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
Cultures
Scraping
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
forehead
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.
Treatment
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
crusting.
Patients have a heightened reaction to a variety of allergens.
Dermatitis
Dermatitis
Assessment
History of asthma, allergic rhinitis
Lesions generally occur in creases.
Management:
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.
Acne
Over activity of oil glands at the base of hair follicles
Hormone activity
Skin cell "plug" pores causing white heads and blackheads.
No "cure"
Acne
Management of Acne
Topical medications
OTC preparations
Prescription - Topical retinoid preparations
Prescription - Topical antibiotics
Systemic medication
Antibiotics
Hormonal therapy – birth control pills
Accutane * use with extreme caution when all else fails
Pediculosis
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.
Pediculosis
Head lice
Pubic lice
Body lice
Signs and Symptoms
Symptoms: itching, whitish colored eggs at shaft of hair, redness at site
of itching.
Nits
Interventions
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
Scabies
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
Assessment
Pruritus especially profound at night or nap time.
Lesions may be generalized but tend to distribute on the palms, soles and
axillae
In older children: finger webs, body creases, beltline and genitalia
Management
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
water.
Vacuum upholstered furniture - rugs
Scabies
Scabies
Impetigo
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
Impetigo
Spread
Highly contagious skin infection.
Most common among children.
Spread through physical contact.
Clothes, bedding, towels and other objects.
Interventions
Outcomes
Self-limiting
No scarring or pox marks post infection.
Super-infection especially in the neonate.
Impetigo / cellulitis
Cellulitis
A full-thickness skin infection involving dermis and underlying connective
tissue.
Any part of the body can be affected.
Cellulitis around the eyes is usually an extension of a sinus infection or
otitis media.
Assessment
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.
Cellulitis
Cellulitis
Interventions
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
Interventions
Prevention:
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
properly.
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.
Alert
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
Management
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
Medication.
Skin Grafts
Compartment Syndrome
Burn Wound Covering
Therapy to Prevent Complications
Burns
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
mother.
Sepsis
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
Prematurity
Sustained fetal tachycardia > 160
Minor Risk Factors
Twin gestation
Premature infant
Low APGAR
Maternal Group B Streptococcus
Foul lochia
Etiology
Group B beta-hemolytic Streptococcus
Escherichia coli
Haemophilus Influenza
Diagnostic Tests
C-Reactive Protein * earliest indicator of infectious / inflammatory
process
CBC with differential
WBC
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
Ampicillin
Gentamicin
Cefotaxime
Acyclovir: herpes
Nursing Interventions
Administer IV antibiotics
Monitor therapeutic levels
Monitor VS, temperature, O2 saturation
Activity level
Sucking
Infant parent bonding
Outcomes
Newborn will achieve normalization of body function
Parents will participate in care
Newborn will demonstrate no signs of CV, neurological or respiratory
compromise
Newborn will experience no hearing loss as a result of antibiotic therapy
SCIDS
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
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.
AIDS
T lymphocytes are critical to fighting infection and developing immunity.
HIV renders the immune system useless and the child is unable to fight
infection.
Killer T-cells
Blood Testing in Infants
Babies born to HIV-positive mothers initially test positive for HIV
antibodies.
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.
Interventions
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
mothers.
HIV has become a chronic disease in children
Team approach
Emphasis on community teaching
