Lecture 11 – Unit 3.4
Nursing Care for Health Problems of
Toddlers and Preschool Children
Skin Alterations in Children
Gail McIlvain-Simpson, MSN, PNP-BC
1
Topic Areas
• Communicable diseases in children,
pathology, diagnosis, nursing
assessment, and treatment.
• Screening and treatment for lead
poisoning, and poison prevention
• Skin alterations in children
•
Lyme Disease
•
2
Communicable Diseases
• Handouts on Blackboard
– Communicable Diseases In Early
Childhood
– Integumentary Disorders
3
Communicable Diseases
• Why has the incidence of childhood
communicable diseases significantly
declined?
• Why have serious complications resulting
from such infections been further
reduced?
• As nurses what are two key reasons nurses
must be familiar with infectious agents?
4
Nursing Process for the Child
with Communicable Disease
•
•
•
•
•
Assessment
Diagnosis – Problem ID
Planning
Implementation
Evaluation
5
What to assess if suspicion of
communicable disease?
•
•
•
•
Recent exposure to known case
Prodromal symptoms
Immunization history
History of having the disease
6
Components of
Prevention
Prevention of disease & control of
spread to others.
• Primary prevention
• Prevent complications
7
A child is admitted with an undiagnosed
exanthema – what should be done in this
case?
8
Chicken Pox Varicella
•
Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New
York, 1998
Chicken Pox - Varicella
Adolescent female
» www.vacineinformation.org/photos/variaap002.jpg
» Originally from AAP
10
Chicken Pox - Varicella
4 year old, day 5
» www.vacinneinformation.org/photos/varicdc006a.jpg
» Originally from CDC
11
Shingles or Herpes Zoster
– Healthy child
– www.vaccineinformation.org/photos/variaap015.jpg
– Originally from AAP
12
Diptheria
Corynebacterium diphtheriae
•
http://www.vaccineinformation.org/photos/diphiac001.jpg
13
Fifth Disease
(Erythema infectiosum)
•
Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998
Roseola (Exanthema Subitum)
•
http://kidshealth.org/parent/infections/skin/roseo
la.html
15
Rubeola (Measles)
Koplik Spots
•
http://lebonheur.adam.com/pages/ency/articleImage.asp?file=2558.jpg&lang=en
16
Rubeola (Measles)
17
Mumps
• http://www.vaccineinformation.org/photos/mumpcdc001a.jpg
18
Mumps
•
http://www.immunize.org/catg.d/iped1861/img0016.htm
19
Pertussis
– http://www.vaccineinformation.org/photos/pertaap002.jpg
20
Pertussis
(Whooping Cough)
•
http://www.vaccineinformation.org/photos/pertiac001.jpg
21
Pertussis Deaths
• “Whooping cough deaths on rise in
infants”
• Each year there are an increase of
5000-7000 cases of whooping cough
each year and has been steadily rising
each year.
22
German Measles
cdn-write.demandstudios.com/.../70/7/238
23
Rubella
• http://www.vaccineinformation.org/photos/rubecdc002a.jpg
24
Congenital rubella syndrome
•
http://www.vaccineinformation.org/photos/rubeiac003.jpg
25
26
Scarlet Fever
•
http://www.dermnetnz.org/dna.strept/scarlet.html
27
White and Red Strawberry
Tongue
•
http://www.dental.mu.edu/oralpath/grad/mucutaneous/sld075.htm
28
Enterobiasus (Pinworms)
• http://ww.dpd.cdc.gov/dpdx/HTML/Enterobiasis.htm
29
Pinworm Life Cycle
Eggs Ingested
Hatch in small Intestine
Attaches to colon wall
Matures in 2-3 weeks
Lives in rectum or colon
Lays eggs on perianal skin
Scratch perianal area
30
Pinworm - Symptoms
•
•
•
•
•
•
•
•
Intense itching of perianal area
No systemic reaction
Unexplained irritability
Restlessness
Poor sleep
Short attention span
Perivaginal itching
www.biosci.ohio~parasite/enterobius.html
31
Pinworms - Diagnosis
• Tape test
• Direct visualization
with flashlight
www.biosci.ohio~parasite/enterobius.html
32
Pinworms - Treatment
• Medications - Anthelmintic
– Mebendazole (Vermox)
– Pyrantel pamoate (Antiminth)
33
Pinworms - Treatment
• Environmental
–
–
–
–
–
–
good hand washing
daily showers
wash bedding
clean pajamas
snug underwear
fingernails short
34
Lead Poisoning
• Is a major preventable environmental
health problem (CDC – 1997)
• Brain & nervous system damage
• Irreversible health effects
