Monday, March 9, 2009

Pediatric Nursing: skin disorders/burns

Skin – Immune Disorders

Key Function of Skin

Protection – shield from internal injury.

Immunity – contains cells that ingest bacteria and other substances.

Thermoregulation – heat regulation through sweating, shivering, and
subcutaneous insulation

Communication / sensation / regeneration

Developmental Variances

Sweat glands function by the time the child is 3-years-old.

The visco-elastic property of the dermis becomes completely functional at
about 2 years.

The neonate’s dermis is thin and very hydrated, thus is at greater risk for
fluid loss and serves as an ineffective barrier.

Diagnostic Tests



Skin biopsy

Skin testing

Woods lamp

Neonatal skin lesions

Vascular birth marks: hemangioma

Port wine stain

Abnormal pigmentation: Mongolian spots

Neonatal acne: small red papules and pustules appear on face trunk.

Milia: white or yellow, 1-2mm papules appearing on cheeks, nose, chin, and

Inflammatory Skin Disorders

Diaper dermatitis

Contact dermatitis

Atopic dermatitis or eczema

Diaper Dermatitis

Diaper Dermatitis

Identify causative agent

Cleanse with mild cleaner

Apply barrier

Expose to air

Teach hazards of baby powder

Cradle Cap

Rash that occurs on the scalp.

It may cause scaling and redness of the scalp.

It may progress to other areas.


If confined to the scalp

Wash area with mild baby shampoo and brush with a soft brush to help remove
the scales.

Do not apply baby oil or mineral oil to the area - this will only allow for
more build up of the scales.

Cradle Cap

Baby Care

Atopic dermatitis or Eczema

Chronic, relapsing inflammation of the dermis and epidermis characterized
by itching, edema, papules, erythema, excoriation, serous discharge and

Patients have a heightened reaction to a variety of allergens.




History of asthma, allergic rhinitis

Lesions generally occur in creases.


Control the itching: OTC Benadryl

Reduce inflammation: topical corticosteroids

Hydrate the skin

Elidel Cream

Preventing infection

Acne Vulgaris

A chronic, inflammatory process of the pilosebaceous follicles.

Occurrence; 85% of teenager aged 15 to 17 years.

More common in females than males.


Over activity of oil glands at the base of hair follicles

Hormone activity

Skin cell "plug" pores causing white heads and blackheads.

No "cure"


Management of Acne

Topical medications

OTC preparations

Prescription - Topical retinoid preparations

Prescription - Topical antibiotics

Systemic medication


Hormonal therapy – birth control pills

Accutane * use with extreme caution when all else fails


Head lice infestation ranges from 1% to 40% in children.

Most common in ages 5 to 12.

Less common in African American due to the shape of the hair shaft.

Transmission by direct contact with infected person, clothing, grooming
articles, bedding, or carpeting.


Head lice

Pubic lice

Body lice

Signs and Symptoms

Symptoms: itching, whitish colored eggs at shaft of hair, redness at site
of itching.



Anti-lice shampoo

Removal of nits

Washing bedding, towels, anything child’s head may have
come in contact with in hot soapy water.

Vacuum all floors and rugs

Do not need to fumigate the house

Child can return to school after 1 day of treatment


A contagious skin condition caused by the human skin mite.

Tiny, eight-legged creature burrows within the skin and penetrate the
epidermis and lays eggs

Allergic reaction occurs

Severe itching


Pruritus especially profound at night or nap time.

Lesions may be generalized but tend to distribute on the palms, soles and

In older children: finger webs, body creases, beltline and genitalia


Permethrin cream is drug of choice

Massage into all skin surfaces – neck to soles of feet - leave on for 8 to
14 hours.

Clothing bedding and other contact items need to be washed in hot soapy

Vacuum upholstered furniture - rugs




The most common skin infection in children.

Causative agent is carried in the nasal area.

Bacteria invade the superficial skin.

