Gilli Lewis and Debbie Rickard Eczema is a common inflammatory skin condition, affecting up to 20% of children in the UK with around 1 in 20 having severe disease (Cork et al. 2019, de Lusignan et al. 2021). Eczema has a higher incidence in infancy and childhood, but can affect individuals throughout life and is typically an episodic disease of exacerbation and remissions. Effective therapy improves quality of life for children with eczema and their parents and carers. Lack of evidence based information and support about therapy leads to poor adherence, and consequently to treatment failure (Axon et al. 2021; Cork et al. 2020; Santer et al. 2012). Environmental and genetic influences can lead to the breakdown of the skin barrier. This makes the skin susceptible to trigger factors, including irritants and allergens, which can make eczema worse. Many cases of eczema resolve or improve during childhood, but some persist into adulthood. Some children who have eczema will go on to develop asthma and/or allergic rhinitis; this sequence of events is sometimes referred to as the ‘atopic march’ (Yang et al. 2020). However while evidence does exist to support the existence of the atopic march, its prevalence may be overstated (Aw et al. 2020). There can be an association with personal or family history of atopy (atopic eczema, allergic rhinitis and/or asthma). Eczema is usually characterised by epidermal changes, pruritus (itch), and lesions with indistinct borders. These lesions can appear as erythema, papules, or scales; they can present in an acute, subacute or chronic phase. Oedema, serous discharge and crusting occur with continued irritation and scratching. In chronic cases, the skin may become thickened and leathery and hyperpigmented from recurrent irritation and scratching. This is called lichenification. Chronic eczema is more likely to have distinct borders. Affected sites vary with age (see https://dermnetnz.org/topics/atopic-dermatitis). Infantile eczema commonly affects the face, sparing around the mouth, and later the hands, feet, and elsewhere (Halkjaer et al. 2006; Thomsen 2014). While the underlying cause of eczema is not yet fully known it is thought to involve complex pathways including skin barrier dysfunction, altered innate or adaptive immune responses. There is increasing evidence disruption of the skin barrier function and atopy affect one another reciprocally. Eczema is a product of interplay between environmental factors and genetic susceptibility (Cork et al. 2020). As described by Leung et al. (2004), ‘the skin represents the interface between the body and the surrounding environment’ (p. 654). When the skin barrier is impaired from dryness (xerosis) by genetic or environmental means and/or excoriated (in response to the pruritis from the skin xerosis) this allows bacteria, viruses, and allergens to penetrate the skin. Historically eczema has been poorly understood and frequently under treated and there continues to be significant unmet need (Cork et al. 2020). There is no cure for eczema however effective management includes minimizing exacerbations (often referred to as flares) with a prevention focus supporting the patient and family to have control (Cork et al. 2020; Thomsen 2014). With the increasing prevalence of eczema, it is no longer dismissed as a trivial disorder; indeed, the impact of this chronic condition on the individual, families, and the community are increasingly being recognised (National Eczema Society 2021; Santer et al. 2012; Wan et al. 2020). Assessment The initial assessment will be carried out during a family interview, in which the nurse may ask questions relevant to the care of the child. It is important to be aware that caregivers of children with eczema are often frustrated and exhausted. If possible, hospitalisation of the child should be avoided as these children are highly susceptible to infections. However, admission may sometimes be the only answer to provide intensive therapy or to relieve an exhausted caregiver. In this interview it is important to cover the history of Henry’s condition, including treatments that have been recently tried and any known allergens or triggers. It is useful to include a review of the home environment and daily routine. The nurse should evaluate Henry’s mother’s knowledge of eczema. To aid management of eczema in children, the children’s nurse should take detailed clinical and drug histories that include: In addition to the interview, data collection about Henry must include vital signs, and height and weight to assess growth. Observing general nutritional state and a complete examination of all body parts, with careful documentation of the eruptions and their location and size. It is helpful to touch the skin to assess skin integrity; rough skin is an indicator of skin dryness. Unaffected areas, as well as those that are weeping and crusted, should be documented to assist review of progress. It may be necessary to reassess when Henry is physically better, and Sharon is not so exhausted (physically and/or emotionally). Identified problems Model of nursing Anne Casey’s model of nursing (Casey 1993) guides nurses to work in partnership with children and their families. The philosophy behind the model is that the best people to care for the child are the family, with help from various professional staff. After all, following discharge from hospital, it is the family who will provide the ongoing care at home. However, forming a partnership of care is not simple, and requires skill and sensitivity. Negotiating care is discussed by Anne Casey in her model. The ability to negotiate care is an underestimated skill, which is essential if nurses are to come alongside families/caregivers in true partnership when planning care for children. The nurse, in this case, will need to discuss the identified problems and possible goals of nursing care with Sharon. Goals for Henry: Goals for Kate/other caregivers: The nursing care plan will be based on the problems identified during assessment, and the goals as discussed with Kate and stated above. Improving and maintaining Henry’s skin integrity, minimising flares Using emollient
CHAPTER 34
Infant with Infected Eczema
ANSWERS TO QUESTIONS
Question 1. What is eczema?
Question 2. On Henry’s admission to the ward, the children’s nurse will need to complete a nursing assessment, from which a nursing plan of care may be developed. Describe how the nurse would carry out this assessment.
Question 3. Identify the key healthcare issues/problems Henry and his mother, Kate, present with and using an appropriate model of nursing plan goals of nursing care in relation to these.
Question 4. Henry has been admitted with infected eczema. Describe the nursing care plan which the children’s nurse should follow to ensure Henry receives appropriate evidence-based skin care.
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