• Reduced intelligence
• Learning disabilities
35
Pathophysiology
• 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 longterm neurocognitive signs
36
Lead Poisoning
Diagnostic 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
37
Lead Poisoning
•
•
•
•
Historical perspective
Lead does not decompose
Cultural perspective
Risk factors
38
Lead Exposure
• Lead based paint is the most common
source
• Ingestion or Inhalation
• See Box 14-6 Wong 8th edition page
476
39
Other sources of Lead
• Lead crystal decanters and glasses
• Pre-1978 tableware and some imported tableware
• Jewelry in vending machines from Jan 2002 to
August 2004
• Toys
• Chewing on household objects that contain lead:
Brass keys, jewelry, fishing sinkers, pre-1970
furniture, pre-1996 mini-blinds
40
Federal Disclosure
Regulations
• Must disclose Known Lead-Based
Paint & LBP Hazards when sell or
lease house
• Many pre-1978 homes have lead
based paint
41
Lead Poison Treatment
• Chelation therapy
– Medications
• Succimer
• Ca Na2EDT
42
Nursing Care Management
• As nurses what is your primary goal?
• ???????
• ???????
43
Anticipatory Guidance
• Hazards of lead based paints in older
homes
• Ways to control led hazard safety
• Hazards accompanying repainteing &
renovations of home to houses built before
1978
• Additional exposures (ie dinnerware from
other countries)
44
Ingestion of Injurious
Agents
45
American Association of
Poison Control Center
• Poison Exposure?
Call Your Poison Center
at 1-800-222-1222.
• Free, professional, 24/7/365
Don’t guess, be sure…
• http://www.1-800-2221222.info/jingles/engver1.asp
46
Poison Prevention
• Post Poison Control
Number
(CDC web site)
47
Poisonings
• Significant health concern
• Majority occur in children younger than 6
years of age
• Can occur with medications & many other
substances
• Children poisoned by ingestion due to their
developmental characteristics
48
Most Common Poisonings
•
•
•
•
•
•
•
Cleaning substances
Pain relievers
Cosmetics
Personal care products
Plants
Cough and cold preparations
Improper use causing poisoning
49
Diffenbachia (Dumb
Cane)
50
Philodendron
51
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.
52
Poison Control
Literature
53
Poisonings
• First Priority is the Child
• Terminate Exposure to toxic
substance
• Determine poison
• Call Poison Control Center before
intervention
54
Gastric Decontamination
• Remove ingested poison:
Absorbing toxin with activated
charcoal
Gastric Lavage
Increase bowel motility (catharsis)
55
Activated Charcoal
• Most commonly used method of gastric
decompression
• 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
56
Gastric Lavage
• When child admitted to ER
• Performed to empty stomach of toxic contents.
• Procedure associated with serious complications:
gastrointestinal perforation, hypoxia, aspiration_
• No longer recommended in 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
57
Cathartics
•
•
•
•
•
Enhances excretion of charcoal-poison complex
If charcoal mixed with sorbital - not necessary
20%Magnesium sulfate 250 mg/kg/dose
Repeat q 1-2 h until stooling begin
Use is controversial particularly in pediatrics
58
Antidotes
• Minority of poisons have specific antidotes to
counteract the poison
• Highly effective & should be available in all
Emergency facilities
• Examples – N-acetlcysteine for acetaminophen
poisoning, oxygen for carbon monoxide inhalation,
naloxoned for opioid overdose, romazicon for
benzodiazipines (valium) overdose , antivenom for
certain poisonous bites
59
Selected Poisonings in
Children •
•
•
•
Corrosives
Hydrocarbons
Plants
Acetaminophen
60
Web sites for Additional
Information on Plant Poisonings
• Guide to Poisonous and Toxic Plants
- http://chppm-www.apgea.army.mil/ento/plant.htm
• Most Commonly Ingested Plants
-
http://www.kidsource.com/kidsource/content/ingested.h
tml
61
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
62
Prevention
• Prevent recurrence
• Discuss difficulties of constantly
watching & safeguarding children
• How to identify risk?
