
myoglobin), CO levels for fire related burns and CXR
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Treatment of major burns
• Focus on▫ Decreasing burn fluid loss▫ Preventing infection▫ Controlling pain▫ Promoting nutrition▫ Salvaging viable tissue
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Pain management• Opioids. Morphine or Dilaudid, Sometimes
Methadone preferred for action on peripheral nerve pain. PCA preferred for dressing changes.
• Prevent pain, especially for first debridement or dressing change.
• Round the clock medication in addition to pre-medication for dressing changes.
• What pain assessment instrument would you use for patients in each age group, and for child with neurocognitive impairment?
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Burn center referral• Burn Center Referral Criteria • * any patient with partial-thickness burns involving more than 10% TBSA• * any patient with burns to the face, hands, feet, genitalia, perineum, or
major joints• * any patient with third-degree burns, regardless of age• * any patient with chemical and/or electrical burns, including injury by
lightning• * any patient with inhalation injury• * any patient with concomitant medical problems that could exacerbate
management, recovery, or mortality• * any patient with burns and concomitant trauma in that the burn injury
presents the greatest risk• * burned children in hospitals without qualified staff or equipment to care
for children• * any patient who will need specialized social, emotional, or long-term
rehabilitation as a result of burn injuries
American Burn Association, 2007
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Prevention• Hot water heater temperatures should be set at a
maximum of 120 degrees F• Smoke detectorsBUT…….90% of unintentional scald burns are not tap water
scalds opening microwaves, older children cooking,
NOODLE SOUP
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Psychosocial issues
• Coping skills, support, pain management
• Referrals: Nurse, child life specialist, social work, psychiatry, pain team, physical therapy
• Association of body image changes with traumatic event, possible loss of family and home.
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Home care/dressing changes
• Dressing changes▫ Pre-medication to prevent pain.▫ Give realistic choices.▫ Distraction techniques.▫ Clean hands. Prevent infection. Monitor for
infection.▫ Do something calming and happy for child
when done.▫ Support family, provide resources