Integumentary Disorders



Integumentary Disorders



Objectives



1. Define the vocabulary terms listed


2. Differentiate diaper dermatitis from candidiasis


3. Summarize the nursing care for an infant who has atopic dermatitis, and give the rationale for each nursing measure


4. Discuss care of the child with impetigo


5. Identify complications associated with Staphylococcus


6. Discuss care of the child with cellulitis


7. Define two sources of pediculosis transmission


8. Identify two methods of evaluating burn injury


9. Discuss wound management precautions associated with burn injury


10. Discuss precautions taken with accutane use



Key Terms








imagehttp://evolve.elsevier.com/Price/pediatric/



Integumentary System


The integumentary system consists of the skin and associated structure (hair, nails), as well as the subcutaneous tissue. The skin is the largest organ in the body. The epidermis is the thinner, outer layer of the skin and the dermis is the inner, thicker layer of skin. The dermis contains the hair, nails, sebaceous and sweat glands, blood vessels, nerve endings, and sensory organs. Below the dermis is the subcutaneous layer, which literally means “under the skin.”


The skin functions to protect the body from pathogens; provides sensory receptors regarding pain, touch, pressure, and temperature; aids in production of Vitamin D; provides cosmetic covering; and regulates temperature as blood vessels dilate and perspiration occurs.


There are many disorders related to this system. Skin disorders range from those caused by infection to those associated with injury. It is important to remember that the immune system is affected by a weakened integumentary system. Skin disorders such as acne can lead to concerns about appearance and have a psychological impact on children, especially adolescents. The disfigurement from burns can have a lifelong effect on children.


Discussion of the skin disorders will begin with those occurring in infants. The mucosal (mucous membrane) disorder “thrush” will be included in the discussion as diaper dermatitis oftentimes accompanies this disorder.



Thrush (Oral Candidiasis)


Thrush is an infection of the mucous membranes of the mouth caused by the fungus Candida. This organism is normally present in the mother’s vagina and is nonpathogenic. However, the altered conditions in the vagina produced by pregnancy may lead to the development of monilial vaginitis. The mucous membranes of the baby’s mouth may become infected by direct contact with this infection during delivery or by contact with the mother’s or nurse’s contaminated hands. Cross-infection of other newborn infants may then result. Breastfed infants may transfer the infection to the mother’s nipples if good hygiene is not followed. Thrush can also occur when oral flora is altered as a result of antimicrobial therapy.




Treatment and Nursing Care


This infection responds well to local application of antimicrobial suspensions. Nystatin, for example, may be applied with a swab or a gloved finger. The mouth is swabbed three or four times a day, after feedings, with a sterile applicator moistened with the prescribed solution. The remainder of the dose is deposited in the infant’s mouth to be swallowed, treating any other lesions of the gastrointestinal tract. With treatment, the disease is usually self-limiting in an otherwise healthy infant. Topical antifungal ointment such as Nystatin may be administered to skin areas that have been affected.



imageNursing Brief


In the home, parents are taught to place nystatin or other medication slowly into each cheek pocket of the baby’s mouth. Medication needs to remain in contact with “patches” as long as possible. The baby should not be fed after medication administration. Instruct parents to watch for dehydration (decrease in number of wet diapers and so on, caused by the baby’s refusal to take fluids because of mouth discomfort).


Prevention of this infection begins in the prenatal period. Mothers suspected of having Candida infection can be properly treated. Effective hand hygiene to prevent reinfection from the mother is necessary. This is particularly true if she is breastfeeding her infant. If bottles are used, nipples require scrupulous cleaning because they come in direct contact with the lesions. Nurses and other personnel must maintain a high quality of nursing care to prevent cross-infection.



Diaper Dermatitis (Diaper Rash)


Diaper dermatitis is an inflammatory disorder caused by prolonged contact with an irritant such as urine or feces. Irritants in diapers or diaper wipes can also cause diaper rash. Washing cloth diapers in harsh laundry detergent can also be a contributing factor.




