Alteration in skin integrity:skin conditions in childrenShawna Mudd, DNP, CPNP-AC,CRNP-BC
Newborn skin• Largest organ of the body ▫ 4% of body weight in a newborn
Structure of skin as it grows
Assessment of skin in a child• Proper setting ▫ Well lit room ▫ Clothes off• Proper documentation of the lesion ▫ Distribu...
Dermatitis• Broad description of changes that occur in the  skin in response to various stimuli• 4 most common types: ▫   ...
Contact dermatitis• Localized inflammatory reaction ▫ Common irritants include soaps, detergents,   lotions, etc• Nursing ...
Dermatlas.orgDiaper dermatitis (contact) ▫ One of the most common skin   disorders of infancy ▫ Sparing of the inguinal fo...
Also contact dermatitis…
Allergic dermatitis• Delayed hypersensitivity  reaction (repeated exposures  needed)• Common allergens include:  ▫ Nickel,...
Atopic dermatitis (Eczema)         “The itch that rashes”• Affects 17% of infants, children and adolescents• 65% develop s...
Factors affecting atopic dermatitis• External ▫ Dry skin, soaps, fabrics, foods, environmental   antigens, etc• agents act...
Acute atopic dermatitis• Intense itching• Characteristic rash in locations  typical of the disease   ▫ Infants- face, trun...
Dermatlas.org
Dermatlas.orgChronic atopic dermatitis
Nursing education for atopicdermatitis• Skin care ▫ Daily bathing with unscented soap ▫ Topical steroids if prescribed, th...
Common bacterial pediatric skininfectionsImpetigo• Highly contagious• Most common bacterial skin  condition in children• S...
Pediatric abscessesMethycillin resistant staphylococcusaureus (MRSA)• Resistant strain of staph  infection• Historically s...
CA-MRSACauses• Crowded living conditions• Sharing of personal items (towels, razors, sports  equipment, etc)• Frequent ski...
Treatment and nursing education• Incision and drainage• Antibiotics•   Keep wounds covered•   Wash hands•   Bath regularly...
Viral skin infections in children• Can range from benign and self limited  conditions to life threatening• For a number of...
Fifth disease“slapped cheek”
dermatlas.comHerpes simplex virus
Fungal infections• Tinea corporis  ▫ Superficial fungal infection  ▫ Annular plaques  ▫ “worm-like” border      AKA ringw...
Fungal infections• Tinea capitis  ▫ Broken off hair  ▫ Erythema and scaling of    underlying scalp  ▫ Needs treatment with...
Skin injuries in childrenBurns• A leading cause of injury related deaths in  children <9 year of age• Causes  ▫   Inadequa...
Burn types• Thermal ▫ Flames, scalds, contact ▫ 80% of all thermal burns in toddlers are from hot   liquids or grease   Sc...
Other burn types• Chemical• Electrical• Radioactive
Exposure time• Temperature and time to cause a full thickness  burn:150°F (66°C) 2 seconds140°F (60°C) 6 seconds125°F (52°...
Emergency management• 1- Circulation, Airway, Breathing• Followed by: ▫ Injury hx and mechanism ▫ Secondary survey for add...
Treatment of major burns• Focus on ▫   Decreasing burn fluid loss ▫   Preventing infection ▫   Controlling pain ▫   Promot...
Pain management• Opioids. Morphine or Dilaudid, Sometimes  Methadone preferred for action on peripheral nerve  pain. PCA p...
American Burn                                                 Association, 2007Burn center referral• Burn Center Referral ...
Prevention• Hot water heater temperatures should be set at a  maximum of 120 degrees F• Smoke detectorsBUT…….90% of uninte...
Psychosocial issues• Coping skills, support, pain management• Referrals: Nurse, child life specialist, social  work, psych...
Home care/dressing changes• Dressing changes ▫ Pre-medication to prevent pain. ▫ Give realistic choices. ▫ Distraction tec...
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Alteration in skin integrity

