Lecture 11 – Unit 3.4Lecture 11 – Unit 3.4Nursing 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, 1061-1089Gail McIlvain-Simpson, MSN, PNP-BC

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Learning ObjectivesAt 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.

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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

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Skin Alterations in Children

• What is key job of skin?

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Skin LesionsEtiologic Factors

• Contact with injurious agents, hereditary factors, external factors; & systemic diseases

• Highly individualized responses• Child’s age is an important factor

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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

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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

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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

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Diagnostic Evaluation• What piece of the nursing process is key ?

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Adolescent female» www.vacineinformation.org/photos/variaap002.jpg» Originally from AAP

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Nursing Assessment

• Inspect - Describe color, shape, size, distribution of lesions

• Palpate for temperature, moisture, elasticity and edema

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Descriptive Characteristics

• Erythema• Ecchymosis• Petechiae• Primary lesions• Secondary lesions• Distribution pattern• Configuration and arrangement

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• http://www.vaccineinformation.org/photos/rubecdc002a.jpg16

Primary Skin Lesions

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www.dermatologyinfo.net/english/chapters/chapter03.htm

PRIMARY SKIN LESIONS• Result of different stimuli either internal or external.

• 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

 

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Therapeutic Management

• Prevent further damage• Eliminate cause• Prevent complications• Provide relief

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Relief of symptoms• Pruritus management• Topical therapy• Systemic Therapy

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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

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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

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Atopic DermatitisEczema

• 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

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Atopic Dermatitis• Diagnosed via combination of history &

morphologic findings• Cause unknown• Majority of those affected have eczema, asthma,

food allergies or allergic rhinitis

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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

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Nursing Care Management

• Take history – Atopy in family

Previous involvement• Controlling pruritus• Dietary modifications• Family Support

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Poison Ivy, Oak, Sumac

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Skin Disorders related to Animal Contacts

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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?

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Nursing Process for the Child with Communicable Disease

• Assessment- signs & symptoms• Diagnosis – ID of disease• Planning- expected patient outcome• Implementation- intervention strategies• Evaluation

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What to assess if suspicion of communicable disease?

• Recent exposure to known case• Prodromal symptoms• Immunization history• History of having the disease

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Components of Prevention

Prevent disease

Prevent spread

Prevent complications

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A child is admitted with an undiagnosed exanthema – what should be done in this

case?

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Communicable Disease

• Know what it looks like• How it acts• What to do• What is the danger?

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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

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Symptomatic and Supportive Care

• Isolation• Skin care• Antipyretics, analgesics, anti inflammatories• Rest• Hydration/Fluids• Comfort measures

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Impetigo Contagiosa(Bacterial)

• Superficial bacterial infection of skin• Easily spread - very contagious• Staph or strep• Reddish macule,

becomes vesicular

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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

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Viral Diseases of Childhood

• Childhood communicable diseases• Such as fifth disease

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What is this?

– Healthy child– www.vaccineinformation.org/photos/variaap015.jpg– Originally from AAP

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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

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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)

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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)

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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.

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Roseola (Exanthema Subitum)

• http://kidshealth.org/parent/infections/skin/roseola.html

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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.

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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

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Scarlet FeverAbrupt 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

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

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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

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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

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Tinea Capitis-Treatment

• Oral griseofulvin - for weeks or months• Oral ketaconazole• Selenium sulfide shampoos• Topical antifungal agents(clortrimazole)

– inactivates organisms on hair

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Tinea Capitis - Teaching

• No exchange of anything that touches area• Use own towel • Protective cap at night• Examine pets• Watch public seats with headrests

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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

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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•

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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

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Pinworms - Diagnosis

• Tape test• Direct visualization

with flashlight

www.biosci.ohio~parasite/enterobius.html

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Pinworms - Treatment

• Medications –

Anti helminthic– **Mebendazole (Vermox)– Pyrantel pamoate (Antiminth) Pinrid– Albendazole

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Pinworms – Nursing Care Management

• Identify parasite, eradicate organism & prevent reinfection• Environmental

– good hand washing– daily showers– wash bedding– clean pajamas– snug underwear– fingernails short

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Pediculosis Capitis(Parasite)

• Head lice • Pediculus humanus

capitis• Common parasite in school

age children

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Pediculosis Capitis

• Lay eggs at junction of a hair shaft

• Nits hatch in 7-10 days• Itching is usually the only

symptom

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Pediculosis Capitis

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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

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Removal of Nit Cases

– Extra fine-tooth comb– “nit-picking”– Examine head daily for 2

weeks

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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

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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

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Ixodes Dammini Nymph

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• From “Your Dog may be at Risk from Lyme Disease”, Fort Dodge Laboratories, 1995.

Univ. of Chicago – 2006 article from Infectious Disease Society

of America• http://www.journals.uchicago.edu/CID/

journal/issues/v43n9/40897/40897.html

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Lyme Disease - Stages

• Stage 1– Tick bite– Erythematous papule– Bull’s eye rash

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• Erythema Migrans -• Bull’s eye rash

Lyme Disease Stages

• Stage 2– Systemic involvement of neurologic, cardiac

and musculoskeletal systems

• Stage 3– Musculoskeletal pain– Arthritis

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Lyme Disease

• Diagnosis– Symptoms– Lab: Elisa, Western Blot, PCR

• Management– Doxycycline or Amoxicillin

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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

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Lead Poisoning

• Major preventable environmental health problem (CDC – 1997)

• Irreversible health effects

Brain & nervous system damage

Reduced intelligence

Learning disabilities

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

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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

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Lead PoisoningDiagnostic 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

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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

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Screening

• Universal screening- ages 1 & 2• Targeting screening- is acceptable when an

area has been determined by existing data to have less risk

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Lead Poison Treatment• Chelation therapy

– Medications• Succimer• Ca Na2EDTA

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

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Ingestion of Injurious Agents

• Significant health concern

• Majority occur in children younger than 6 years of age

• Can occur with medications & many other substances

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Most Common Poisonings

• Cleaning substances• Cosmetics & Personal care products• Plants• Foreign bodies• Pharmaceuticals

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Poisonings

• First Priority – Assess the child• Terminate exposure • Identify poison• Prevent poison absorption

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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

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Gastric Decontamination

• Remove ingested poison:

Absorbing toxin with activated charcoal

Gastric Lavage

Increase bowel motility (catharsis)

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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

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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

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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

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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

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Poison Prevention

• Ultimate objective – to prevent poisonings from occurring or

recurring• Think developmentally

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Prevention• Prevent recurrence• Discuss difficulties of constantly watching

& safeguarding children• How to identify risk?

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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

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Questions

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