Treatment and Nursing Care


Diaper dermatitis responds well to zinc oxide ointments (Balmex, Desitin). See previous discussion for Candidiasis treatment. Frequent diaper changes, liberal application of a zinc oxide–based barrier cream, and using a moist, damp cloth for cleansing are generally all that is needed for diaper dermatitis control. Only mild soap and water should be used to remove stool from the skin, particularly if commercial wipes are irritating. Petroleum jelly can be an inexpensive barrier that helps prevent diaper dermatitis. Powder is not recommended because it can be aspirated into the lungs. Powder can also become a skin irritant, especially if it becomes “caked” on. If it must be used (parental preference), parents need to be taught to first apply it to their hand, then to the dry diaper area. Always keep powder containers closed and out of the infant’s reach as they can be a choking and aspiration hazard.



image Nursing Brief


If cloth diapers are used, use overwraps that allow air to circulate; do not use “plastic” pants.



Atopic Dermatitis (Infantile Eczema)


Atopic dermatitis is an inflammation of genetically hypersensitive skin. The pathophysiology is characterized by local vasodilation in affected areas. This progresses to spongiosis, or the breakdown of dermal cells and the formation of intradermal vesicles. Chronic scratching produces weeping and results in lichenification, or coarsening of the skin folds. The exact cause of this condition is unclear, but several factors may contribute to the condition. Factors can include a family history and/or triggers such as household aeroallergens (dust mites, cat dander, mold), environmental irritants (soaps, detergent, clothing, smoke), extreme temperatures, chemical vapors and gases, food sensitivities, and infections. Atopic dermatitis is seen less frequently in breastfed babies, and delaying introduction of solid food can decrease atopic dermatitis in the first 4 years of life. It seems to have a familial tendency, and emotional factors are often involved.


Development of symptoms indicates that the infant is oversensitive to certain substances called allergens, which enter the body via the digestive tract (food), inhalation (dust, pollen), direct contact (wool, soap, strong sunlight), or injections (insect bites, vaccines). Of children who have atopic dermatitis, 50% to 60% present with symptoms in the first year of life and 80% to 85% present by 5 years of age. Overall, 10% to 20% of children are affected by the disease (Cardona et al., 2006). Many children (80%) develop the triad of atopic dermatitis, asthma, and allergic rhinitis.



Signs and Symptoms


The lesions form vesicles that weep and develop a dry crust. They are more severe on the face (Figure 16-2) but may occur on the entire body, particularly in the skin folds. Eczema is worse in winter than in summer and has periods of temporary remission.


image
FIGURE 16-2 A, Infantile atopic dermatitis or eczema is shown with acute weeping lesions on the cheeks and forehead. B, In childhood, eczema can involve the flexor surfaces of extremities.

The infant scratches because the itching is constant and he or she becomes irritable and unable to sleep. The lesions are easily infected by bacterial or viral agents. Herpes simplex is the viral agent of particular concern. Infants and children with eczema should not be exposed to adults with “cold sores.” Streptococcal and staphylococcal infection can also complicate the disease process. Eczema may flare up after immunization. Laboratory studies may show an increase in immunoglobulin E (IgE) and eosinophil levels.



Treatment


Treatment is aimed at maintaining the skin integrity, skin hydration, decreasing pruritus, and identification and avoidance of triggers. Treatment includes topical corticosteroids, topical immunosuppressants, and antihistamines. Corticosteroids vary from low potency to strong potency. They are used for different severities and areas of the body. Topical immunosuppressants (tacrolimus or pimecrolimus) are effective on all body areas, and because they cause fewer side effects, they are appropriate for long-term usage. Antihistamines (Atarax, Benadryl) given at bedtime can help control nighttime itching and enhance sleep. Sleep deprivation is a major problem for children with atopic dermatitis. If pharmacologic therapy is not effective, food allergies should be explored. Foods to which these infants may be sensitive include eggs, wheat, cow’s milk, peanuts, and citrus fruits. If food allergies are identified, a restrictive diet may be required.


An emollient bath may provide a soothing effect on the infant’s skin. Oatmeal and a mixture of cornstarch and baking soda are examples of substances prescribed. Tepid baths (15 to 20 minutes of soaking) and immediate application of emollient moisturizer afterward are key to skin hydration. Occlusive ointments such as Aquaphor, Eucerin, and Cetaphil are effective. Lotions are less effective and not recommended. Application of moisturizer while the skin is damp assists in hydration of the skin. Any lotions with alcohol should be avoided.