63
Skin Alterations in
Children
• Review A & P of skin
• Know primary skin lesions
64
Primary Skin Lesions
65
•
•
•
•
•
•
•
•
•
•
•
•
•
•
PRIMARY SKIN LESIONS
The primary skin lesions are the original lesions that appear as a result of
different stimuli either internal or external. The different primary skin
lesions seen on examination are:
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.
Plaque - a raised thick portion of the skin, which has well defined edges
with a flat or rough surface.
Erythema (redness of the skin surface) -This is the commonest primary
skin lesions, which appears in most skin diseases. Erythema is due to
dilatation of dermal blood vessels and edema.
Blister - a skin bleb filled with clear fluid
Vesicle - a small blister.
Bulla - a large vesicle
Pustule - a skin elevation filled with pus
Cyst - a cavity filled with fluid.
Nevus - hereditary skin disorders due to deficiency or excess of the
normal constituents of the skin and usually defined as nevi.
66
Skin Lesions
Etiologic Factors
• Contact with injurious agents
• Highly individualized responses
• Child’s age is an important factor
67
Integument of Infants &
Young Children
• Epidermis loosely bound to dermis
• More susceptible to superficial bacterial
infections
• More likely to have associated systemic symptoms
• React to a primary irritant versus sensitizing
antigen
68
Pathophysiology of
Dermatitis
• More than half the problems in children –
dermatitis
• Inflammatory changes in skin – grossly &
microscopically similar but different in
course &causation
• Changes reversible
• More permanent issues with chronic
problem
69
Integumentary Nursing History
–
–
–
–
–
–
–
–
Painful, itching, tingling
Restless or irritable
Favor or avoid a body part
Access to chemicals, been in the woods,
around a woodpile
Eaten a new food
Taking any medications
Have any allergies
Playmates with similar lesions
70
Nursing Assessment
• Describe color, shape, size,
distribution of lesions
• Palpate for temperature, moisture,
elasticity and edema
72
Therapeutic Management
•
•
•
•
Eliminate cause
Prevent further damage
Prevent complications
Provide relief
73
Pruritis
• Mittens
• Fingernails short, well-trimmed
• Antipruritic medications - Benadryl,
Atarax
74
Topical Management
• Glucocorticoids
– anti-inflammatory effects
• Topical therapy
– cool compresses
– Burrow’s solution
– Oatmeal baths (Aveeno)
75
Impetigo contagiosa
•
•
•
•
Superficial infection of skin
Easily spread - very contagious
Staph or strep
Reddish macule, becomes
vesicular
76
Impetigo
•
Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill,
New York, 1998
Treatment of Impetigo
• Topical antibiotics
• Oral or parenteral antibiotics in
severe or extensive cases
• Tends to heal without scarring
• Common in toddler, preschooler
• May superimpose on eczema
78
Scalded Skin Syndrome
• Staph aureus infection
• Macular erythema with sandpaper
texture of involved skin
• Large bullae
• Systemic antibiotics
• Burow solution
79
Scalded Skin Syndrome
•
Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill,
New York, 1998
Tinea Capitis (Fungal)
• Ringworm of scalp
• Fungal infection
• Scaly circumscribed patches and or
patchy scaling areas of alopecia
• Pruritic
• Person to person or animal to person
transmission
81
Tinea Capitis
•
http://dermatlas.med.jhmi.edu/derm/result.cfm?Diagnosis=108
82
Tinea Capitis
•
Lissauer, Tom and Clayden, Graham, Illustrated Textbook of Paediatrics,
Mosby, Philadelphia, 1997, p. 263
Tinea Capitis
• Oral griseofulvin - for weeks or
months
• Selenium sulfide shampoos
• Topical antifungal agents
– inactivates organisms on hair
84
Teaching
• No exchange of anything that
touches area
• Use own towel
• Protective cap at night
• Examine pets
• Watch public seats with headrests
85
Pediculosis Capitis
• Head lice
• Pediculus humanus
capitis
Common parasite in school
age children
86
87
Pediculosis Capitis
88
Pediculosis Capitis
• Lay eggs at junction of a hair shaft
• Nits hatch in 7-10 days
• Itching is usually the only symptom
89
Nit Case under Microscope
•
Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New
York, 1998
Empty & Live Nit Case
CDC Fact sheet –
Head Lice Infestation
92
93
Pediculosis capitis
• Symptoms
– Pruritic
• Diagnosis
94
Three Steps to Treatment
• Application of pediculicidal product
–
–
–
–
Permethrin (1%) crème rinse
Pyrethin Preparations – RID
Lindane shampoos - 1% Kwell, Scabene
Malathion 0.5%Ovide
• Manual removal of nit cases
• Environmental
95
Application of Pediculocidal
Product
– Do not administer after warm bath or
shower
– Must remain on scalp and hair for
several minutes
– Keep off rest of body
96
Removal of Nit Cases
–
–
–
–
Soak hair in vinegar solution
Extra fine-tooth comb
“nit-picking”
Examine head daily for 2 weeks
97
Lice combs
98
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
99
100
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
101
Distribution of Lyme
Disease
102
103
Ixodes dammini nymph
• From “Your Dog may be at Risk from Lyme
Disease”, Fort Dodge Laboratories, 1995.