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  • Thin-very little sq fat- loses heat quicker, greater difficulty regulating temperature; also increased absorption of harmful chemicals and topical medications; Melanin- amount is low at birth-accounts for lighter skin in newborns of all races
  • Clothes off- this may be problematic in babies and teenagers to prevent cooling or embarrassment- may need to examine in segments
  • Why-bathed in urine and stool and occluded by a diaper (mostly stool)
  • The “contact” part of the dermatitis is the constant wetting and drying of the skin
  • How would you describe this? irregularly shaped, asymmetric, edematous, red, discrete, and confluent papules and plaques
  • red excoriated crusted lichenified scaly patches Comments: This toddler had recurrent flares of severe atopic dermatitis particularly when the weather was cold and dry. Exposed areas including the face and distal extremities were most severely affected.
  • Lichenification—darkened, thickened skin
  • Bathing once or twice daily (depending on the severity of AD) in warm water for 10-15 minutes is recommended to help hydrate and cleanse the skin, assist in the debridement of infected skin, and improve the penetration of topical therapies. Moisturizing cleansers are recommended while highly fragranced soaps should be avoided as they may irritate the skin. After bathing, the patient’s skin should be patted dry with a towel (so it remains slightly wet) and moisturizers and emollients (e.g., petroleum jelly, Eucerin, mineral oil, baby oil) should be applied liberally to help prevent moisture loss and drying of the skin.
  • Disproportionately affects children-in Baltimore in 2002, highest incidence was in children less than 2 years; often mistaken as spider bites
  • Antibiotic use- very important issue with young children- not treating viral infections with antibiotics
  • If they can’t keep wounds covered/maintain hygiene, then no sports participation
  • Early recognition-especially in immunocompromised patients is essential
  • School aged children-parvovirus, slapped cheek erythema, may have reticulated blanching erythema on trunk, fever, arthralgias
  • Common cause of oral lesions in toddlers and school age; red, friable gingiva, fever, irritability; lesions scattered on face and trunk; lesions frequently autoinnoculated onto the hands; clustered red papules, which evolve into vesicles; most is HSV type 1; can disseminate over entire skin surface in certain situations (ie eczema); enters dormancy
  • 10-25% of all burns in children are due to abuse 4 types of burns- thermal (flames/scalds), chemical, electrical and radioactive
  • Chemical-ingesting or touching caustic agents Electrical-exposure to direct or alternating currents in electrical wires, appliances, etc Radioactive- radioactive substances or sunlight
  • Neonate- CRIES- crying, requires O2, increased vital signs, expression, sleeplessness; NIPS Infants/young children- FLACC (faces, legs, activity, cry, consolability) Preschool and school age- Faces scale Older children- Visual analog scale, Adolescent pediatric pain tool Neurocognitive delay- FLACC
  • Alteration in skin integrity

    1. 1. Alteration in skin integrity:skin conditions in childrenShawna Mudd, DNP, CPNP-AC,CRNP-BC
    2. 2. Newborn skin• Largest organ of the body ▫ 4% of body weight in a newborn
    3. 3. Structure of skin as it grows
    4. 4. 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
    5. 5. Dermatitis• Broad description of changes that occur in the skin in response to various stimuli• 4 most common types: ▫ Atopic ▫ Contact ▫ Allergic ▫ Seborrheic
    6. 6. 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
    7. 7. Dermatlas.orgDiaper 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
    8. 8. Also contact dermatitis…
    9. 9. Allergic dermatitis• Delayed hypersensitivity reaction (repeated exposures needed)• Common allergens include: ▫ Nickel, poison ivy, neomycin, bacitracin, latex
    10. 10. 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
    11. 11. Factors affecting atopic dermatitis• External ▫ Dry skin, soaps, fabrics, foods, environmental antigens, etc• agents act together to produce- PRURITIS!
    12. 12. 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)
    13. 13. Dermatlas.org
    14. 14. Dermatlas.orgChronic atopic dermatitis
    15. 15. Nursing education for atopicdermatitis• Skin care ▫ Daily bathing with unscented soap ▫ Topical steroids if prescribed, then ▫ Lubrication, lubrication, lubrication
    16. 16. Common bacterial pediatric skininfectionsImpetigo• Highly contagious• Most common bacterial skin condition in children• Staphylococci or streptococcus, or both• Vesicles that easily rupture forming honey crusted lesions
    17. 17. Pediatric abscessesMethycillin resistant staphylococcusaureus (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
    18. 18. CA-MRSACauses• Crowded living conditions• Sharing of personal items (towels, razors, sports equipment, etc)• Frequent skin to skin activities• Frequent antibiotic use
    19. 19. Treatment and nursing education• Incision and drainage• Antibiotics• Keep wounds covered• Wash hands• Bath regularly• Avoid sharing of hygiene products
    20. 20. 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
    21. 21. Fifth disease“slapped cheek”
    22. 22. dermatlas.comHerpes simplex virus
    23. 23. Fungal infections• Tinea corporis ▫ Superficial fungal infection ▫ Annular plaques ▫ “worm-like” border  AKA ringworm ▫ Respond readily to topical antifungals
    24. 24. Fungal infections• Tinea capitis ▫ Broken off hair ▫ Erythema and scaling of underlying scalp ▫ Needs treatment with oral antifungals
    25. 25. 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)
    26. 26. Burn types• Thermal ▫ Flames, scalds, contact ▫ 80% of all thermal burns in toddlers are from hot liquids or grease Scalds  The most common type of inflicted burn, particularly between the ages of 1-3
    27. 27. Other burn types• Chemical• Electrical• Radioactive
    28. 28. 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
    29. 29. 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
    30. 30. Treatment of major burns• Focus on ▫ Decreasing burn fluid loss ▫ Preventing infection ▫ Controlling pain ▫ Promoting nutrition ▫ Salvaging viable tissue
    31. 31. 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?
    32. 32. American Burn Association, 2007Burn 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
    33. 33. 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
    34. 34. 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.
    35. 35. 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

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