Nursing Care


The nurse plays a vital role in the treatment of children with skin problems. Shortening fingernails and putting cotton mittens on hands and feet can be effective. Medicated or oatmeal baths may be part of the treatment. The child should be patted or air-dried, not rubbed. Children with eczema should not be overdressed because undue warmth adds to their discomfort. One-piece soft clothing to prevent binding and irritation is recommended. Wool should be avoided.


Wet dressings are applied to the areas to reduce itching and in some cases to remove crusts. A gauze bandage is dipped into the prescribed solution (such as Burow’s solution), squeezed gently to remove excess fluid, and applied to the involved area. The bandage must cover the entire rash. Soaks are usually ordered to be done continuously, and their effectiveness depends on their being wet. When they are left on too long and become dried out, itching increases. This type of bandage is not covered with towels or rubber sheeting in an effort to protect the bed linens because the itching is relieved by the cooling effect of the medication, and covering the bandage prevents evaporation. Observations for the nurse to chart regarding the application of wet soaks include time of application, name of solution, strength of solution, area to which it was applied, length of time applied, general condition of the involved area (changes in the appearance or area of the rash), and comfort and tolerance of the patient during and after the procedure.


The physician may prescribe an elimination diet. A basic diet consisting of only hypoallergenic foods is given to the child initially. One new food at a time is added to determine the infant’s reaction. When the baby is allergic to cow’s milk, a substitute such as soybean milk can be used. Vitamin supplements are needed, particularly if the infant is not consuming enough of the prescribed fruits and vegetables. The nurse charts the kind and amount of food taken at each meal and any allergic reactions that may have occurred.



imageHome Care Considerations


The Child with Atopic Dermatitis (Eczema)





imageNursing Brief


An effective moisturizer that is also inexpensive is Crisco shortening (Cardona et al., 2006). Parents need to be taught that it should not be used around the eyes or nasal passages.


The nurse should establish a good working relationship with the parents. Families report high stress and feelings of helplessness in caring for children with atopic dermatitis. Parents express issues with the child’s sleeplessness due to itching and the child’s decreased self-esteem due to his or her physical appearance. The nurse should listen to ensure that parents understand the physician’s instructions and should clarify matters as needed (Nursing Care Plan 16-1).



Nursing Care Plan 16-1   imageThe Child with Atopic Dermatitis (Eczema)




Nursing Diagnosis 


Imbalanced nutrition, less than body requirements, related to irritability, sensitivity to certain foods, and increased metabolic needs





























Goals/Outcome Criteria Nursing Interventions Rationales

Assess diet according to age. As the child grows, the nutritional needs change.
Determine with history whether the child is sensitive to any specific foods. Food sensitivity can trigger a stronger response to the condition.
Administer hypoallergenic diet. Hypoallergenic foods have been found to be less offensive to many people.
Observe child for any food sensitivity. Any food item can be a potential substance to which the body is sensitive.
Administer vitamins and minerals as prescribed. May be given in supplemental form to aid the body in healing and growth.
Provide adequate fluids. Fluids are important to the child because the child’s body is made up of a higher percentage of fluids than the adult’s. If fluid is lost through the skin, the child can easily become dehydrated.


image



Nursing Diagnosis 


Deficient knowledge related to the nature of the disorder









































Goals/Outcome Criteria Nursing Interventions Rationales

Assess the knowledge of the parents. Allows the nurse to teach the parents.
Instruct the parents in the care of the child’s skin These are all areas that decrease the irritation to the skin or aid in healing of the skin.
• Remove clothing that might irritate the skin (e.g., wool). Wool is an irritant to the skin.
• Provide loose cotton clothing. Cotton absorbs if it is loose, does not constrict.
• Use a mild detergent to launder clothing. Decreases the irritation of soap in the clothing.
• Thoroughly rinse clothing. Ensures that most of the soap is removed from the clothing.
• Bathe the child in tepid water. Tepid water decreases the amount of vasodilation, thus causing a decrease in stimulation to the skin and resulting in a decrease in itching.
Expose infant to sunlight but monitor closely. Sunlight can be healing to the skin, but because of the skin’s condition, too much sunlight can cause more irritation.
Help parents identify products that contain wheat, milk, eggs, and peanuts. These foods have been found to cause allergic reactions in children.
Advise parents to expect exacerbations and remissions. Eczema can recur. If the parents know this, treatment can be sought earlier and the intensity of the condition can be lessened.

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Dec 22, 2016 | Posted by in NURSING | Comments Off on Integumentary Disorders

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