Causative agent

Group A beta-hemolytic streptococcal (GABHS)

Staph aureus



Highly contagious skin infection.

Most common among children.

Spread through physical contact.

Clothes, bedding, towels and other objects.




No scarring or pox marks post infection.

Super-infection especially in the neonate.

Impetigo / cellulitis


A full-thickness skin infection involving dermis and underlying connective

Any part of the body can be affected.

Cellulitis around the eyes is usually an extension of a sinus infection or
otitis media.


History and physical exam

WBC count

Blood culture

Culturing organism from lesion aspiration.

CT scan with peri-orbital cellulitis

Clinical Manifestations

Characteristic reddened or lilac-colored, swollen skin that pits when
pressed with finger.

Borders are indistinct.

Warm to touch.

Superficial blistering.




Hospitalization if large area involved or facial cellulitis.

IV antibiotics.

Tylenol for pain management.

Warm moist packs to area if ordered.

Assess for spread

If peri-orbital test for ocular movement and vision acuity

Poison Oak, Ivy and Sumac

Three potent antigens that characteristically produce an intense
dermatologic inflammatory reaction when contact is made between the skin and
the allergens contained in the plant.

Poison Ivy

Poison Oak



Wear long pants when hiking or playing in the brush.

Wash with soap and water to remove sticky sap.

Cleanse under finger nails.

Sap on fur, clothing or shoes can last up to 1 week if not cleansed

Topical cortisone to lesions.

Systemic Response

Burns in Children

Young children who have been severely burned have a higher mortality rate
than adults.

Shorter exposure to chemicals or temperature can injure child sooner.

Increased risk for for fluid and heat loss due to larger body surface area.

Burns in Children

Burns involving more that 10% of TBSA require fluid resuscitation.

Infants and children are at increased risk for protein and calorie
deficiency due to decreased muscle mass and poor eating habits.

Scarring in more severe.

Burns in Children

Immature immune system can lead to increased risk of infection.

Delay in growth may follow extensive burns.

Management of Burns

Ascertain adequacy of airway, oxygen, intubation

Large bore needle to deliver sufficient fluids at a rapid rate.

Remove clothing and jewelry and examine.


The most common cause of unconsciousness in the flame burn patient is
hypoxia due to smoke inhalation.

Look for ash and soot around nares.

Management of Burns

Admission weight.

Nasogastric tube to maintain gastric decompression.

Foley catheter for urine specimen and monitor output.

Evaluate burn area and determine the extent and depth of injury.

Flame Burn


NG tube in place.

Catheter for fluid replacement.

Ambulation to prevent problems

associated with immobilization

Percentage of Areas Affected

Depth of Burns

First Degree Burn

Involves only the epidermis and part of the underlying skin layers.

Area is hot, red, and painful, but without swelling or blistering.

Sunburn is usually a first-degree burn.

Second Degree Burn

Involves the epidermis and part of the underlying skin layers.

Pain is severe.

Area is pink or red or mottled.

Area is moist and seeping, swollen, with blisters.

Third Degree or Full-thickness

Involves injury to all layers of skin.

Destroys the nerve and blood vessels

No pain at first

Area may be white, yellow, black or cherry red.

Skin may appear dry and leathery.

Wound Management

Wound Management

Wound Management

Hydrotherapy is used to cleanse the wound. Gauze pads are used

To debride the wound by removing exudates and previous applied


Skin Grafts

Compartment Syndrome

Burn Wound Covering

Therapy to Prevent Complications


Keep Kids Safe

Infants Immune System

No active immune response at birth

Passive immunity from mother

Potential for immune response is present / active response is lacking

Immune Response

IgG is received from mother trans-placental and in breast milk

6 to 9 months infants start to produce IgG

Immune system starts to assume defensive role

Active immunity begins after exposure to antigens

Neonatal Sepsis

Can be caused by bacterial, fugal, parasitic or viral pathogens.