105
Lyme Disease Carrier ID
Fort Dodge Laboratories,
1995
106
Univ. of Chicago – 2006 article
from Infectious Disease
Society of America
• http://www.journals.uchicago.edu/CI
D/journal/issues/v43n9/40897/408
97.html
107
Lyme Disease - Stages
• Stage 1
– Yick bite
– Erythematous papule
– Bull’s eye rash
108
• Erythema Migrans • Bull’s eye rash
Erythema migrans
•
•
www.acponline.org/shellcgi/printhappy.pl/lyme/patient/diagnosis.htm
110
Lyme Disease Stages
• Stage 2
– systemic involvement of neurologic,
cardiac and musculoskeletal systems
• Stage 3
– Musculoskeletal pain
– Arthritis
111
Lyme arthritis
Lyme Disease
• Diagnosis
– By symptoms
– Elisa, Western Blot, PCR
• Management
– Doxycycline or Amoxicillin
113
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 a hat
• tuck pant legs into socks
• wear shoes that leave no part of the
foot exposed
114
Lyme Disease Prevention
• Wear light colored clothing
• Carefully examine for ticks
• No DEET - insect repellent - for
infants and small children
• www.cdc.gov/ncidod/ticktips2005
115
Steven-Johnson
Syndrome
•
•
•
•
Erythema multiforme exudativum
lesions of skin and mucous membranes
Hypersensitivity reaction to certain drugs
Erythematous papular rash on any
cutaneous surface
116
Nursing
•
•
•
•
•
•
•
•
Protective isolation
Monitor IV
Maintain fluid and electrolyte balance
Liquid diet
Viscous lidocaine
Meticulous mouth care
Administer Antibiotics
Artificial tears
117
Scabies
• Sarcoptes Scabiei - Parasitic mite
118
Scabies
•
Lissauer, Tom and Clayden, Graham, Illustrated Textbook of Paediatrics,
Mosby, Philadelphia, 1997, p. 264
Scabies
•
•
•
•
Burrows
Intense pruritis - esp. at night
Maculopapular lesions
Intertriginous areas
120
Management
• 5% Permethrin (Elimite)
• 1% Gamma benzene hexaxhloride
(Lindane)
• Soothing ointments or lotions
121
Contact Dermatitis
• Inflammatory reaction of the skin to chemical substances
(natural or synthetic)
• Causes a hypersensitivity response or direct irritationInitial
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
122
Treatment of Contact
Dermatitis
• Major goal – to prevent further exposure of the
skin to offending substance
• Otherwise based on severity
• Following exposure cleanse as soon as possible
• Prevention – avoiding contact
123
Atopic Dermatitis
Eczema
• Descriptive category of Dermatologic diseases
• Pruritic eczema
• Usually occurs during infancy & is associated with
allergic tendancy
• 3 Forms based on age & distribution of lesions:
• Infantile eczema
• Childhood
• Preadolewscent & adolescent,
124
Atopic Dermatitis
• Diagnosed via combination of history
& morphologic findings
• Cause unknown
• Majority of those affected have
eczema, asthma, food allergies or
allergic rhinitis
125
Atopic Dermatitis
Management
• Major goals: hydrate the skin, relieve pruritis,
reduce flare-ups, prevent & control secondary
infection.
• Avoid skin irritants & overheating
• Administer medications
126
Nursing Care Management
• Take history – atopy in family
• History of previous involvement
• Fingernails & toenails shortened
127
The END
128