Etiology: complex interaction of maternal-fetal colonization,
transplacental immunity and physical and cellular defenses of the fetus and


Laboratory confirmed blood stream infection

Neonatal sepsis

Mortality rate 50%

1 to 8 cases per 1000 live births

Meningitis occurs in 1/3

Major Risk Factors

Maternal prolonged rupture of membranes > 24 hours

Intra-partum maternal fever > 38C


Sustained fetal tachycardia > 160

Minor Risk Factors

Twin gestation

Premature infant


Maternal Group B Streptococcus

Foul lochia


Group B beta-hemolytic Streptococcus

Escherichia coli

Haemophilus Influenza

Diagnostic Tests

C-Reactive Protein * earliest indicator of infectious / inflammatory

CBC with differential


Blood Culture – rule out blood borne bacteria – sepsis (take 3 days for
final culture results)

Lumbar Puncture – rule out meningitis

Urine Culture – rule out UTI

Clinical Manifestations

Respiratory distress

Tachypnea / apnea / hypoxia

Temperature instability

> 99.6 (37 C) or < 97 (36 C)

Gastrointestinal symptoms

Vomiting, diarrhea, poor feeding

Decreased activity: lethargic / not eating

Blood Test

C-Reactive Protein

Protein appears within 6 hours or exposure

Blood culture to identify causative agent

Medical Management




Acyclovir: herpes

Nursing Interventions

Administer IV antibiotics

Monitor therapeutic levels

Monitor VS, temperature, O2 saturation

Activity level


Infant parent bonding


Newborn will achieve normalization of body function

Parents will participate in care

Newborn will demonstrate no signs of CV, neurological or respiratory

Newborn will experience no hearing loss as a result of antibiotic therapy


Severe Combined Immunodeficiency Disease

Hereditary disease

Absence of both humoral and cell mediated immunity

Clinical Manifestations

Susceptibility to infection

Frequent infection

Failure of infection to respond to antibiotic treatment


Manage infection

Bone marrow transplant

Acquired Immunodeficiency Syndrome / AIDS

Human immunodeficiency virus type 1

is a retro virus that attacks the immune

system by destroying T lymphocytes.


T lymphocytes are critical to fighting infection and developing immunity.

HIV renders the immune system useless and the child is unable to fight

Killer T-cells

Blood Testing in Infants

Babies born to HIV-positive mothers initially test positive for HIV

Only 13 to 39% of these infants are actually infected.

Infants who are not infected with HIV may remain positive until they are
about 18- months-old.

Treating Infants in Utero

Routinely offer HIV testing to all pregnant women.

Administration of zidovudine (AZT) can decrease the likelihood of perinatal
transmission from 25% to 8%.

Modes of Transmission

Three chief modes of transmission:

Sexual contact (both homosexual and heterosexual).

Exposure to needles or other sharp instruments contaminated with blood or
bloody body fluids.

Mother-to-infant transmission before or around the time of birth.

Symptoms in Children

An infant who is HIV positive will generally exhibit symptoms between 9
months to 3 years.

Failure to thrive

Pneumonia, chronic diarrhea, opportunistic infections

Encephalopathy: leading to developmental delay, or loss of previously
obtained milestones.

Interdisciplinary Interventions

Maternal treatment during pregnancy.

Newborn receives zidovudine for 6 weeks after birth.

Prophylaxis with Septra or Bactrim when CD4 level starts to drop.


Age-appropriate immunizations except those containing live attenuated
viruses. Can be given when T-Cell count is adequate

Chicken pox - Varicella

MMR – measles, mumps, rubella

Community Interventions

Education and prevention are the best ways to manage AIDS.

Safe sexual practices

Monogamous relationship

Avoidance of substances such as alcohol and drugs that can cloud judgment.

Changes in HIV

Number of infected newborns has dropped due to treatment of HIV infected

HIV has become a chronic disease in children

Team approach

Emphasis on community teaching